Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION [229807]

Facility

$264.72

Service Code	CPT Q5106
Hospital Charge Code	NDG229807
Hospital Revenue Code	636
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$198.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$158.83
Rate for Payer: Aetna of CA Government/Medicare	$158.83
Rate for Payer: Cash Price	$119.12
Rate for Payer: Health Smart Auto/Commercial	$158.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$158.83
Rate for Payer: LLUH Dept of Risk Management WC	$145.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$198.54

EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION [221919]

Facility

$26.47

Service Code	CPT Q5106
Hospital Charge Code	NDG221919
Hospital Revenue Code	636
Min. Negotiated Rate	$14.56
Max. Negotiated Rate	$21.18
Rate for Payer: Cash Price	$11.91
Rate for Payer: Cigna of CA HMO/PPO	$21.18
Rate for Payer: Health Smart Auto/Commercial	$15.88
Rate for Payer: LLUH Dept of Risk Management WC	$14.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.85

EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION [221919]

Facility

$26.47

Service Code	CPT Q5106
Hospital Charge Code	NDG221919
Hospital Revenue Code	636
Min. Negotiated Rate	$14.56
Max. Negotiated Rate	$19.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.88
Rate for Payer: Aetna of CA Government/Medicare	$15.88
Rate for Payer: Cash Price	$11.91
Rate for Payer: Health Smart Auto/Commercial	$15.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.88
Rate for Payer: LLUH Dept of Risk Management WC	$14.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.85

EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION [221920]

Facility

$39.71

Service Code	CPT Q5106
Hospital Charge Code	NDG221920
Hospital Revenue Code	636
Min. Negotiated Rate	$21.84
Max. Negotiated Rate	$29.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.83
Rate for Payer: Aetna of CA Government/Medicare	$23.83
Rate for Payer: Cash Price	$17.87
Rate for Payer: Health Smart Auto/Commercial	$23.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.83
Rate for Payer: LLUH Dept of Risk Management WC	$21.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.78

EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION [221920]

Facility

$39.71

Service Code	CPT Q5106
Hospital Charge Code	NDG221920
Hospital Revenue Code	636
Min. Negotiated Rate	$21.84
Max. Negotiated Rate	$31.77
Rate for Payer: Cash Price	$17.87
Rate for Payer: Cigna of CA HMO/PPO	$31.77
Rate for Payer: Health Smart Auto/Commercial	$23.83
Rate for Payer: LLUH Dept of Risk Management WC	$21.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.78

EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION [221923]

Facility

$529.44

Service Code	CPT Q5106
Hospital Charge Code	NDG221923
Hospital Revenue Code	636
Min. Negotiated Rate	$291.19
Max. Negotiated Rate	$423.55
Rate for Payer: Cash Price	$238.25
Rate for Payer: Cigna of CA HMO/PPO	$423.55
Rate for Payer: Health Smart Auto/Commercial	$317.66
Rate for Payer: LLUH Dept of Risk Management WC	$291.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$397.08

EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION [221923]

Facility

$529.44

Service Code	CPT Q5106
Hospital Charge Code	NDG221923
Hospital Revenue Code	636
Min. Negotiated Rate	$291.19
Max. Negotiated Rate	$397.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$317.66
Rate for Payer: Aetna of CA Government/Medicare	$317.66
Rate for Payer: Cash Price	$238.25
Rate for Payer: Health Smart Auto/Commercial	$317.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$317.66
Rate for Payer: LLUH Dept of Risk Management WC	$291.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$397.08

EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION [221921]

Facility

$52.94

Service Code	CPT Q5106
Hospital Charge Code	NDG221921
Hospital Revenue Code	636
Min. Negotiated Rate	$29.12
Max. Negotiated Rate	$42.35
Rate for Payer: Cash Price	$23.82
Rate for Payer: Cigna of CA HMO/PPO	$42.35
Rate for Payer: Health Smart Auto/Commercial	$31.76
Rate for Payer: LLUH Dept of Risk Management WC	$29.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$39.70

EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION [221921]

Facility

$52.94

Service Code	CPT Q5106
Hospital Charge Code	NDG221921
Hospital Revenue Code	636
Min. Negotiated Rate	$29.12
Max. Negotiated Rate	$39.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.76
Rate for Payer: Aetna of CA Government/Medicare	$31.76
Rate for Payer: Cash Price	$23.82
Rate for Payer: Health Smart Auto/Commercial	$31.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$31.76
Rate for Payer: LLUH Dept of Risk Management WC	$29.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$39.70

EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION [153307]

Facility

$59.02

Service Code	CPT J1325
Hospital Charge Code	NDC155307
Hospital Revenue Code	636
Min. Negotiated Rate	$32.46
Max. Negotiated Rate	$44.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.41
Rate for Payer: Aetna of CA Government/Medicare	$35.41
Rate for Payer: Cash Price	$26.56
Rate for Payer: Health Smart Auto/Commercial	$35.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.41
Rate for Payer: LLUH Dept of Risk Management WC	$32.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.26

EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION [153307]

Facility

$53.40

Service Code	CPT J1325
Hospital Charge Code	1771290
Hospital Revenue Code	636
Min. Negotiated Rate	$29.37
Max. Negotiated Rate	$40.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$32.04
Rate for Payer: Aetna of CA Government/Medicare	$32.04
Rate for Payer: Cash Price	$24.03
Rate for Payer: Health Smart Auto/Commercial	$32.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$32.04
Rate for Payer: LLUH Dept of Risk Management WC	$29.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$40.05

EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION [153307]

Facility

$59.02

Service Code	CPT J1325
Hospital Charge Code	NDC155307
Hospital Revenue Code	636
Min. Negotiated Rate	$32.46
Max. Negotiated Rate	$47.22
Rate for Payer: Cash Price	$26.56
Rate for Payer: Cigna of CA HMO/PPO	$47.22
Rate for Payer: Health Smart Auto/Commercial	$35.41
Rate for Payer: LLUH Dept of Risk Management WC	$32.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.26

EPOPROSTENOL 1.5 MG INTRAVENOUS SOLUTION [153307]

Facility

$53.40

Service Code	CPT J1325
Hospital Charge Code	1771290
Hospital Revenue Code	636
Min. Negotiated Rate	$29.37
Max. Negotiated Rate	$42.72
Rate for Payer: Cash Price	$24.03
Rate for Payer: Cigna of CA HMO/PPO	$42.72
Rate for Payer: Health Smart Auto/Commercial	$32.04
Rate for Payer: LLUH Dept of Risk Management WC	$29.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$40.05

EPOPROSTENOL (GLYCINE) 0.5 MG INTRAVENOUS SOLUTION [15897]

Facility

$22.43

Service Code	CPT J1325
Hospital Charge Code	1759843
Hospital Revenue Code	636
Min. Negotiated Rate	$12.34
Max. Negotiated Rate	$17.94
Rate for Payer: Cigna of CA HMO/PPO	$17.94
Rate for Payer: Health Smart Auto/Commercial	$13.46
Rate for Payer: Cash Price	$10.09
Rate for Payer: LLUH Dept of Risk Management WC	$12.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.82

EPOPROSTENOL (GLYCINE) 0.5 MG INTRAVENOUS SOLUTION [15897]

Facility

$22.43

Service Code	CPT J1325
Hospital Charge Code	1759843
Hospital Revenue Code	636
Min. Negotiated Rate	$12.34
Max. Negotiated Rate	$16.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.46
Rate for Payer: Aetna of CA Government/Medicare	$13.46
Rate for Payer: Cash Price	$10.09
Rate for Payer: Health Smart Auto/Commercial	$13.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.46
Rate for Payer: LLUH Dept of Risk Management WC	$12.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.82

EPOPROSTENOL (GLYCINE) 1.5 MG INTRAVENOUS SOLUTION [15898]

Facility

$54.17

Service Code	CPT J1325
Hospital Charge Code	1759954
Hospital Revenue Code	636
Min. Negotiated Rate	$29.79
Max. Negotiated Rate	$43.34
Rate for Payer: Cash Price	$24.38
Rate for Payer: Cigna of CA HMO/PPO	$43.34
Rate for Payer: Health Smart Auto/Commercial	$32.50
Rate for Payer: LLUH Dept of Risk Management WC	$29.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$40.63

EPOPROSTENOL (GLYCINE) 1.5 MG INTRAVENOUS SOLUTION [15898]

Facility

$54.17

Service Code	CPT J1325
Hospital Charge Code	1759954
Hospital Revenue Code	636
Min. Negotiated Rate	$29.79
Max. Negotiated Rate	$40.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$32.50
Rate for Payer: Aetna of CA Government/Medicare	$32.50
Rate for Payer: Cash Price	$24.38
Rate for Payer: Health Smart Auto/Commercial	$32.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$32.50
Rate for Payer: LLUH Dept of Risk Management WC	$29.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$40.63

EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION [23123]

Facility

$1.20

Service Code	CPT J1327
Hospital Charge Code	1722021
Hospital Revenue Code	636
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cash Price	$1.52
Rate for Payer: Cash Price	$1.35
Rate for Payer: Cigna of CA HMO/PPO	$2.40
Rate for Payer: Cigna of CA HMO/PPO	$0.96
Rate for Payer: Cigna of CA HMO/PPO	$2.70
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Health Smart Auto/Commercial	$2.03
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$1.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.54

EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION [23123]

Facility

$3.00

Service Code	CPT J1327
Hospital Charge Code	1722021
Hospital Revenue Code	636
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.03
Rate for Payer: Aetna of CA Government/Medicare	$2.03
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$1.80
Rate for Payer: Cash Price	$1.52
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cash Price	$1.35
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: Health Smart Auto/Commercial	$2.03
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.86
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90

EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [23124]

Facility

$6.00

Service Code	CPT J3490
Hospital Charge Code	NDG23124
Hospital Revenue Code	636
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$2.70
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [23124]

Facility

$11.28

Service Code	CPT J3490
Hospital Charge Code	1722020
Hospital Revenue Code	636
Min. Negotiated Rate	$6.20
Max. Negotiated Rate	$8.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.24
Rate for Payer: Aetna of CA Government/Medicare	$3.24
Rate for Payer: Aetna of CA Government/Medicare	$6.77
Rate for Payer: Cash Price	$5.08
Rate for Payer: Cash Price	$2.43
Rate for Payer: Health Smart Auto/Commercial	$3.24
Rate for Payer: Health Smart Auto/Commercial	$6.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.77
Rate for Payer: LLUH Dept of Risk Management WC	$2.97
Rate for Payer: LLUH Dept of Risk Management WC	$6.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.05

EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [23124]

Facility

$6.00

Service Code	CPT J3490
Hospital Charge Code	NDG23124
Hospital Revenue Code	636
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cigna of CA HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [23124]

Facility

$11.28

Service Code	CPT J3490
Hospital Charge Code	1722020
Hospital Revenue Code	636
Min. Negotiated Rate	$6.20
Max. Negotiated Rate	$9.02
Rate for Payer: Cash Price	$5.08
Rate for Payer: Cash Price	$2.43
Rate for Payer: Cigna of CA HMO/PPO	$4.32
Rate for Payer: Cigna of CA HMO/PPO	$9.02
Rate for Payer: Health Smart Auto/Commercial	$6.77
Rate for Payer: Health Smart Auto/Commercial	$3.24
Rate for Payer: LLUH Dept of Risk Management WC	$6.20
Rate for Payer: LLUH Dept of Risk Management WC	$2.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.05

ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION [222798]

Facility

$68.40

Service Code	CPT J0122
Hospital Charge Code	ERX222798
Hospital Revenue Code	636
Min. Negotiated Rate	$37.62
Max. Negotiated Rate	$54.72
Rate for Payer: Cash Price	$30.78
Rate for Payer: Cigna of CA HMO/PPO	$54.72
Rate for Payer: Health Smart Auto/Commercial	$41.04
Rate for Payer: LLUH Dept of Risk Management WC	$37.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.30

ERAVACYCLINE 50 MG INTRAVENOUS SOLUTION [222798]

Facility

$68.40

Service Code	CPT J0122
Hospital Charge Code	ERX222798
Hospital Revenue Code	636
Min. Negotiated Rate	$37.62
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$41.04
Rate for Payer: Aetna of CA Government/Medicare	$41.04
Rate for Payer: Cash Price	$30.78
Rate for Payer: Health Smart Auto/Commercial	$41.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$41.04
Rate for Payer: LLUH Dept of Risk Management WC	$37.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.30

Know your out-of-pocket cost for care.

All Charges