Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

AMPICILLIN-SULBACTAM 3 G/100 ML IN NS [400006]

Facility

$86.08

Service Code	NDC 9940-8203-96
Min. Negotiated Rate	$47.34
Max. Negotiated Rate	$68.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.65
Rate for Payer: Aetna of CA Government/Medicare	$51.65
Rate for Payer: Cash Price	$47.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.86
Rate for Payer: Health Smart Auto/Commercial	$51.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.65
Rate for Payer: LLUH Dept of Risk Management WC	$47.34
Rate for Payer: Multiplan Commercial	$64.56

AMPICILLIN-SULBACTAM 3 G/100 ML IN NS [400006]

Facility

$86.08

Service Code	NDC 9940-8203-96
Min. Negotiated Rate	$47.34
Max. Negotiated Rate	$68.86
Rate for Payer: Cash Price	$47.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.86
Rate for Payer: Health Smart Auto/Commercial	$51.65
Rate for Payer: LLUH Dept of Risk Management WC	$47.34
Rate for Payer: Multiplan Commercial	$64.56

AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [32471]

Facility

$6.36

Service Code	HCPCS J0295
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.86
Rate for Payer: Aetna of CA Government/Medicare	$3.82
Rate for Payer: Aetna of CA Government/Medicare	$10.48
Rate for Payer: Aetna of CA Government/Medicare	$3.86
Rate for Payer: Cash Price	$3.53
Rate for Payer: Cash Price	$9.61
Rate for Payer: Cash Price	$3.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.14
Rate for Payer: Health Smart Auto/Commercial	$10.48
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: Health Smart Auto/Commercial	$3.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.48
Rate for Payer: LLUH Dept of Risk Management WC	$9.61
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: LLUH Dept of Risk Management WC	$3.54
Rate for Payer: Multiplan Commercial	$13.10
Rate for Payer: Multiplan Commercial	$4.77
Rate for Payer: Multiplan Commercial	$4.82

AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [32471]

Facility

$6.36

Service Code	HCPCS J0295
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.09
Rate for Payer: Cash Price	$3.50
Rate for Payer: Cash Price	$9.61
Rate for Payer: Cash Price	$3.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.09
Rate for Payer: Health Smart Auto/Commercial	$3.86
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: Health Smart Auto/Commercial	$10.48
Rate for Payer: LLUH Dept of Risk Management WC	$9.61
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: LLUH Dept of Risk Management WC	$3.54
Rate for Payer: Multiplan Commercial	$4.77
Rate for Payer: Multiplan Commercial	$13.10
Rate for Payer: Multiplan Commercial	$4.82

ANAGRELIDE 0.5 MG CAPSULE [20446]

Facility

$1.00

Service Code	NDC 13668-453-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.60
Rate for Payer: Aetna of CA Government/Medicare	$0.60
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

ANAGRELIDE 0.5 MG CAPSULE [20446]

Facility

$1.00

Service Code	NDC 13668-453-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

ANAKINRA 100 MG/0.67 ML SUBCUTANEOUS SYRINGE [31784]

Facility

$377.35

Service Code	HCPCS J3590
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$207.54
Max. Negotiated Rate	$301.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$226.41
Rate for Payer: Aetna of CA Government/Medicare	$226.41
Rate for Payer: Cash Price	$207.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$301.88
Rate for Payer: Health Smart Auto/Commercial	$226.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$226.41
Rate for Payer: LLUH Dept of Risk Management WC	$207.54
Rate for Payer: Multiplan Commercial	$283.01

ANAKINRA 100 MG/0.67 ML SUBCUTANEOUS SYRINGE [31784]

Facility

$377.35

Service Code	HCPCS J3590
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$207.54
Max. Negotiated Rate	$301.88
Rate for Payer: Cash Price	$207.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$301.88
Rate for Payer: Health Smart Auto/Commercial	$226.41
Rate for Payer: LLUH Dept of Risk Management WC	$207.54
Rate for Payer: Multiplan Commercial	$283.01

ANASTROZOLE 1 MG TABLET [16205]

Facility

$1.09

Service Code	HCPCS S0170
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cash Price	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Commercial	$0.82
Rate for Payer: Multiplan Commercial	$0.27

ANASTROZOLE 1 MG TABLET [16205]

Facility

$0.36

Service Code	HCPCS S0170
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cash Price	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Commercial	$0.27
Rate for Payer: Multiplan Commercial	$0.82

ANIDULAFUNGIN 100 MG INTRAVENOUS SOLUTION [88093]

Facility

$229.07

Service Code	HCPCS J0348
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$125.99
Max. Negotiated Rate	$183.26
Rate for Payer: Cash Price	$125.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$183.26
Rate for Payer: Health Smart Auto/Commercial	$137.44
Rate for Payer: LLUH Dept of Risk Management WC	$125.99
Rate for Payer: Multiplan Commercial	$171.80

ANIDULAFUNGIN 100 MG INTRAVENOUS SOLUTION [88093]

Facility

$229.07

Service Code	HCPCS J0348
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$125.99
Max. Negotiated Rate	$183.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$137.44
Rate for Payer: Aetna of CA Government/Medicare	$137.44
Rate for Payer: Cash Price	$125.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$183.26
Rate for Payer: Health Smart Auto/Commercial	$137.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$137.44
Rate for Payer: LLUH Dept of Risk Management WC	$125.99
Rate for Payer: Multiplan Commercial	$171.80

ANTICOAG CITRATE/DEXTROSE CPD UNIT 450 ML [4081055]

Facility

$55.87

Service Code	NDC 9994-0810-55
Hospital Charge Code	901700017
Hospital Revenue Code	272
Min. Negotiated Rate	$30.73
Max. Negotiated Rate	$44.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.52
Rate for Payer: Aetna of CA Government/Medicare	$33.52
Rate for Payer: Cash Price	$30.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.70
Rate for Payer: Health Smart Auto/Commercial	$33.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.52
Rate for Payer: LLUH Dept of Risk Management WC	$30.73
Rate for Payer: Multiplan Commercial	$41.90

ANTICOAG CITRATE/DEXTROSE CPD UNIT 450 ML [4081055]

Facility

$55.87

Service Code	NDC 9994-0810-55
Hospital Charge Code	901700017
Hospital Revenue Code	272
Min. Negotiated Rate	$30.73
Max. Negotiated Rate	$44.70
Rate for Payer: Cash Price	$30.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.70
Rate for Payer: Health Smart Auto/Commercial	$33.52
Rate for Payer: LLUH Dept of Risk Management WC	$30.73
Rate for Payer: Multiplan Commercial	$41.90

ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,500 (+/-) UNIT IV SOLUTION [76368]

Facility

$2.35

Service Code	HCPCS J7192
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.88
Rate for Payer: Cash Price	$1.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.88
Rate for Payer: Health Smart Auto/Commercial	$1.41
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Commercial	$1.76

ANTIHEMOPHILIC FACTOR VIII, FULL LENGTH 1,500 (+/-) UNIT IV SOLUTION [76368]

Facility

$2.35

Service Code	HCPCS J7192
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.41
Rate for Payer: Aetna of CA Government/Medicare	$1.41
Rate for Payer: Cash Price	$1.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.88
Rate for Payer: Health Smart Auto/Commercial	$1.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.41
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Commercial	$1.76

ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION [70406]

Facility

$1.98

Service Code	HCPCS J7187
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.19
Rate for Payer: Aetna of CA Government/Medicare	$1.19
Rate for Payer: Cash Price	$1.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.58
Rate for Payer: Health Smart Auto/Commercial	$1.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.19
Rate for Payer: LLUH Dept of Risk Management WC	$1.09
Rate for Payer: Multiplan Commercial	$1.49

ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT INTRAVENOUS SOLUTION [70406]

Facility

$1.98

Service Code	HCPCS J7187
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.58
Rate for Payer: Cash Price	$1.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.58
Rate for Payer: Health Smart Auto/Commercial	$1.19
Rate for Payer: LLUH Dept of Risk Management WC	$1.09
Rate for Payer: Multiplan Commercial	$1.49

ANTIHEMOPHILIC FACTOR-VWF 1,000(VWF 1,000) UNIT/10 ML INTRAVENOUS SOLN [214027]

Facility

$2.10

Service Code	HCPCS J7183
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.26
Rate for Payer: Aetna of CA Government/Medicare	$1.26
Rate for Payer: Cash Price	$1.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.68
Rate for Payer: Health Smart Auto/Commercial	$1.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.26
Rate for Payer: LLUH Dept of Risk Management WC	$1.16
Rate for Payer: Multiplan Commercial	$1.57

ANTIHEMOPHILIC FACTOR-VWF 1,000(VWF 1,000) UNIT/10 ML INTRAVENOUS SOLN [214027]

Facility

$2.10

Service Code	HCPCS J7183
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.68
Rate for Payer: Cash Price	$1.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.68
Rate for Payer: Health Smart Auto/Commercial	$1.26
Rate for Payer: LLUH Dept of Risk Management WC	$1.16
Rate for Payer: Multiplan Commercial	$1.57

ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION [70404]

Facility

$1.98

Service Code	HCPCS J7187
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.58
Rate for Payer: Cash Price	$1.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.58
Rate for Payer: Health Smart Auto/Commercial	$1.19
Rate for Payer: LLUH Dept of Risk Management WC	$1.09
Rate for Payer: Multiplan Commercial	$1.49

ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT INTRAVENOUS SOLUTION [70404]

Facility

$1.98

Service Code	HCPCS J7187
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.19
Rate for Payer: Aetna of CA Government/Medicare	$1.19
Rate for Payer: Cash Price	$1.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.58
Rate for Payer: Health Smart Auto/Commercial	$1.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.19
Rate for Payer: LLUH Dept of Risk Management WC	$1.09
Rate for Payer: Multiplan Commercial	$1.49

ANTIHEMOPHILIC FACTOR-VWF 500 (200 VWF) UNIT/5 ML INTRAVENOUS SOLUTION [88336]

Facility

$1.66

Service Code	HCPCS J7186
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.33
Rate for Payer: Cash Price	$0.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.33
Rate for Payer: Health Smart Auto/Commercial	$1.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.91
Rate for Payer: Multiplan Commercial	$1.25

ANTIHEMOPHILIC FACTOR-VWF 500 (200 VWF) UNIT/5 ML INTRAVENOUS SOLUTION [88336]

Facility

$1.66

Service Code	HCPCS J7186
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.00
Rate for Payer: Aetna of CA Government/Medicare	$1.00
Rate for Payer: Cash Price	$0.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.33
Rate for Payer: Health Smart Auto/Commercial	$1.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.91
Rate for Payer: Multiplan Commercial	$1.25

ANTIHEMOPHILIC FACTOR-VWF 500 (500 VWF) UNIT/5 ML INTRAVENOUS SOLUTION [214026]

Facility

$2.10

Service Code	HCPCS J7183
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.68
Rate for Payer: Cash Price	$1.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.68
Rate for Payer: Health Smart Auto/Commercial	$1.26
Rate for Payer: LLUH Dept of Risk Management WC	$1.16
Rate for Payer: Multiplan Commercial	$1.57

Know your out-of-pocket cost for care.

All Charges