Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ANTICOAG CITRATE/DEXTROSE CPD UNIT 450 ML [4081055]

Facility

$55.87

Service Code	NDC 9994-0810-55
Hospital Charge Code	1771241
Hospital Revenue Code	272
Min. Negotiated Rate	$30.73
Max. Negotiated Rate	$41.90
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	$25.14
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 Beech St/Commercial/PHCS	$41.90

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

Facility

$2.21

Service Code	CPT J7192
Hospital Charge Code	ERX76368
Hospital Revenue Code	636
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$1.77
Rate for Payer: Cash Price	$0.99
Rate for Payer: Cigna of CA HMO/PPO	$1.77
Rate for Payer: Health Smart Auto/Commercial	$1.33
Rate for Payer: LLUH Dept of Risk Management WC	$1.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.66

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

Facility

$2.21

Service Code	CPT J7192
Hospital Charge Code	ERX76368
Hospital Revenue Code	636
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$1.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.33
Rate for Payer: Aetna of CA Government/Medicare	$1.33
Rate for Payer: Cash Price	$0.99
Rate for Payer: Health Smart Auto/Commercial	$1.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.33
Rate for Payer: LLUH Dept of Risk Management WC	$1.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.66

ANTIHEMOPHILIC FACTOR-VWF 1,000 (400 VWF) UNIT/10 ML INTRAVENOUS SOLN [88337]

Facility

$1.52

Service Code	CPT J7186
Hospital Charge Code	ERX88337
Hospital Revenue Code	636
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.91
Rate for Payer: Aetna of CA Government/Medicare	$0.91
Rate for Payer: Cash Price	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

ANTIHEMOPHILIC FACTOR-VWF 1,000 (400 VWF) UNIT/10 ML INTRAVENOUS SOLN [88337]

Facility

$1.52

Service Code	CPT J7186
Hospital Charge Code	ERX88337
Hospital Revenue Code	636
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.22
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA HMO/PPO	$1.22
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

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

Facility

$1.78

Service Code	CPT J7187
Hospital Charge Code	ERX70406
Hospital Revenue Code	636
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.42
Rate for Payer: Cash Price	$0.80
Rate for Payer: Cigna of CA HMO/PPO	$1.42
Rate for Payer: Health Smart Auto/Commercial	$1.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.34

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

Facility

$1.78

Service Code	CPT J7187
Hospital Charge Code	ERX70406
Hospital Revenue Code	636
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.07
Rate for Payer: Aetna of CA Government/Medicare	$1.07
Rate for Payer: Cash Price	$0.80
Rate for Payer: Health Smart Auto/Commercial	$1.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.34

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

Facility

$2.00

Service Code	CPT J7183
Hospital Charge Code	ERX214027
Hospital Revenue Code	636
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.20
Rate for Payer: Aetna of CA Government/Medicare	$1.20
Rate for Payer: Cash Price	$0.90
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.50

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

Facility

$2.00

Service Code	CPT J7183
Hospital Charge Code	ERX214027
Hospital Revenue Code	636
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.60
Rate for Payer: Cash Price	$0.90
Rate for Payer: Cigna of CA HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.50

ANTIHEMOPHILIC FACTOR-VWF 1,500 (600 VWF) UNIT/10 ML INTRAVENOUS SOLN [88338]

Facility

$1.52

Service Code	CPT J7186
Hospital Charge Code	ERX88338
Hospital Revenue Code	636
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.22
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA HMO/PPO	$1.22
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

ANTIHEMOPHILIC FACTOR-VWF 1,500 (600 VWF) UNIT/10 ML INTRAVENOUS SOLN [88338]

Facility

$1.52

Service Code	CPT J7186
Hospital Charge Code	ERX88338
Hospital Revenue Code	636
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.91
Rate for Payer: Aetna of CA Government/Medicare	$0.91
Rate for Payer: Cash Price	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

ANTIHEMOPHILIC FACTOR-VWF 2,000 (800 VWF) UNIT/10 ML INTRAVENOUS SOLN [207372]

Facility

$1.52

Service Code	CPT J7186
Hospital Charge Code	ERX207372
Hospital Revenue Code	636
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.22
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA HMO/PPO	$1.22
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

ANTIHEMOPHILIC FACTOR-VWF 2,000 (800 VWF) UNIT/10 ML INTRAVENOUS SOLN [207372]

Facility

$1.52

Service Code	CPT J7186
Hospital Charge Code	ERX207372
Hospital Revenue Code	636
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.91
Rate for Payer: Aetna of CA Government/Medicare	$0.91
Rate for Payer: Cash Price	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

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

Facility

$1.78

Service Code	CPT J7187
Hospital Charge Code	1720668
Hospital Revenue Code	636
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.42
Rate for Payer: Cash Price	$0.80
Rate for Payer: Cigna of CA HMO/PPO	$1.42
Rate for Payer: Health Smart Auto/Commercial	$1.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.34

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

Facility

$1.78

Service Code	CPT J7187
Hospital Charge Code	1720668
Hospital Revenue Code	636
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.07
Rate for Payer: Aetna of CA Government/Medicare	$1.07
Rate for Payer: Cash Price	$0.80
Rate for Payer: Health Smart Auto/Commercial	$1.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.34

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

Facility

$1.61

Service Code	CPT J7186
Hospital Charge Code	ERX88336
Hospital Revenue Code	636
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.29
Rate for Payer: Cash Price	$0.72
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA HMO/PPO	$1.22
Rate for Payer: Cigna of CA HMO/PPO	$1.29
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: Health Smart Auto/Commercial	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: LLUH Dept of Risk Management WC	$0.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14

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

Facility

$1.52

Service Code	CPT J7186
Hospital Charge Code	ERX88336
Hospital Revenue Code	636
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.97
Rate for Payer: Aetna of CA Government/Medicare	$0.91
Rate for Payer: Aetna of CA Government/Medicare	$0.97
Rate for Payer: Cash Price	$0.72
Rate for Payer: Cash Price	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.97
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: LLUH Dept of Risk Management WC	$0.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.21

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

Facility

$2.00

Service Code	CPT J7183
Hospital Charge Code	ERX214026
Hospital Revenue Code	636
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.60
Rate for Payer: Cash Price	$0.90
Rate for Payer: Cigna of CA HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.50

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

Facility

$2.00

Service Code	CPT J7183
Hospital Charge Code	ERX214026
Hospital Revenue Code	636
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.20
Rate for Payer: Aetna of CA Government/Medicare	$1.20
Rate for Payer: Cash Price	$0.90
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.50

ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION [70405]

Facility

$1.78

Service Code	CPT J7187
Hospital Charge Code	ERX70405
Hospital Revenue Code	636
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.42
Rate for Payer: Cash Price	$0.80
Rate for Payer: Cigna of CA HMO/PPO	$1.42
Rate for Payer: Health Smart Auto/Commercial	$1.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.34

ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION [70405]

Facility

$1.78

Service Code	CPT J7187
Hospital Charge Code	ERX70405
Hospital Revenue Code	636
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.07
Rate for Payer: Aetna of CA Government/Medicare	$1.07
Rate for Payer: Cash Price	$0.80
Rate for Payer: Health Smart Auto/Commercial	$1.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.34

ANTIHEMOPHILIC FVIII,FULL LENGTH(ALB-FREE) 1,000(+/-) UNIT IV SOLUTION (ADVATE) [408076367]

Facility

$2.21

Service Code	CPT J7192
Hospital Charge Code	ERX408076367
Hospital Revenue Code	636
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$1.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.33
Rate for Payer: Aetna of CA Government/Medicare	$1.33
Rate for Payer: Cash Price	$0.99
Rate for Payer: Health Smart Auto/Commercial	$1.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.33
Rate for Payer: LLUH Dept of Risk Management WC	$1.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.66

ANTIHEMOPHILIC FVIII,FULL LENGTH(ALB-FREE) 1,000(+/-) UNIT IV SOLUTION (ADVATE) [408076367]

Facility

$2.21

Service Code	CPT J7192
Hospital Charge Code	ERX408076367
Hospital Revenue Code	636
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$1.77
Rate for Payer: Cash Price	$0.99
Rate for Payer: Cigna of CA HMO/PPO	$1.77
Rate for Payer: Health Smart Auto/Commercial	$1.33
Rate for Payer: LLUH Dept of Risk Management WC	$1.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.66

ANTIHEMOPHILIC FVIII,FULL LENGTH(ALB-FREE)1,000(+/-)UNIT IV SOLUTION (KOGENATE FS) [408376367]

Facility

$2.42

Service Code	CPT J7192
Hospital Charge Code	ERX408376367
Hospital Revenue Code	636
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$1.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.45
Rate for Payer: Aetna of CA Government/Medicare	$1.45
Rate for Payer: Cash Price	$1.09
Rate for Payer: Health Smart Auto/Commercial	$1.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.45
Rate for Payer: LLUH Dept of Risk Management WC	$1.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.82

ANTIHEMOPHILIC FVIII,FULL LENGTH(ALB-FREE)1,000(+/-)UNIT IV SOLUTION (KOGENATE FS) [408376367]

Facility

$2.42

Service Code	CPT J7192
Hospital Charge Code	ERX408376367
Hospital Revenue Code	636
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.09
Rate for Payer: Cigna of CA HMO/PPO	$1.94
Rate for Payer: Health Smart Auto/Commercial	$1.45
Rate for Payer: LLUH Dept of Risk Management WC	$1.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.82

Know your out-of-pocket cost for care.

All Charges