Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

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

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 500 UNIT-1,200 UNIT INTRAVENOUS SOLUTION [70405]

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

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

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

Facility

$2.42

Service Code	HCPCS J7192
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$1.81

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

Facility

$2.42

Service Code	HCPCS J7192
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$1.94
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	$1.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.94
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 Commercial	$1.81

ANTIHEMOPHILIC FVIII,FULL LENGTH(ALB-FREE) 2,000(+/-)UNIT IV SOLUTION (ADVATE) [408078225]

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 FVIII,FULL LENGTH(ALB-FREE) 2,000(+/-)UNIT IV SOLUTION (ADVATE) [408078225]

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 FVIII,FULL LENGTH(ALB-FREE) 2,000(+/-)UNIT IV SOLUTION (KOGENATE FS) [408378225]

Facility

$2.42

Service Code	HCPCS J7192
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$1.94
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	$1.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.94
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 Commercial	$1.81

ANTIHEMOPHILIC FVIII,FULL LENGTH(ALB-FREE) 2,000(+/-)UNIT IV SOLUTION (KOGENATE FS) [408378225]

Facility

$2.42

Service Code	HCPCS J7192
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$1.81

ANTIHEMOPHILIC FVIII,FULL LENGTH (ALB-FREE) 250 (+/-)UNIT IV SOLUTION (ADVATE) [408076365]

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 FVIII,FULL LENGTH (ALB-FREE) 250 (+/-)UNIT IV SOLUTION (ADVATE) [408076365]

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 FVIII,FULL LENGTH(ALB-FREE) 3,000(+/-) UNIT IV SOLUTION (ADVATE) [408099576]

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 FVIII,FULL LENGTH(ALB-FREE) 3,000(+/-) UNIT IV SOLUTION (ADVATE) [408099576]

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 FVIII,FULL LENGTH (ALB-FREE) 500 (+/-) UNIT IV SOLUTION (ADVATE) [408076366]

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 FVIII,FULL LENGTH (ALB-FREE) 500 (+/-) UNIT IV SOLUTION (ADVATE) [408076366]

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

ANTI-INHIBITOR COAGULANT COMPLEX 700 UNIT-1,300 UNIT INTRAVENOUS SOLN [225933]

Facility

$3.24

Service Code	HCPCS J7198
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.59
Rate for Payer: Cash Price	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.59
Rate for Payer: Health Smart Auto/Commercial	$1.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.78
Rate for Payer: Multiplan Commercial	$2.43

ANTI-INHIBITOR COAGULANT COMPLEX 700 UNIT-1,300 UNIT INTRAVENOUS SOLN [225933]

Facility

$3.24

Service Code	HCPCS J7198
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.94
Rate for Payer: Aetna of CA Government/Medicare	$1.94
Rate for Payer: Cash Price	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.59
Rate for Payer: Health Smart Auto/Commercial	$1.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.78
Rate for Payer: Multiplan Commercial	$2.43

ANTI-INHIBITOR COAGULANT COMPLX 1,750 UNIT-3,250 UNIT INTRAVENOUS SOLN [117944]

Facility

$3.24

Service Code	HCPCS J7198
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.94
Rate for Payer: Aetna of CA Government/Medicare	$1.94
Rate for Payer: Cash Price	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.59
Rate for Payer: Health Smart Auto/Commercial	$1.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.78
Rate for Payer: Multiplan Commercial	$2.43

ANTI-INHIBITOR COAGULANT COMPLX 1,750 UNIT-3,250 UNIT INTRAVENOUS SOLN [117944]

Facility

$3.24

Service Code	HCPCS J7198
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.59
Rate for Payer: Cash Price	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.59
Rate for Payer: Health Smart Auto/Commercial	$1.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.78
Rate for Payer: Multiplan Commercial	$2.43

ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION [9116]

Facility

$5.35

Service Code	HCPCS J7197
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$4.28
Rate for Payer: Cash Price	$2.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.28
Rate for Payer: Health Smart Auto/Commercial	$3.21
Rate for Payer: LLUH Dept of Risk Management WC	$2.94
Rate for Payer: Multiplan Commercial	$4.01

ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION [9116]

Facility

$5.35

Service Code	HCPCS J7197
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$4.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.21
Rate for Payer: Aetna of CA Government/Medicare	$3.21
Rate for Payer: Cash Price	$2.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.28
Rate for Payer: Health Smart Auto/Commercial	$3.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.21
Rate for Payer: LLUH Dept of Risk Management WC	$2.94
Rate for Payer: Multiplan Commercial	$4.01

APIXABAN 2.5 MG TABLET [199666]

Facility

$12.13

Service Code	NDC 0003-0893-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.67
Max. Negotiated Rate	$9.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.28
Rate for Payer: Aetna of CA Government/Medicare	$7.28
Rate for Payer: Cash Price	$6.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.70
Rate for Payer: Health Smart Auto/Commercial	$7.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.28
Rate for Payer: LLUH Dept of Risk Management WC	$6.67
Rate for Payer: Multiplan Commercial	$9.10

APIXABAN 2.5 MG TABLET [199666]

Facility

$12.13

Service Code	NDC 0003-0893-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.67
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.70
Rate for Payer: Health Smart Auto/Commercial	$7.28
Rate for Payer: LLUH Dept of Risk Management WC	$6.67
Rate for Payer: Multiplan Commercial	$9.10

Know your out-of-pocket cost for care.

All Charges