Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

Facility

$2.21

Service Code	CPT J7192
Hospital Charge Code	ERX408078225
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) 2,000(+/-)UNIT IV SOLUTION (ADVATE) [408078225]

Facility

$2.21

Service Code	CPT J7192
Hospital Charge Code	ERX408078225
Hospital Revenue Code	636
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$1.66
Rate for Payer: Cash Price	$0.99
Rate for Payer: Health Smart Auto/Commercial	$1.33
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: 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) 2,000(+/-)UNIT IV SOLUTION (KOGENATE FS) [408378225]

Facility

$2.42

Service Code	CPT J7192
Hospital Charge Code	ER408378225
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) 2,000(+/-)UNIT IV SOLUTION (KOGENATE FS) [408378225]

Facility

$2.42

Service Code	CPT J7192
Hospital Charge Code	ER408378225
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

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

Facility

$2.21

Service Code	CPT J7192
Hospital Charge Code	ERX408076365
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) 250 (+/-)UNIT IV SOLUTION (ADVATE) [408076365]

Facility

$2.21

Service Code	CPT J7192
Hospital Charge Code	ERX408076365
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) 3,000(+/-) UNIT IV SOLUTION (ADVATE) [408099576]

Facility

$2.21

Service Code	CPT J7192
Hospital Charge Code	ERX408099576
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) 3,000(+/-) UNIT IV SOLUTION (ADVATE) [408099576]

Facility

$2.21

Service Code	CPT J7192
Hospital Charge Code	ERX408099576
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) 500 (+/-) UNIT IV SOLUTION (ADVATE) [408076366]

Facility

$2.21

Service Code	CPT J7192
Hospital Charge Code	ERX408076366
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) 500 (+/-) UNIT IV SOLUTION (ADVATE) [408076366]

Facility

$2.21

Service Code	CPT J7192
Hospital Charge Code	ERX408076366
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

ANTI-INHIBITOR COAGULANT COMPLEX 350 UNIT-650 UNIT INTRAVENOUS SOLN [225932]

Facility

$2.70

Service Code	CPT J7198
Hospital Charge Code	ERX225932
Hospital Revenue Code	636
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$2.16
Rate for Payer: Cash Price	$1.22
Rate for Payer: Cigna of CA HMO/PPO	$2.16
Rate for Payer: Health Smart Auto/Commercial	$1.62
Rate for Payer: LLUH Dept of Risk Management WC	$1.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.02

ANTI-INHIBITOR COAGULANT COMPLEX 350 UNIT-650 UNIT INTRAVENOUS SOLN [225932]

Facility

$2.70

Service Code	CPT J7198
Hospital Charge Code	ERX225932
Hospital Revenue Code	636
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.62
Rate for Payer: Aetna of CA Government/Medicare	$1.62
Rate for Payer: Cash Price	$1.22
Rate for Payer: Health Smart Auto/Commercial	$1.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.62
Rate for Payer: LLUH Dept of Risk Management WC	$1.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.02

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

Facility

$3.05

Service Code	NDC 64193-424-02
Hospital Revenue Code	636
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.83
Rate for Payer: Aetna of CA Government/Medicare	$1.83
Rate for Payer: Cash Price	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.83
Rate for Payer: LLUH Dept of Risk Management WC	$1.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.29

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

Facility

$3.05

Service Code	NDC 64193-424-02
Hospital Revenue Code	636
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.44
Rate for Payer: Cash Price	$1.37
Rate for Payer: Cigna of CA HMO/PPO	$2.44
Rate for Payer: Health Smart Auto/Commercial	$1.83
Rate for Payer: LLUH Dept of Risk Management WC	$1.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.29

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

Facility

$3.05

Service Code	CPT J7198
Hospital Charge Code	ERX117944
Hospital Revenue Code	636
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.44
Rate for Payer: Cash Price	$1.37
Rate for Payer: Cigna of CA HMO/PPO	$2.44
Rate for Payer: Health Smart Auto/Commercial	$1.83
Rate for Payer: LLUH Dept of Risk Management WC	$1.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.29

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

Facility

$3.05

Service Code	CPT J7198
Hospital Charge Code	ERX117944
Hospital Revenue Code	636
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.83
Rate for Payer: Aetna of CA Government/Medicare	$1.83
Rate for Payer: Cash Price	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.83
Rate for Payer: LLUH Dept of Risk Management WC	$1.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.29

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

Facility

$5.04

Service Code	CPT J7197
Hospital Charge Code	1720745
Hospital Revenue Code	636
Min. Negotiated Rate	$2.77
Max. Negotiated Rate	$4.03
Rate for Payer: Cash Price	$2.27
Rate for Payer: Cigna of CA HMO/PPO	$4.03
Rate for Payer: Health Smart Auto/Commercial	$3.02
Rate for Payer: LLUH Dept of Risk Management WC	$2.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.78

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

Facility

$5.04

Service Code	CPT J7197
Hospital Charge Code	1720745
Hospital Revenue Code	636
Min. Negotiated Rate	$2.77
Max. Negotiated Rate	$3.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.02
Rate for Payer: Aetna of CA Government/Medicare	$3.02
Rate for Payer: Cash Price	$2.27
Rate for Payer: Health Smart Auto/Commercial	$3.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.02
Rate for Payer: LLUH Dept of Risk Management WC	$2.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.78

ANTI-THYMOCYTE GLOBULIN (RABBIT) 25 MG INTRAVENOUS SOLUTION [24585]

Facility

$1,224.89

Service Code	CPT J7511
Hospital Charge Code	1759922
Hospital Revenue Code	636
Min. Negotiated Rate	$673.69
Max. Negotiated Rate	$979.91
Rate for Payer: Cash Price	$551.20
Rate for Payer: Cigna of CA HMO/PPO	$979.91
Rate for Payer: Health Smart Auto/Commercial	$734.93
Rate for Payer: LLUH Dept of Risk Management WC	$673.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$918.67

ANTI-THYMOCYTE GLOBULIN (RABBIT) 25 MG INTRAVENOUS SOLUTION [24585]

Facility

$1,224.89

Service Code	CPT J7511
Hospital Charge Code	1759922
Hospital Revenue Code	636
Min. Negotiated Rate	$673.69
Max. Negotiated Rate	$918.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$734.93
Rate for Payer: Aetna of CA Government/Medicare	$734.93
Rate for Payer: Cash Price	$551.20
Rate for Payer: Health Smart Auto/Commercial	$734.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$734.93
Rate for Payer: LLUH Dept of Risk Management WC	$673.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$918.67

ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION [222871]

Facility

$1,584.00

Service Code	CPT J0841
Hospital Charge Code	ERX222871
Hospital Revenue Code	636
Min. Negotiated Rate	$871.20
Max. Negotiated Rate	$1,267.20
Rate for Payer: Cash Price	$712.80
Rate for Payer: Cigna of CA HMO/PPO	$1,267.20
Rate for Payer: Health Smart Auto/Commercial	$950.40
Rate for Payer: LLUH Dept of Risk Management WC	$871.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,188.00

ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION [222871]

Facility

$1,584.00

Service Code	CPT J0841
Hospital Charge Code	ERX222871
Hospital Revenue Code	636
Min. Negotiated Rate	$871.20
Max. Negotiated Rate	$1,188.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$950.40
Rate for Payer: Aetna of CA Government/Medicare	$950.40
Rate for Payer: Cash Price	$712.80
Rate for Payer: Health Smart Auto/Commercial	$950.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$950.40
Rate for Payer: LLUH Dept of Risk Management WC	$871.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,188.00

APIXABAN 2.5 MG TABLET [199666]

Facility

$11.22

Service Code	NDC 0003-0893-21
Hospital Charge Code	ERX199666
Hospital Revenue Code	259
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$8.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.73
Rate for Payer: Aetna of CA Government/Medicare	$6.73
Rate for Payer: Cash Price	$5.05
Rate for Payer: Health Smart Auto/Commercial	$6.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.73
Rate for Payer: LLUH Dept of Risk Management WC	$6.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.42

APIXABAN 2.5 MG TABLET [199666]

Facility

$11.22

Service Code	NDC 0003-0893-21
Hospital Charge Code	ERX199666
Hospital Revenue Code	259
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$8.98
Rate for Payer: Cash Price	$5.05
Rate for Payer: Cigna of CA HMO/PPO	$8.98
Rate for Payer: Health Smart Auto/Commercial	$6.73
Rate for Payer: LLUH Dept of Risk Management WC	$6.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.42

APIXABAN 5 MG TABLET [199782]

Facility

$11.22

Service Code	NDC 0003-0894-21
Hospital Charge Code	ERX199782
Hospital Revenue Code	259
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$8.98
Rate for Payer: Cash Price	$5.05
Rate for Payer: Cigna of CA HMO/PPO	$8.98
Rate for Payer: Health Smart Auto/Commercial	$6.73
Rate for Payer: LLUH Dept of Risk Management WC	$6.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.42

Know your out-of-pocket cost for care.

All Charges