Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC XA INHIBITION LMW HEPARIN

Facility

$119.00

Service Code	CPT 85520
Hospital Charge Code	900910107
Hospital Revenue Code	305
Min. Negotiated Rate	$13.09
Max. Negotiated Rate	$95.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$71.40
Rate for Payer: Aetna of CA Government/Medicare	$71.40
Rate for Payer: Cash Price	$53.55
Rate for Payer: Cash Price	$53.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$95.20
Rate for Payer: Health Smart Auto/Commercial	$71.40
Rate for Payer: Intervalley Health Plan Commercial	$13.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$71.40
Rate for Payer: LLUH Dept of Risk Management WC	$65.45
Rate for Payer: Multiplan Commercial	$89.25

HC XA INHIBITION LMW HEPARIN

Facility

$123.00

Service Code	CPT 85520
Hospital Charge Code	900910107
Hospital Revenue Code	305
Min. Negotiated Rate	$67.65
Max. Negotiated Rate	$98.40
Rate for Payer: Cash Price	$55.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$98.40
Rate for Payer: Health Smart Auto/Commercial	$73.80
Rate for Payer: LLUH Dept of Risk Management WC	$67.65
Rate for Payer: Multiplan Commercial	$92.25

HC XRAY FEMUR 1 VIEW

Facility

$523.00

Service Code	CPT 73551
Hospital Charge Code	909073551
Hospital Revenue Code	320
Min. Negotiated Rate	$287.65
Max. Negotiated Rate	$418.40
Rate for Payer: Cash Price	$235.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$418.40
Rate for Payer: Health Smart Auto/Commercial	$313.80
Rate for Payer: LLUH Dept of Risk Management WC	$287.65
Rate for Payer: Multiplan Commercial	$392.25

HC XRAY FEMUR 1 VIEW

Facility

$523.00

Service Code	CPT 73551
Hospital Charge Code	909073551
Hospital Revenue Code	320
Min. Negotiated Rate	$287.65
Max. Negotiated Rate	$418.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$313.80
Rate for Payer: Aetna of CA Government/Medicare	$313.80
Rate for Payer: Cash Price	$235.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$418.40
Rate for Payer: Health Smart Auto/Commercial	$313.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$313.80
Rate for Payer: LLUH Dept of Risk Management WC	$287.65
Rate for Payer: Multiplan Commercial	$392.25

HC XRAY FEMUR MIN 2 VIEWS

Facility

$655.00

Service Code	CPT 73552
Hospital Charge Code	909073552
Hospital Revenue Code	320
Min. Negotiated Rate	$360.25
Max. Negotiated Rate	$524.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$393.00
Rate for Payer: Aetna of CA Government/Medicare	$393.00
Rate for Payer: Cash Price	$294.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$524.00
Rate for Payer: Health Smart Auto/Commercial	$393.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$393.00
Rate for Payer: LLUH Dept of Risk Management WC	$360.25
Rate for Payer: Multiplan Commercial	$491.25

HC XRAY FEMUR MIN 2 VIEWS

Facility

$655.00

Service Code	CPT 73552
Hospital Charge Code	909073552
Hospital Revenue Code	320
Min. Negotiated Rate	$360.25
Max. Negotiated Rate	$524.00
Rate for Payer: Cash Price	$294.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$524.00
Rate for Payer: Health Smart Auto/Commercial	$393.00
Rate for Payer: LLUH Dept of Risk Management WC	$360.25
Rate for Payer: Multiplan Commercial	$491.25

HC XRAY HIP W/PELVIS BI 2 VIEWS

Facility

$1,296.00

Service Code	CPT 73521
Hospital Charge Code	909073521
Hospital Revenue Code	320
Min. Negotiated Rate	$712.80
Max. Negotiated Rate	$1,036.80
Rate for Payer: Cash Price	$583.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,036.80
Rate for Payer: Health Smart Auto/Commercial	$777.60
Rate for Payer: LLUH Dept of Risk Management WC	$712.80
Rate for Payer: Multiplan Commercial	$972.00

HC XRAY HIP W/PELVIS BI 2 VIEWS

Facility

$1,296.00

Service Code	CPT 73521
Hospital Charge Code	909073521
Hospital Revenue Code	320
Min. Negotiated Rate	$712.80
Max. Negotiated Rate	$1,036.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$777.60
Rate for Payer: Aetna of CA Government/Medicare	$777.60
Rate for Payer: Cash Price	$583.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,036.80
Rate for Payer: Health Smart Auto/Commercial	$777.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$777.60
Rate for Payer: LLUH Dept of Risk Management WC	$712.80
Rate for Payer: Multiplan Commercial	$972.00

HC XRAY HIP W/PELVIS BI 3-4 VIEWS

Facility

$1,446.00

Service Code	CPT 73522
Hospital Charge Code	909073522
Hospital Revenue Code	320
Min. Negotiated Rate	$795.30
Max. Negotiated Rate	$1,156.80
Rate for Payer: Cash Price	$650.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,156.80
Rate for Payer: Health Smart Auto/Commercial	$867.60
Rate for Payer: LLUH Dept of Risk Management WC	$795.30
Rate for Payer: Multiplan Commercial	$1,084.50

HC XRAY HIP W/PELVIS BI 3-4 VIEWS

Facility

$1,446.00

Service Code	CPT 73522
Hospital Charge Code	909073522
Hospital Revenue Code	320
Min. Negotiated Rate	$795.30
Max. Negotiated Rate	$1,156.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$867.60
Rate for Payer: Aetna of CA Government/Medicare	$867.60
Rate for Payer: Cash Price	$650.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,156.80
Rate for Payer: Health Smart Auto/Commercial	$867.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$867.60
Rate for Payer: LLUH Dept of Risk Management WC	$795.30
Rate for Payer: Multiplan Commercial	$1,084.50

HC XRAY HIP W/PELVIS BI 5/GT VIEWS

Facility

$1,519.00

Service Code	CPT 73523
Hospital Charge Code	909073523
Hospital Revenue Code	320
Min. Negotiated Rate	$835.45
Max. Negotiated Rate	$1,215.20
Rate for Payer: Cash Price	$683.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,215.20
Rate for Payer: Health Smart Auto/Commercial	$911.40
Rate for Payer: LLUH Dept of Risk Management WC	$835.45
Rate for Payer: Multiplan Commercial	$1,139.25

HC XRAY HIP W/PELVIS BI 5/GT VIEWS

Facility

$1,519.00

Service Code	CPT 73523
Hospital Charge Code	909073523
Hospital Revenue Code	320
Min. Negotiated Rate	$835.45
Max. Negotiated Rate	$1,215.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$911.40
Rate for Payer: Aetna of CA Government/Medicare	$911.40
Rate for Payer: Cash Price	$683.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,215.20
Rate for Payer: Health Smart Auto/Commercial	$911.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$911.40
Rate for Payer: LLUH Dept of Risk Management WC	$835.45
Rate for Payer: Multiplan Commercial	$1,139.25

HC XRAY HIP W/PELVIS UNI 1 VIEW

Facility

$796.00

Service Code	CPT 73501
Hospital Charge Code	909073501
Hospital Revenue Code	320
Min. Negotiated Rate	$437.80
Max. Negotiated Rate	$636.80
Rate for Payer: Cash Price	$358.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$636.80
Rate for Payer: Health Smart Auto/Commercial	$477.60
Rate for Payer: LLUH Dept of Risk Management WC	$437.80
Rate for Payer: Multiplan Commercial	$597.00

HC XRAY HIP W/PELVIS UNI 1 VIEW

Facility

$796.00

Service Code	CPT 73501
Hospital Charge Code	909073501
Hospital Revenue Code	320
Min. Negotiated Rate	$437.80
Max. Negotiated Rate	$636.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$477.60
Rate for Payer: Aetna of CA Government/Medicare	$477.60
Rate for Payer: Cash Price	$358.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$636.80
Rate for Payer: Health Smart Auto/Commercial	$477.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$477.60
Rate for Payer: LLUH Dept of Risk Management WC	$437.80
Rate for Payer: Multiplan Commercial	$597.00

HC XRAY HIP W/PELVIS UNI 2-3 VIEW

Facility

$1,106.00

Service Code	CPT 73502
Hospital Charge Code	909073502
Hospital Revenue Code	320
Min. Negotiated Rate	$608.30
Max. Negotiated Rate	$884.80
Rate for Payer: Cash Price	$497.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$884.80
Rate for Payer: Health Smart Auto/Commercial	$663.60
Rate for Payer: LLUH Dept of Risk Management WC	$608.30
Rate for Payer: Multiplan Commercial	$829.50

HC XRAY HIP W/PELVIS UNI 2-3 VIEW

Facility

$1,106.00

Service Code	CPT 73502
Hospital Charge Code	909073502
Hospital Revenue Code	320
Min. Negotiated Rate	$608.30
Max. Negotiated Rate	$884.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$663.60
Rate for Payer: Aetna of CA Government/Medicare	$663.60
Rate for Payer: Cash Price	$497.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$884.80
Rate for Payer: Health Smart Auto/Commercial	$663.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$663.60
Rate for Payer: LLUH Dept of Risk Management WC	$608.30
Rate for Payer: Multiplan Commercial	$829.50

HC XRAY HIP W/PELVIS UNI 4 GT VIEWS

Facility

$1,365.00

Service Code	CPT 73503
Hospital Charge Code	909073503
Hospital Revenue Code	320
Min. Negotiated Rate	$750.75
Max. Negotiated Rate	$1,092.00
Rate for Payer: Cash Price	$614.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,092.00
Rate for Payer: Health Smart Auto/Commercial	$819.00
Rate for Payer: LLUH Dept of Risk Management WC	$750.75
Rate for Payer: Multiplan Commercial	$1,023.75

HC XRAY HIP W/PELVIS UNI 4 GT VIEWS

Facility

$1,365.00

Service Code	CPT 73503
Hospital Charge Code	909073503
Hospital Revenue Code	320
Min. Negotiated Rate	$750.75
Max. Negotiated Rate	$1,092.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$819.00
Rate for Payer: Aetna of CA Government/Medicare	$819.00
Rate for Payer: Cash Price	$614.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,092.00
Rate for Payer: Health Smart Auto/Commercial	$819.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$819.00
Rate for Payer: LLUH Dept of Risk Management WC	$750.75
Rate for Payer: Multiplan Commercial	$1,023.75

HC XYLOSE TOLERANCE BLD

Facility

$55.00

Service Code	CPT 84620
Hospital Charge Code	900910321
Hospital Revenue Code	301
Min. Negotiated Rate	$12.91
Max. Negotiated Rate	$44.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.00
Rate for Payer: Aetna of CA Government/Medicare	$33.00
Rate for Payer: Cash Price	$24.75
Rate for Payer: Cash Price	$24.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.00
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: Intervalley Health Plan Commercial	$12.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Commercial	$41.25

HC XYLOSE TOLERANCE BLD

Facility

$235.00

Service Code	CPT 84620
Hospital Charge Code	900910321
Hospital Revenue Code	301
Min. Negotiated Rate	$129.25
Max. Negotiated Rate	$188.00
Rate for Payer: Cash Price	$105.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$188.00
Rate for Payer: Health Smart Auto/Commercial	$141.00
Rate for Payer: LLUH Dept of Risk Management WC	$129.25
Rate for Payer: Multiplan Commercial	$176.25

HEPARIN 1000 UNIT/ML INJECTION SOLUTION. [408117968]

Facility

$6.24

Service Code	HCPCS J1644
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.43
Max. Negotiated Rate	$4.99
Rate for Payer: Cash Price	$3.43
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cash Price	$1.22
Rate for Payer: Cash Price	$1.89
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cash Price	$1.58
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.75
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Health Smart Auto/Commercial	$1.73
Rate for Payer: Health Smart Auto/Commercial	$2.06
Rate for Payer: Health Smart Auto/Commercial	$3.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$1.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$3.43
Rate for Payer: LLUH Dept of Risk Management WC	$1.89
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.20
Rate for Payer: Multiplan Commercial	$0.31
Rate for Payer: Multiplan Commercial	$1.67
Rate for Payer: Multiplan Commercial	$0.23
Rate for Payer: Multiplan Commercial	$0.32
Rate for Payer: Multiplan Commercial	$4.68
Rate for Payer: Multiplan Commercial	$2.58
Rate for Payer: Multiplan Commercial	$2.16
Rate for Payer: Multiplan Commercial	$0.21

HEPARIN 1000 UNIT/ML INJECTION SOLUTION. [408117968]

Facility

$6.24

Service Code	HCPCS J1644
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.43
Max. Negotiated Rate	$4.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.73
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$1.73
Rate for Payer: Aetna of CA Government/Medicare	$1.34
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$3.74
Rate for Payer: Aetna of CA Government/Medicare	$2.06
Rate for Payer: Cash Price	$1.22
Rate for Payer: Cash Price	$1.89
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cash Price	$1.58
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cash Price	$3.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Health Smart Auto/Commercial	$1.73
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Health Smart Auto/Commercial	$2.06
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Health Smart Auto/Commercial	$3.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: LLUH Dept of Risk Management WC	$3.43
Rate for Payer: LLUH Dept of Risk Management WC	$1.89
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$2.16
Rate for Payer: Multiplan Commercial	$2.58
Rate for Payer: Multiplan Commercial	$4.68
Rate for Payer: Multiplan Commercial	$0.23
Rate for Payer: Multiplan Commercial	$0.20
Rate for Payer: Multiplan Commercial	$0.32
Rate for Payer: Multiplan Commercial	$0.21
Rate for Payer: Multiplan Commercial	$0.31
Rate for Payer: Multiplan Commercial	$1.67

HEPARIN FOR NICU TPN [4080765]

Facility

$3.37

Service Code	HCPCS J1642
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$2.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.02
Rate for Payer: Aetna of CA Government/Medicare	$2.02
Rate for Payer: Cash Price	$1.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.70
Rate for Payer: Health Smart Auto/Commercial	$2.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.02
Rate for Payer: LLUH Dept of Risk Management WC	$1.85
Rate for Payer: Multiplan Commercial	$2.53

HEPARIN FOR NICU TPN [4080765]

Facility

$3.37

Service Code	HCPCS J1642
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$2.70
Rate for Payer: Cash Price	$1.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.70
Rate for Payer: Health Smart Auto/Commercial	$2.02
Rate for Payer: LLUH Dept of Risk Management WC	$1.85
Rate for Payer: Multiplan Commercial	$2.53

HEPARIN FOR_TPN 1000 UNITS/ML [4080751]

Facility

$2.23

Service Code	HCPCS J1644
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$1.34
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cash Price	$1.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Commercial	$1.67
Rate for Payer: Multiplan Commercial	$0.31

Know your out-of-pocket cost for care.

All Charges