Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML INJECTION SYRINGE [117969]

Facility

$7.96

Service Code	CPT J1644
Hospital Charge Code	1720049
Hospital Revenue Code	636
Min. Negotiated Rate	$4.38
Max. Negotiated Rate	$5.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.78
Rate for Payer: Aetna of CA Government/Medicare	$4.78
Rate for Payer: Cash Price	$3.58
Rate for Payer: Health Smart Auto/Commercial	$4.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.78
Rate for Payer: LLUH Dept of Risk Management WC	$4.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.97

HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML SUBCUTANEOUS SYRINGE [224551]

Facility

$14.40

Service Code	CPT J1644
Hospital Charge Code	NDG224551
Hospital Revenue Code	636
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$10.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.64
Rate for Payer: Aetna of CA Government/Medicare	$8.64
Rate for Payer: Cash Price	$6.48
Rate for Payer: Health Smart Auto/Commercial	$8.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.64
Rate for Payer: LLUH Dept of Risk Management WC	$7.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.80

HEPARIN, PORCINE (PF) 5,000 UNIT/0.5 ML SUBCUTANEOUS SYRINGE [224551]

Facility

$14.40

Service Code	CPT J1644
Hospital Charge Code	NDG224551
Hospital Revenue Code	636
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$11.52
Rate for Payer: Cash Price	$6.48
Rate for Payer: Cigna of CA HMO/PPO	$11.52
Rate for Payer: Health Smart Auto/Commercial	$8.64
Rate for Payer: LLUH Dept of Risk Management WC	$7.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.80

HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE [118915]

Facility

$143.88

Service Code	CPT 90636
Hospital Charge Code	NDG118915
Hospital Revenue Code	636
Min. Negotiated Rate	$79.13
Max. Negotiated Rate	$115.10
Rate for Payer: Cash Price	$64.75
Rate for Payer: Cigna of CA HMO/PPO	$115.10
Rate for Payer: Health Smart Auto/Commercial	$86.33
Rate for Payer: LLUH Dept of Risk Management WC	$79.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$107.91

HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE [118915]

Facility

$143.88

Service Code	CPT 90636
Hospital Charge Code	NDG118915
Hospital Revenue Code	636
Min. Negotiated Rate	$79.13
Max. Negotiated Rate	$107.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$86.33
Rate for Payer: Aetna of CA Government/Medicare	$86.33
Rate for Payer: Cash Price	$64.75
Rate for Payer: Health Smart Auto/Commercial	$86.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$86.33
Rate for Payer: LLUH Dept of Risk Management WC	$79.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$107.91

HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE [118741]

Facility

$94.75

Service Code	CPT 90632
Hospital Charge Code	1726016
Hospital Revenue Code	636
Min. Negotiated Rate	$52.11
Max. Negotiated Rate	$75.80
Rate for Payer: Cash Price	$42.64
Rate for Payer: Cigna of CA HMO/PPO	$75.80
Rate for Payer: Health Smart Auto/Commercial	$56.85
Rate for Payer: LLUH Dept of Risk Management WC	$52.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$71.06

HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE [118741]

Facility

$94.75

Service Code	CPT 90632
Hospital Charge Code	1726016
Hospital Revenue Code	636
Min. Negotiated Rate	$52.11
Max. Negotiated Rate	$71.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$56.85
Rate for Payer: Aetna of CA Government/Medicare	$56.85
Rate for Payer: Cash Price	$42.64
Rate for Payer: Health Smart Auto/Commercial	$56.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$56.85
Rate for Payer: LLUH Dept of Risk Management WC	$52.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$71.06

HEPATITIS B IMMUNE GLOBULIN > 1,560 UNIT/5 ML INTRAMUSCULAR SOLUTION [91047]

Facility

$170.29

Service Code	CPT 90371
Hospital Charge Code	1720099
Hospital Revenue Code	636
Min. Negotiated Rate	$93.66
Max. Negotiated Rate	$136.23
Rate for Payer: Cash Price	$76.63
Rate for Payer: Cigna of CA HMO/PPO	$136.23
Rate for Payer: Health Smart Auto/Commercial	$102.17
Rate for Payer: LLUH Dept of Risk Management WC	$93.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$127.72

HEPATITIS B IMMUNE GLOBULIN > 1,560 UNIT/5 ML INTRAMUSCULAR SOLUTION [91047]

Facility

$170.29

Service Code	CPT 90371
Hospital Charge Code	1720099
Hospital Revenue Code	636
Min. Negotiated Rate	$93.66
Max. Negotiated Rate	$127.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$102.17
Rate for Payer: Aetna of CA Government/Medicare	$102.17
Rate for Payer: Cash Price	$76.63
Rate for Payer: Health Smart Auto/Commercial	$102.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$102.17
Rate for Payer: LLUH Dept of Risk Management WC	$93.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$127.72

HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE [222472]

Facility

$337.44

Service Code	CPT 90739
Hospital Charge Code	NDG222472
Hospital Revenue Code	636
Min. Negotiated Rate	$185.59
Max. Negotiated Rate	$253.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$202.46
Rate for Payer: Aetna of CA Government/Medicare	$202.46
Rate for Payer: Cash Price	$151.85
Rate for Payer: Health Smart Auto/Commercial	$202.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$202.46
Rate for Payer: LLUH Dept of Risk Management WC	$185.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$253.08

HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE [222472]

Facility

$337.44

Service Code	CPT 90739
Hospital Charge Code	NDG222472
Hospital Revenue Code	636
Min. Negotiated Rate	$185.59
Max. Negotiated Rate	$269.95
Rate for Payer: Cash Price	$151.85
Rate for Payer: Cigna of CA HMO/PPO	$269.95
Rate for Payer: Health Smart Auto/Commercial	$202.46
Rate for Payer: LLUH Dept of Risk Management WC	$185.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$253.08

HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE [118672]

Facility

$63.86

Service Code	CPT 90744
Hospital Charge Code	1720519
Hospital Revenue Code	636
Min. Negotiated Rate	$35.12
Max. Negotiated Rate	$51.09
Rate for Payer: Cash Price	$28.74
Rate for Payer: Cigna of CA HMO/PPO	$51.09
Rate for Payer: Health Smart Auto/Commercial	$38.32
Rate for Payer: LLUH Dept of Risk Management WC	$35.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$47.90

HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE [118672]

Facility

$63.86

Service Code	CPT 90744
Hospital Charge Code	1720519
Hospital Revenue Code	636
Min. Negotiated Rate	$35.12
Max. Negotiated Rate	$47.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$38.32
Rate for Payer: Aetna of CA Government/Medicare	$38.32
Rate for Payer: Cash Price	$28.74
Rate for Payer: Health Smart Auto/Commercial	$38.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$38.32
Rate for Payer: LLUH Dept of Risk Management WC	$35.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$47.90

HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML INTRAMUSCULAR. [4081931]

Facility

$63.86

Service Code	CPT 90744
Hospital Charge Code	1720519
Hospital Revenue Code	636
Min. Negotiated Rate	$35.12
Max. Negotiated Rate	$47.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$38.32
Rate for Payer: Aetna of CA Government/Medicare	$38.32
Rate for Payer: Cash Price	$28.74
Rate for Payer: Health Smart Auto/Commercial	$38.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$38.32
Rate for Payer: LLUH Dept of Risk Management WC	$35.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$47.90

HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML INTRAMUSCULAR. [4081931]

Facility

$63.86

Service Code	CPT 90744
Hospital Charge Code	1720519
Hospital Revenue Code	636
Min. Negotiated Rate	$35.12
Max. Negotiated Rate	$51.09
Rate for Payer: Cash Price	$28.74
Rate for Payer: Cigna of CA HMO/PPO	$51.09
Rate for Payer: Health Smart Auto/Commercial	$38.32
Rate for Payer: LLUH Dept of Risk Management WC	$35.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$47.90

HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/ML INTRAMUSCULAR SUSP [119731]

Facility

$76.98

Service Code	CPT 90744
Hospital Charge Code	NDG119731
Hospital Revenue Code	636
Min. Negotiated Rate	$42.34
Max. Negotiated Rate	$61.58
Rate for Payer: Cash Price	$34.64
Rate for Payer: Cigna of CA HMO/PPO	$61.58
Rate for Payer: Health Smart Auto/Commercial	$46.19
Rate for Payer: LLUH Dept of Risk Management WC	$42.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$57.74

HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/ML INTRAMUSCULAR SUSP [119731]

Facility

$76.98

Service Code	CPT 90744
Hospital Charge Code	NDG119731
Hospital Revenue Code	636
Min. Negotiated Rate	$42.34
Max. Negotiated Rate	$57.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$46.19
Rate for Payer: Aetna of CA Government/Medicare	$46.19
Rate for Payer: Cash Price	$34.64
Rate for Payer: Health Smart Auto/Commercial	$46.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$46.19
Rate for Payer: LLUH Dept of Risk Management WC	$42.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$57.74

HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE [118608]

Facility

$79.32

Service Code	CPT 90746
Hospital Charge Code	1720633
Hospital Revenue Code	636
Min. Negotiated Rate	$43.63
Max. Negotiated Rate	$63.46
Rate for Payer: Cash Price	$35.69
Rate for Payer: Cigna of CA HMO/PPO	$63.46
Rate for Payer: Health Smart Auto/Commercial	$47.59
Rate for Payer: LLUH Dept of Risk Management WC	$43.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$59.49

HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE [118608]

Facility

$79.32

Service Code	CPT 90746
Hospital Charge Code	1720633
Hospital Revenue Code	636
Min. Negotiated Rate	$43.63
Max. Negotiated Rate	$59.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$47.59
Rate for Payer: Aetna of CA Government/Medicare	$47.59
Rate for Payer: Cash Price	$35.69
Rate for Payer: Health Smart Auto/Commercial	$47.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$47.59
Rate for Payer: LLUH Dept of Risk Management WC	$43.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$59.49

HEPATITIS B VIRUS VACCINE RECOMB (PF) 40 MCG/ML INTRAMUSCULAR SUSP [108150]

Facility

$210.43

Service Code	CPT 90740
Hospital Charge Code	1722054
Hospital Revenue Code	636
Min. Negotiated Rate	$115.74
Max. Negotiated Rate	$157.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$126.26
Rate for Payer: Aetna of CA Government/Medicare	$126.26
Rate for Payer: Cash Price	$94.69
Rate for Payer: Health Smart Auto/Commercial	$126.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$126.26
Rate for Payer: LLUH Dept of Risk Management WC	$115.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$157.82

HEPATITIS B VIRUS VACCINE RECOMB (PF) 40 MCG/ML INTRAMUSCULAR SUSP [108150]

Facility

$210.43

Service Code	CPT 90740
Hospital Charge Code	1722054
Hospital Revenue Code	636
Min. Negotiated Rate	$115.74
Max. Negotiated Rate	$168.34
Rate for Payer: Cash Price	$94.69
Rate for Payer: Cigna of CA HMO/PPO	$168.34
Rate for Payer: Health Smart Auto/Commercial	$126.26
Rate for Payer: LLUH Dept of Risk Management WC	$115.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$157.82

HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE [34550]

Facility

$213.32

Service Code	CPT 90723
Hospital Charge Code	1721119
Hospital Revenue Code	636
Min. Negotiated Rate	$117.33
Max. Negotiated Rate	$159.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$127.99
Rate for Payer: Aetna of CA Government/Medicare	$127.99
Rate for Payer: Cash Price	$95.99
Rate for Payer: Health Smart Auto/Commercial	$127.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$127.99
Rate for Payer: LLUH Dept of Risk Management WC	$117.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$159.99

HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE [34550]

Facility

$213.32

Service Code	CPT 90723
Hospital Charge Code	1721119
Hospital Revenue Code	636
Min. Negotiated Rate	$117.33
Max. Negotiated Rate	$170.66
Rate for Payer: Cash Price	$95.99
Rate for Payer: Cigna of CA HMO/PPO	$170.66
Rate for Payer: Health Smart Auto/Commercial	$127.99
Rate for Payer: LLUH Dept of Risk Management WC	$117.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$159.99

HETASTARCH 6 % IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [25174]

Facility

$0.06

Service Code	NDC 0264-1965-10
Hospital Charge Code	1771089
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

HETASTARCH 6 % IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [25174]

Facility

$0.06

Service Code	NDC 0264-1965-10
Hospital Charge Code	1771089
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

Know your out-of-pocket cost for care.

All Charges