Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LEUPROLIDE 11.25 MG INTRAMUSCULAR KIT [10390]

Facility

$4,281.55

Service Code	CPT J1950
Hospital Charge Code	1722009
Hospital Revenue Code	636
Min. Negotiated Rate	$2,354.85
Max. Negotiated Rate	$3,425.24
Rate for Payer: Cash Price	$1,926.70
Rate for Payer: Cigna of CA HMO/PPO	$3,425.24
Rate for Payer: Health Smart Auto/Commercial	$2,568.93
Rate for Payer: LLUH Dept of Risk Management WC	$2,354.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,211.16

LEUPROLIDE 11.25 MG INTRAMUSCULAR KIT [10390]

Facility

$4,281.55

Service Code	CPT J1950
Hospital Charge Code	1722009
Hospital Revenue Code	636
Min. Negotiated Rate	$2,354.85
Max. Negotiated Rate	$3,211.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,568.93
Rate for Payer: Aetna of CA Government/Medicare	$2,568.93
Rate for Payer: Cash Price	$1,926.70
Rate for Payer: Health Smart Auto/Commercial	$2,568.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,568.93
Rate for Payer: LLUH Dept of Risk Management WC	$2,354.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,211.16

LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT [14135]

Facility

$855.36

Service Code	CPT J9218
Hospital Revenue Code	636
Min. Negotiated Rate	$470.45
Max. Negotiated Rate	$684.29
Rate for Payer: Cash Price	$384.91
Rate for Payer: Cigna of CA HMO/PPO	$684.29
Rate for Payer: Health Smart Auto/Commercial	$513.22
Rate for Payer: LLUH Dept of Risk Management WC	$470.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$641.52

LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT [14135]

Facility

$855.36

Service Code	CPT J9218
Hospital Revenue Code	636
Min. Negotiated Rate	$470.45
Max. Negotiated Rate	$641.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$513.22
Rate for Payer: Aetna of CA Government/Medicare	$513.22
Rate for Payer: Cash Price	$384.91
Rate for Payer: Health Smart Auto/Commercial	$513.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$513.22
Rate for Payer: LLUH Dept of Risk Management WC	$470.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$641.52

LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT. [40814135]

Facility

$855.36

Service Code	CPT J9218
Hospital Charge Code	1756590
Hospital Revenue Code	636
Min. Negotiated Rate	$470.45
Max. Negotiated Rate	$684.29
Rate for Payer: Cash Price	$384.91
Rate for Payer: Cigna of CA HMO/PPO	$684.29
Rate for Payer: Health Smart Auto/Commercial	$513.22
Rate for Payer: LLUH Dept of Risk Management WC	$470.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$641.52

LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT. [40814135]

Facility

$855.36

Service Code	CPT J9218
Hospital Charge Code	1756590
Hospital Revenue Code	636
Min. Negotiated Rate	$470.45
Max. Negotiated Rate	$641.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$513.22
Rate for Payer: Aetna of CA Government/Medicare	$513.22
Rate for Payer: Cash Price	$384.91
Rate for Payer: Health Smart Auto/Commercial	$513.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$513.22
Rate for Payer: LLUH Dept of Risk Management WC	$470.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$641.52

LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21045]

Facility

$7,008.31

Service Code	CPT J9217
Hospital Charge Code	1720692
Hospital Revenue Code	636
Min. Negotiated Rate	$3,854.57
Max. Negotiated Rate	$5,606.65
Rate for Payer: Cash Price	$3,153.74
Rate for Payer: Cigna of CA HMO/PPO	$5,606.65
Rate for Payer: Health Smart Auto/Commercial	$4,204.99
Rate for Payer: LLUH Dept of Risk Management WC	$3,854.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5,256.23

LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21045]

Facility

$7,008.31

Service Code	CPT J9217
Hospital Charge Code	1720692
Hospital Revenue Code	636
Min. Negotiated Rate	$3,854.57
Max. Negotiated Rate	$5,256.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4,204.99
Rate for Payer: Aetna of CA Government/Medicare	$4,204.99
Rate for Payer: Cash Price	$3,153.74
Rate for Payer: Health Smart Auto/Commercial	$4,204.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4,204.99
Rate for Payer: LLUH Dept of Risk Management WC	$3,854.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5,256.23

LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [33669]

Facility

$1,626.08

Service Code	CPT J9217
Hospital Charge Code	1721163
Hospital Revenue Code	636
Min. Negotiated Rate	$894.34
Max. Negotiated Rate	$1,219.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$975.65
Rate for Payer: Aetna of CA Government/Medicare	$975.65
Rate for Payer: Cash Price	$731.74
Rate for Payer: Health Smart Auto/Commercial	$975.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$975.65
Rate for Payer: LLUH Dept of Risk Management WC	$894.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,219.56

LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [33669]

Facility

$1,626.08

Service Code	CPT J9217
Hospital Charge Code	1721163
Hospital Revenue Code	636
Min. Negotiated Rate	$894.34
Max. Negotiated Rate	$1,300.86
Rate for Payer: Cash Price	$731.74
Rate for Payer: Cigna of CA HMO/PPO	$1,300.86
Rate for Payer: Health Smart Auto/Commercial	$975.65
Rate for Payer: LLUH Dept of Risk Management WC	$894.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,219.56

LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT [21108]

Facility

$9,344.44

Service Code	CPT J9217
Hospital Charge Code	1720911
Hospital Revenue Code	636
Min. Negotiated Rate	$5,139.44
Max. Negotiated Rate	$7,008.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5,606.66
Rate for Payer: Aetna of CA Government/Medicare	$5,606.66
Rate for Payer: Cash Price	$4,205.00
Rate for Payer: Health Smart Auto/Commercial	$5,606.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5,606.66
Rate for Payer: LLUH Dept of Risk Management WC	$5,139.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7,008.33

LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT [21108]

Facility

$9,344.44

Service Code	CPT J9217
Hospital Charge Code	1720911
Hospital Revenue Code	636
Min. Negotiated Rate	$5,139.44
Max. Negotiated Rate	$7,475.55
Rate for Payer: Cash Price	$4,205.00
Rate for Payer: Cigna of CA HMO/PPO	$7,475.55
Rate for Payer: Health Smart Auto/Commercial	$5,606.66
Rate for Payer: LLUH Dept of Risk Management WC	$5,139.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7,008.33

LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT [13691]

Facility

$1,960.39

Service Code	CPT J1950
Hospital Charge Code	1721031
Hospital Revenue Code	636
Min. Negotiated Rate	$1,078.21
Max. Negotiated Rate	$1,470.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,176.23
Rate for Payer: Aetna of CA Government/Medicare	$1,176.23
Rate for Payer: Cash Price	$882.18
Rate for Payer: Health Smart Auto/Commercial	$1,176.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,176.23
Rate for Payer: LLUH Dept of Risk Management WC	$1,078.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,470.29

LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT [13691]

Facility

$1,960.39

Service Code	CPT J1950
Hospital Charge Code	1721031
Hospital Revenue Code	636
Min. Negotiated Rate	$1,078.21
Max. Negotiated Rate	$1,568.31
Rate for Payer: Cash Price	$882.18
Rate for Payer: Cigna of CA HMO/PPO	$1,568.31
Rate for Payer: Health Smart Auto/Commercial	$1,176.23
Rate for Payer: LLUH Dept of Risk Management WC	$1,078.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,470.29

LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]

Facility

$542.03

Service Code	CPT J9217
Hospital Charge Code	1721162
Hospital Revenue Code	636
Min. Negotiated Rate	$298.12
Max. Negotiated Rate	$406.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$325.22
Rate for Payer: Aetna of CA Government/Medicare	$325.22
Rate for Payer: Cash Price	$243.91
Rate for Payer: Health Smart Auto/Commercial	$325.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$325.22
Rate for Payer: LLUH Dept of Risk Management WC	$298.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$406.52

LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]

Facility

$542.03

Service Code	CPT J9217
Hospital Charge Code	1721162
Hospital Revenue Code	636
Min. Negotiated Rate	$298.12
Max. Negotiated Rate	$433.62
Rate for Payer: Cash Price	$243.91
Rate for Payer: Cigna of CA HMO/PPO	$433.62
Rate for Payer: Health Smart Auto/Commercial	$325.22
Rate for Payer: LLUH Dept of Risk Management WC	$298.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$406.52

LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT [187503]

Facility

$2,336.11

Service Code	CPT J9217
Hospital Charge Code	ERX187503
Hospital Revenue Code	636
Min. Negotiated Rate	$1,284.86
Max. Negotiated Rate	$1,868.89
Rate for Payer: Cash Price	$1,051.25
Rate for Payer: Cigna of CA HMO/PPO	$1,868.89
Rate for Payer: Health Smart Auto/Commercial	$1,401.67
Rate for Payer: LLUH Dept of Risk Management WC	$1,284.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,752.08

LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT [187503]

Facility

$2,336.11

Service Code	CPT J9217
Hospital Charge Code	ERX187503
Hospital Revenue Code	636
Min. Negotiated Rate	$1,284.86
Max. Negotiated Rate	$1,752.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,401.67
Rate for Payer: Aetna of CA Government/Medicare	$1,401.67
Rate for Payer: Cash Price	$1,051.25
Rate for Payer: Health Smart Auto/Commercial	$1,401.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,401.67
Rate for Payer: LLUH Dept of Risk Management WC	$1,284.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,752.08

LEUPROLIDE 7.5 MG (PED) INTRAMUSCULAR KIT [27123]

Facility

$2,358.36

Service Code	CPT J9217
Hospital Charge Code	1720544
Hospital Revenue Code	636
Min. Negotiated Rate	$1,297.10
Max. Negotiated Rate	$1,886.69
Rate for Payer: Cash Price	$1,061.26
Rate for Payer: Cigna of CA HMO/PPO	$1,886.69
Rate for Payer: Health Smart Auto/Commercial	$1,415.02
Rate for Payer: LLUH Dept of Risk Management WC	$1,297.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,768.77

LEUPROLIDE 7.5 MG (PED) INTRAMUSCULAR KIT [27123]

Facility

$2,358.36

Service Code	CPT J9217
Hospital Charge Code	1720544
Hospital Revenue Code	636
Min. Negotiated Rate	$1,297.10
Max. Negotiated Rate	$1,768.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,415.02
Rate for Payer: Aetna of CA Government/Medicare	$1,415.02
Rate for Payer: Cash Price	$1,061.26
Rate for Payer: Health Smart Auto/Commercial	$1,415.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,415.02
Rate for Payer: LLUH Dept of Risk Management WC	$1,297.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,768.77

LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT [153492]

Facility

$14,016.85

Service Code	CPT J9217
Hospital Charge Code	ERX153492
Hospital Revenue Code	636
Min. Negotiated Rate	$7,709.27
Max. Negotiated Rate	$10,512.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8,410.11
Rate for Payer: Aetna of CA Government/Medicare	$8,410.11
Rate for Payer: Cash Price	$6,307.58
Rate for Payer: Health Smart Auto/Commercial	$8,410.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8,410.11
Rate for Payer: LLUH Dept of Risk Management WC	$7,709.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10,512.64

LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT [153492]

Facility

$14,016.85

Service Code	CPT J9217
Hospital Charge Code	ERX153492
Hospital Revenue Code	636
Min. Negotiated Rate	$7,709.27
Max. Negotiated Rate	$11,213.48
Rate for Payer: Cash Price	$6,307.58
Rate for Payer: Cigna of CA HMO/PPO	$11,213.48
Rate for Payer: Health Smart Auto/Commercial	$8,410.11
Rate for Payer: LLUH Dept of Risk Management WC	$7,709.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10,512.64

LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [24916]

Facility

$0.64

Service Code	NDC 0093-4148-45
Hospital Charge Code	1781108
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.48

LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [24916]

Facility

$0.64

Service Code	NDC 0093-4148-45
Hospital Charge Code	1781108
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.48

LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154435]

Facility

$0.26

Service Code	CPT J1953
Hospital Charge Code	NDG154435
Hospital Revenue Code	636
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cigna of CA HMO/PPO	$0.54
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50

Know your out-of-pocket cost for care.

All Charges