Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PIMECROLIMUS 1 % TOPICAL CREAM [32052]

Facility

$11.96

Service Code	NDC 0187-5100-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.58
Max. Negotiated Rate	$9.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.18
Rate for Payer: Aetna of CA Government/Medicare	$7.18
Rate for Payer: Cash Price	$6.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.57
Rate for Payer: Health Smart Auto/Commercial	$7.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.18
Rate for Payer: LLUH Dept of Risk Management WC	$6.58
Rate for Payer: Multiplan Commercial	$8.97

PIMECROLIMUS 1 % TOPICAL CREAM [32052]

Facility

$11.96

Service Code	NDC 0187-5100-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.58
Max. Negotiated Rate	$9.57
Rate for Payer: Cash Price	$6.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.57
Rate for Payer: Health Smart Auto/Commercial	$7.18
Rate for Payer: LLUH Dept of Risk Management WC	$6.58
Rate for Payer: Multiplan Commercial	$8.97

PIOGLITAZONE 30 MG TABLET [25529]

Facility

$0.22

Service Code	NDC 33342-055-07
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

PIOGLITAZONE 30 MG TABLET [25529]

Facility

$0.22

Service Code	NDC 33342-055-07
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

PIPERACILLIN-TAZOBACTAM 2.25 GRAM/50 ML IN DEXTROSE(ISO) IV PIGGYBACK [34523]

Facility

$0.36

Service Code	HCPCS J2543
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

PIPERACILLIN-TAZOBACTAM 2.25 GRAM/50 ML IN DEXTROSE(ISO) IV PIGGYBACK [34523]

Facility

$0.36

Service Code	HCPCS J2543
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION [18304]

Facility

$3.60

Service Code	HCPCS J2543
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cash Price	$6.11
Rate for Payer: Cash Price	$2.27
Rate for Payer: Cash Price	$2.18
Rate for Payer: Cash Price	$1.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.30
Rate for Payer: Health Smart Auto/Commercial	$6.66
Rate for Payer: Health Smart Auto/Commercial	$2.15
Rate for Payer: Health Smart Auto/Commercial	$2.47
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$6.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: LLUH Dept of Risk Management WC	$1.97
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$2.69
Rate for Payer: Multiplan Commercial	$2.70
Rate for Payer: Multiplan Commercial	$2.97
Rate for Payer: Multiplan Commercial	$3.09
Rate for Payer: Multiplan Commercial	$8.32

PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION [18304]

Facility

$11.10

Service Code	HCPCS J2543
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$6.11
Max. Negotiated Rate	$8.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.15
Rate for Payer: Aetna of CA Government/Medicare	$2.15
Rate for Payer: Aetna of CA Government/Medicare	$2.38
Rate for Payer: Aetna of CA Government/Medicare	$2.47
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$6.66
Rate for Payer: Cash Price	$1.97
Rate for Payer: Cash Price	$2.27
Rate for Payer: Cash Price	$6.11
Rate for Payer: Cash Price	$2.18
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.17
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Health Smart Auto/Commercial	$6.66
Rate for Payer: Health Smart Auto/Commercial	$2.15
Rate for Payer: Health Smart Auto/Commercial	$2.38
Rate for Payer: Health Smart Auto/Commercial	$2.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.47
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$6.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.97
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: LLUH Dept of Risk Management WC	$2.18
Rate for Payer: Multiplan Commercial	$3.09
Rate for Payer: Multiplan Commercial	$2.97
Rate for Payer: Multiplan Commercial	$8.32
Rate for Payer: Multiplan Commercial	$2.70
Rate for Payer: Multiplan Commercial	$2.69

PIPERACILLIN-TAZOBACTAM 3.375 GRAM/50 ML DEXTROSE(ISO-OS) IV PIGGYBACK [34524]

Facility

$0.49

Service Code	HCPCS J2543
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36
Rate for Payer: Multiplan Commercial	$0.37

PIPERACILLIN-TAZOBACTAM 3.375 GRAM/50 ML DEXTROSE(ISO-OS) IV PIGGYBACK [34524]

Facility

$0.49

Service Code	HCPCS J2543
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.37
Rate for Payer: Multiplan Commercial	$0.36

PIPERACILLIN-TAZOBACTAM 3.375 GRAM/50 ML IN D5W INFUSION ADMIXTURE KIT (ADSOK) [504084141]

Facility

$2.69

Service Code	NDC 9994-8147-10
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$2.15
Rate for Payer: Cash Price	$1.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.15
Rate for Payer: Health Smart Auto/Commercial	$1.61
Rate for Payer: LLUH Dept of Risk Management WC	$1.48
Rate for Payer: Multiplan Commercial	$2.02

PIPERACILLIN-TAZOBACTAM 3.375 GRAM/50 ML IN D5W INFUSION ADMIXTURE KIT (ADSOK) [504084141]

Facility

$2.69

Service Code	NDC 9994-8147-10
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$2.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.61
Rate for Payer: Aetna of CA Government/Medicare	$1.61
Rate for Payer: Cash Price	$1.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.15
Rate for Payer: Health Smart Auto/Commercial	$1.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.61
Rate for Payer: LLUH Dept of Risk Management WC	$1.48
Rate for Payer: Multiplan Commercial	$2.02

PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]

Facility

$6.60

Service Code	HCPCS J2543
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.63
Max. Negotiated Rate	$5.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.52
Rate for Payer: Aetna of CA Government/Medicare	$3.96
Rate for Payer: Aetna of CA Government/Medicare	$2.52
Rate for Payer: Cash Price	$2.31
Rate for Payer: Cash Price	$3.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.28
Rate for Payer: Health Smart Auto/Commercial	$3.96
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$3.63
Rate for Payer: Multiplan Commercial	$3.15
Rate for Payer: Multiplan Commercial	$4.95

PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]

Facility

$4.20

Service Code	HCPCS J2543
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Cash Price	$2.31
Rate for Payer: Cash Price	$3.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: Health Smart Auto/Commercial	$3.96
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: LLUH Dept of Risk Management WC	$3.63
Rate for Payer: Multiplan Commercial	$4.95
Rate for Payer: Multiplan Commercial	$3.15

PIPERACILLIN-TAZOBACTAM 40.5 GRAM INTRAVENOUS SOLUTION [12587]

Facility

$82.80

Service Code	HCPCS J2543
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$45.54
Max. Negotiated Rate	$66.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$49.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$52.49
Rate for Payer: Aetna of CA Government/Medicare	$105.67
Rate for Payer: Aetna of CA Government/Medicare	$52.49
Rate for Payer: Aetna of CA Government/Medicare	$49.68
Rate for Payer: Cash Price	$48.11
Rate for Payer: Cash Price	$96.87
Rate for Payer: Cash Price	$45.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$140.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$66.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$69.98
Rate for Payer: Health Smart Auto/Commercial	$52.49
Rate for Payer: Health Smart Auto/Commercial	$49.68
Rate for Payer: Health Smart Auto/Commercial	$105.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$52.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$49.68
Rate for Payer: LLUH Dept of Risk Management WC	$45.54
Rate for Payer: LLUH Dept of Risk Management WC	$96.87
Rate for Payer: LLUH Dept of Risk Management WC	$48.11
Rate for Payer: Multiplan Commercial	$132.09
Rate for Payer: Multiplan Commercial	$65.61
Rate for Payer: Multiplan Commercial	$62.10

PIPERACILLIN-TAZOBACTAM 40.5 GRAM INTRAVENOUS SOLUTION [12587]

Facility

$176.12

Service Code	HCPCS J2543
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$96.87
Max. Negotiated Rate	$140.90
Rate for Payer: Cash Price	$96.87
Rate for Payer: Cash Price	$45.54
Rate for Payer: Cash Price	$48.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$69.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$140.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$66.24
Rate for Payer: Health Smart Auto/Commercial	$105.67
Rate for Payer: Health Smart Auto/Commercial	$49.68
Rate for Payer: Health Smart Auto/Commercial	$52.49
Rate for Payer: LLUH Dept of Risk Management WC	$96.87
Rate for Payer: LLUH Dept of Risk Management WC	$45.54
Rate for Payer: LLUH Dept of Risk Management WC	$48.11
Rate for Payer: Multiplan Commercial	$132.09
Rate for Payer: Multiplan Commercial	$65.61
Rate for Payer: Multiplan Commercial	$62.10

PIPERACILLIN-TAZOBACTAM 4.5 GRAM/100 ML DEXTROSE(ISO-OSM) IV PIGGYBACK [108121]

Facility

$0.30

Service Code	HCPCS J2543
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

PIPERACILLIN-TAZOBACTAM 4.5 GRAM/100 ML DEXTROSE(ISO-OSM) IV PIGGYBACK [108121]

Facility

$0.30

Service Code	HCPCS J2543
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION [18302]

Facility

$6.73

Service Code	HCPCS J2543
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.70
Max. Negotiated Rate	$5.38
Rate for Payer: Cash Price	$3.70
Rate for Payer: Cash Price	$6.98
Rate for Payer: Cash Price	$4.29
Rate for Payer: Cash Price	$4.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.53
Rate for Payer: Health Smart Auto/Commercial	$4.90
Rate for Payer: Health Smart Auto/Commercial	$4.68
Rate for Payer: Health Smart Auto/Commercial	$7.62
Rate for Payer: Health Smart Auto/Commercial	$4.04
Rate for Payer: LLUH Dept of Risk Management WC	$6.99
Rate for Payer: LLUH Dept of Risk Management WC	$3.70
Rate for Payer: LLUH Dept of Risk Management WC	$4.29
Rate for Payer: LLUH Dept of Risk Management WC	$4.49
Rate for Payer: Multiplan Commercial	$5.05
Rate for Payer: Multiplan Commercial	$9.53
Rate for Payer: Multiplan Commercial	$6.12
Rate for Payer: Multiplan Commercial	$5.85

PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION [18302]

Facility

$12.70

Service Code	HCPCS J2543
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$6.99
Max. Negotiated Rate	$10.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.90
Rate for Payer: Aetna of CA Government/Medicare	$4.90
Rate for Payer: Aetna of CA Government/Medicare	$4.04
Rate for Payer: Aetna of CA Government/Medicare	$7.62
Rate for Payer: Aetna of CA Government/Medicare	$4.68
Rate for Payer: Cash Price	$6.98
Rate for Payer: Cash Price	$4.49
Rate for Payer: Cash Price	$3.70
Rate for Payer: Cash Price	$4.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.53
Rate for Payer: Health Smart Auto/Commercial	$4.90
Rate for Payer: Health Smart Auto/Commercial	$4.68
Rate for Payer: Health Smart Auto/Commercial	$4.04
Rate for Payer: Health Smart Auto/Commercial	$7.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.62
Rate for Payer: LLUH Dept of Risk Management WC	$4.49
Rate for Payer: LLUH Dept of Risk Management WC	$6.99
Rate for Payer: LLUH Dept of Risk Management WC	$4.29
Rate for Payer: LLUH Dept of Risk Management WC	$3.70
Rate for Payer: Multiplan Commercial	$5.05
Rate for Payer: Multiplan Commercial	$5.85
Rate for Payer: Multiplan Commercial	$6.12
Rate for Payer: Multiplan Commercial	$9.53

PLERIXAFOR 24 MG/1.2 ML (20 MG/ML) SUBCUTANEOUS SOLUTION [95849]

Facility

$500.00

Service Code	HCPCS J2562
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$275.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$300.00
Rate for Payer: Aetna of CA Government/Medicare	$300.00
Rate for Payer: Cash Price	$275.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$400.00
Rate for Payer: Health Smart Auto/Commercial	$300.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$300.00
Rate for Payer: LLUH Dept of Risk Management WC	$275.00
Rate for Payer: Multiplan Commercial	$375.00

PLERIXAFOR 24 MG/1.2 ML (20 MG/ML) SUBCUTANEOUS SOLUTION [95849]

Facility

$500.00

Service Code	HCPCS J2562
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$275.00
Max. Negotiated Rate	$400.00
Rate for Payer: Cash Price	$275.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$400.00
Rate for Payer: Health Smart Auto/Commercial	$300.00
Rate for Payer: LLUH Dept of Risk Management WC	$275.00
Rate for Payer: Multiplan Commercial	$375.00

PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [231988]

Facility

$657.24

Service Code	HCPCS 90677
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$361.48
Max. Negotiated Rate	$525.79
Rate for Payer: Cash Price	$361.48
Rate for Payer: Cash Price	$372.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$542.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$525.79
Rate for Payer: Health Smart Auto/Commercial	$394.34
Rate for Payer: Health Smart Auto/Commercial	$406.74
Rate for Payer: LLUH Dept of Risk Management WC	$361.48
Rate for Payer: LLUH Dept of Risk Management WC	$372.85
Rate for Payer: Multiplan Commercial	$492.93
Rate for Payer: Multiplan Commercial	$508.43

PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [231988]

Facility

$677.90

Service Code	HCPCS 90677
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$372.85
Max. Negotiated Rate	$542.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$406.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$394.34
Rate for Payer: Aetna of CA Government/Medicare	$394.34
Rate for Payer: Aetna of CA Government/Medicare	$406.74
Rate for Payer: Cash Price	$361.48
Rate for Payer: Cash Price	$372.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$542.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$525.79
Rate for Payer: Health Smart Auto/Commercial	$406.74
Rate for Payer: Health Smart Auto/Commercial	$394.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$394.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$406.74
Rate for Payer: LLUH Dept of Risk Management WC	$361.48
Rate for Payer: LLUH Dept of Risk Management WC	$372.85
Rate for Payer: Multiplan Commercial	$508.43
Rate for Payer: Multiplan Commercial	$492.93

PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE [113995]

Facility

$280.99

Service Code	HCPCS 90732
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$154.54
Max. Negotiated Rate	$224.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$168.59
Rate for Payer: Aetna of CA Government/Medicare	$168.59
Rate for Payer: Cash Price	$154.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$224.79
Rate for Payer: Health Smart Auto/Commercial	$168.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$168.59
Rate for Payer: LLUH Dept of Risk Management WC	$154.54
Rate for Payer: Multiplan Commercial	$210.74

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