Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PEG-ELECTROLYTE SOLUTION 420 GRAM ORAL SOLUTION [110896]

Facility

$0.01

Service Code	NDC 52268-302-01
Hospital Charge Code	NDG110896A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01

PEG-ELECTROLYTE SOLUTION 420 GRAM ORAL SOLUTION [110896]

Facility

$0.01

Service Code	NDC 43386-050-19
Hospital Charge Code	NDG110896A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01

PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR [208788]

Facility

$12,835.98

Service Code	CPT J2506
Hospital Charge Code	ERX208788
Hospital Revenue Code	636
Min. Negotiated Rate	$7,059.79
Max. Negotiated Rate	$9,626.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7,701.59
Rate for Payer: Aetna of CA Government/Medicare	$7,701.59
Rate for Payer: Cash Price	$5,776.19
Rate for Payer: Health Smart Auto/Commercial	$7,701.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7,701.59
Rate for Payer: LLUH Dept of Risk Management WC	$7,059.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9,626.98

PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR [208788]

Facility

$12,835.98

Service Code	CPT J2506
Hospital Charge Code	ERX208788
Hospital Revenue Code	636
Min. Negotiated Rate	$7,059.79
Max. Negotiated Rate	$10,268.78
Rate for Payer: Cash Price	$5,776.19
Rate for Payer: Cigna of CA HMO/PPO	$10,268.78
Rate for Payer: Health Smart Auto/Commercial	$7,701.59
Rate for Payer: LLUH Dept of Risk Management WC	$7,059.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9,626.98

PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [32267]

Facility

$12,835.98

Service Code	CPT J2506
Hospital Charge Code	1720967
Hospital Revenue Code	636
Min. Negotiated Rate	$7,059.79
Max. Negotiated Rate	$10,268.78
Rate for Payer: Cash Price	$5,776.19
Rate for Payer: Cigna of CA HMO/PPO	$10,268.78
Rate for Payer: Health Smart Auto/Commercial	$7,701.59
Rate for Payer: LLUH Dept of Risk Management WC	$7,059.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9,626.98

PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [32267]

Facility

$12,835.98

Service Code	CPT J2506
Hospital Charge Code	1720967
Hospital Revenue Code	636
Min. Negotiated Rate	$7,059.79
Max. Negotiated Rate	$9,626.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7,701.59
Rate for Payer: Aetna of CA Government/Medicare	$7,701.59
Rate for Payer: Cash Price	$5,776.19
Rate for Payer: Health Smart Auto/Commercial	$7,701.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7,701.59
Rate for Payer: LLUH Dept of Risk Management WC	$7,059.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9,626.98

PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [225861]

Facility

$7,851.06

Service Code	CPT Q5120
Hospital Charge Code	NDG225861
Hospital Revenue Code	636
Min. Negotiated Rate	$4,318.08
Max. Negotiated Rate	$6,280.85
Rate for Payer: Cash Price	$3,532.98
Rate for Payer: Cigna of CA HMO/PPO	$6,280.85
Rate for Payer: Health Smart Auto/Commercial	$4,710.64
Rate for Payer: LLUH Dept of Risk Management WC	$4,318.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5,888.30

PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [225861]

Facility

$7,851.06

Service Code	CPT Q5120
Hospital Charge Code	NDG225861
Hospital Revenue Code	636
Min. Negotiated Rate	$4,318.08
Max. Negotiated Rate	$5,888.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4,710.64
Rate for Payer: Aetna of CA Government/Medicare	$4,710.64
Rate for Payer: Cash Price	$3,532.98
Rate for Payer: Health Smart Auto/Commercial	$4,710.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4,710.64
Rate for Payer: LLUH Dept of Risk Management WC	$4,318.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5,888.30

PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [222174]

Facility

$8,350.00

Service Code	CPT Q5108
Hospital Charge Code	NDG222174
Hospital Revenue Code	636
Min. Negotiated Rate	$4,592.50
Max. Negotiated Rate	$6,262.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5,010.00
Rate for Payer: Aetna of CA Government/Medicare	$5,010.00
Rate for Payer: Cash Price	$3,757.50
Rate for Payer: Health Smart Auto/Commercial	$5,010.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5,010.00
Rate for Payer: LLUH Dept of Risk Management WC	$4,592.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6,262.50

PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [222174]

Facility

$8,350.00

Service Code	CPT Q5108
Hospital Charge Code	NDG222174
Hospital Revenue Code	636
Min. Negotiated Rate	$4,592.50
Max. Negotiated Rate	$6,680.00
Rate for Payer: Cash Price	$3,757.50
Rate for Payer: Cigna of CA HMO/PPO	$6,680.00
Rate for Payer: Health Smart Auto/Commercial	$5,010.00
Rate for Payer: LLUH Dept of Risk Management WC	$4,592.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6,262.50

PEGINTERFERON ALFA-2A 180 MCG/ML SUBCUTANEOUS SOLUTION [34034]

Facility

$1,225.79

Service Code	CPT J3490
Hospital Charge Code	1720953
Hospital Revenue Code	636
Min. Negotiated Rate	$674.18
Max. Negotiated Rate	$919.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$735.47
Rate for Payer: Aetna of CA Government/Medicare	$735.47
Rate for Payer: Cash Price	$551.61
Rate for Payer: Health Smart Auto/Commercial	$735.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$735.47
Rate for Payer: LLUH Dept of Risk Management WC	$674.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$919.34

PEGINTERFERON ALFA-2A 180 MCG/ML SUBCUTANEOUS SOLUTION [34034]

Facility

$1,225.79

Service Code	CPT J3490
Hospital Charge Code	1720953
Hospital Revenue Code	636
Min. Negotiated Rate	$674.18
Max. Negotiated Rate	$980.63
Rate for Payer: Cash Price	$551.61
Rate for Payer: Cigna of CA HMO/PPO	$980.63
Rate for Payer: Health Smart Auto/Commercial	$735.47
Rate for Payer: LLUH Dept of Risk Management WC	$674.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$919.34

PEGLOTICASE 8 MG/ML INTRAVENOUS SOLUTION [107664]

Facility

$33,552.67

Service Code	CPT J2507
Hospital Charge Code	NDG107664
Hospital Revenue Code	636
Min. Negotiated Rate	$18,453.97
Max. Negotiated Rate	$25,164.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20,131.60
Rate for Payer: Aetna of CA Government/Medicare	$20,131.60
Rate for Payer: Cash Price	$15,098.70
Rate for Payer: Health Smart Auto/Commercial	$20,131.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20,131.60
Rate for Payer: LLUH Dept of Risk Management WC	$18,453.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25,164.50

PEGLOTICASE 8 MG/ML INTRAVENOUS SOLUTION [107664]

Facility

$33,552.67

Service Code	CPT J2507
Hospital Charge Code	NDG107664
Hospital Revenue Code	636
Min. Negotiated Rate	$18,453.97
Max. Negotiated Rate	$26,842.14
Rate for Payer: Cash Price	$15,098.70
Rate for Payer: Cigna of CA HMO/PPO	$26,842.14
Rate for Payer: Health Smart Auto/Commercial	$20,131.60
Rate for Payer: LLUH Dept of Risk Management WC	$18,453.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25,164.50

PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [208822]

Facility

$1,634.57

Service Code	CPT J9271
Hospital Charge Code	NDG2359
Hospital Revenue Code	636
Min. Negotiated Rate	$899.01
Max. Negotiated Rate	$1,307.66
Rate for Payer: Cash Price	$735.56
Rate for Payer: Cigna of CA HMO/PPO	$1,307.66
Rate for Payer: Health Smart Auto/Commercial	$980.74
Rate for Payer: LLUH Dept of Risk Management WC	$899.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,225.93

PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [208822]

Facility

$1,634.57

Service Code	CPT J9271
Hospital Charge Code	NDG2359
Hospital Revenue Code	636
Min. Negotiated Rate	$899.01
Max. Negotiated Rate	$1,225.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$980.74
Rate for Payer: Aetna of CA Government/Medicare	$980.74
Rate for Payer: Cash Price	$735.56
Rate for Payer: Health Smart Auto/Commercial	$980.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$980.74
Rate for Payer: LLUH Dept of Risk Management WC	$899.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,225.93

PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]

Facility

$970.32

Service Code	CPT J9305
Hospital Charge Code	1755746
Hospital Revenue Code	636
Min. Negotiated Rate	$533.68
Max. Negotiated Rate	$727.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$582.19
Rate for Payer: Aetna of CA Government/Medicare	$582.19
Rate for Payer: Cash Price	$436.64
Rate for Payer: Health Smart Auto/Commercial	$582.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$582.19
Rate for Payer: LLUH Dept of Risk Management WC	$533.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$727.74

PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]

Facility

$970.32

Service Code	CPT J9305
Hospital Charge Code	1755746
Hospital Revenue Code	636
Min. Negotiated Rate	$533.68
Max. Negotiated Rate	$776.26
Rate for Payer: Cash Price	$436.64
Rate for Payer: Cigna of CA HMO/PPO	$776.26
Rate for Payer: Health Smart Auto/Commercial	$582.19
Rate for Payer: LLUH Dept of Risk Management WC	$533.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$727.74

PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]

Facility

$951.60

Service Code	NDC 43598-387-11
Hospital Charge Code	1755727
Hospital Revenue Code	636
Min. Negotiated Rate	$523.38
Max. Negotiated Rate	$713.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$570.96
Rate for Payer: Aetna of CA Government/Medicare	$570.96
Rate for Payer: Cash Price	$428.22
Rate for Payer: Health Smart Auto/Commercial	$570.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$570.96
Rate for Payer: LLUH Dept of Risk Management WC	$523.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$713.70

PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]

Facility

$951.60

Service Code	NDC 43598-387-11
Hospital Charge Code	1755727
Hospital Revenue Code	636
Min. Negotiated Rate	$523.38
Max. Negotiated Rate	$761.28
Rate for Payer: Cash Price	$428.22
Rate for Payer: Cigna of CA HMO/PPO	$761.28
Rate for Payer: Health Smart Auto/Commercial	$570.96
Rate for Payer: LLUH Dept of Risk Management WC	$523.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$713.70

PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]

Facility

$600.00

Service Code	NDC 55150-382-01
Hospital Charge Code	1755727
Hospital Revenue Code	636
Min. Negotiated Rate	$330.00
Max. Negotiated Rate	$480.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna of CA HMO/PPO	$480.00
Rate for Payer: Health Smart Auto/Commercial	$360.00
Rate for Payer: LLUH Dept of Risk Management WC	$330.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$450.00

PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]

Facility

$600.00

Service Code	NDC 55150-382-01
Hospital Charge Code	1755727
Hospital Revenue Code	636
Min. Negotiated Rate	$330.00
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$360.00
Rate for Payer: Aetna of CA Government/Medicare	$360.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Health Smart Auto/Commercial	$360.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$360.00
Rate for Payer: LLUH Dept of Risk Management WC	$330.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$450.00

PEMIGATINIB 13.5 MG TABLET [227743]

Facility

$1,500.86

Service Code	NDC 50881-028-01
Hospital Charge Code	ERX227743
Hospital Revenue Code	259
Min. Negotiated Rate	$825.47
Max. Negotiated Rate	$1,200.69
Rate for Payer: Cash Price	$675.39
Rate for Payer: Cigna of CA HMO/PPO	$1,200.69
Rate for Payer: Health Smart Auto/Commercial	$900.52
Rate for Payer: LLUH Dept of Risk Management WC	$825.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,125.64

PEMIGATINIB 13.5 MG TABLET [227743]

Facility

$1,500.86

Service Code	NDC 50881-028-01
Hospital Charge Code	ERX227743
Hospital Revenue Code	259
Min. Negotiated Rate	$825.47
Max. Negotiated Rate	$1,125.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$900.52
Rate for Payer: Aetna of CA Government/Medicare	$900.52
Rate for Payer: Cash Price	$675.39
Rate for Payer: Health Smart Auto/Commercial	$900.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$900.52
Rate for Payer: LLUH Dept of Risk Management WC	$825.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,125.64

PEMIGATINIB 4.5 MG TABLET [227741]

Facility

$1,500.86

Service Code	NDC 50881-026-01
Hospital Charge Code	ERX227741
Hospital Revenue Code	259
Min. Negotiated Rate	$825.47
Max. Negotiated Rate	$1,200.69
Rate for Payer: Cash Price	$675.39
Rate for Payer: Cigna of CA HMO/PPO	$1,200.69
Rate for Payer: Health Smart Auto/Commercial	$900.52
Rate for Payer: LLUH Dept of Risk Management WC	$825.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,125.64

Know your out-of-pocket cost for care.

All Charges