Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

GABAPENTIN 400 MG CAPSULE [18307]

Facility

$0.25

Service Code	NDC 0904-6667-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

GABAPENTIN 400 MG CAPSULE [18307]

Facility

$0.09

Service Code	NDC 67877-224-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

GABAPENTIN 400 MG CAPSULE [18307]

Facility

$0.07

Service Code	NDC 16571-869-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
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	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
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	$0.04
Rate for Payer: Multiplan Commercial	$0.05

GABAPENTIN 400 MG CAPSULE [18307]

Facility

$0.07

Service Code	NDC 16571-869-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

GABAPENTIN 400 MG CAPSULE [18307]

Facility

$0.25

Service Code	NDC 0904-6667-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

GABAPENTIN 400 MG CAPSULE [18307]

Facility

$0.15

Service Code	NDC 65162-103-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

GABAPENTIN 400 MG CAPSULE [18307]

Facility

$0.15

Service Code	NDC 65162-103-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.09
Rate for Payer: Aetna of CA Government/Medicare	$0.09
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

GABAPENTIN 400 MG CAPSULE [18307]

Facility

$0.09

Service Code	NDC 67877-224-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

GABAPENTIN 400 MG CAPSULE [18307]

Facility

$0.10

Service Code	NDC 65862-200-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

GABAPENTIN 400 MG CAPSULE [18307]

Facility

$0.15

Service Code	NDC 65162-103-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.09
Rate for Payer: Aetna of CA Government/Medicare	$0.09
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

GABAPENTIN 400 MG CAPSULE [18307]

Facility

$0.15

Service Code	NDC 65162-103-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]

Facility

$6.81

Service Code	HCPCS A9577
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$3.75
Max. Negotiated Rate	$5.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.27
Rate for Payer: Aetna of CA Government/Medicare	$4.09
Rate for Payer: Aetna of CA Government/Medicare	$4.27
Rate for Payer: Aetna of CA Government/Medicare	$3.79
Rate for Payer: Aetna of CA Government/Medicare	$4.19
Rate for Payer: Cash Price	$3.47
Rate for Payer: Cash Price	$3.84
Rate for Payer: Cash Price	$3.74
Rate for Payer: Cash Price	$3.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.70
Rate for Payer: Health Smart Auto/Commercial	$4.27
Rate for Payer: Health Smart Auto/Commercial	$3.79
Rate for Payer: Health Smart Auto/Commercial	$4.19
Rate for Payer: Health Smart Auto/Commercial	$4.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.27
Rate for Payer: LLUH Dept of Risk Management WC	$3.75
Rate for Payer: LLUH Dept of Risk Management WC	$3.84
Rate for Payer: LLUH Dept of Risk Management WC	$3.47
Rate for Payer: LLUH Dept of Risk Management WC	$3.92
Rate for Payer: Multiplan Commercial	$5.24
Rate for Payer: Multiplan Commercial	$4.73
Rate for Payer: Multiplan Commercial	$5.11
Rate for Payer: Multiplan Commercial	$5.34

GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]

Facility

$6.31

Service Code	HCPCS A9577
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$3.47
Max. Negotiated Rate	$5.05
Rate for Payer: Cash Price	$3.47
Rate for Payer: Cash Price	$3.84
Rate for Payer: Cash Price	$3.91
Rate for Payer: Cash Price	$3.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.70
Rate for Payer: Health Smart Auto/Commercial	$3.79
Rate for Payer: Health Smart Auto/Commercial	$4.09
Rate for Payer: Health Smart Auto/Commercial	$4.19
Rate for Payer: Health Smart Auto/Commercial	$4.27
Rate for Payer: LLUH Dept of Risk Management WC	$3.47
Rate for Payer: LLUH Dept of Risk Management WC	$3.84
Rate for Payer: LLUH Dept of Risk Management WC	$3.92
Rate for Payer: LLUH Dept of Risk Management WC	$3.75
Rate for Payer: Multiplan Commercial	$5.34
Rate for Payer: Multiplan Commercial	$5.24
Rate for Payer: Multiplan Commercial	$5.11
Rate for Payer: Multiplan Commercial	$4.73

GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121917]

Facility

$9.96

Service Code	HCPCS A9585
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$5.48
Max. Negotiated Rate	$7.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.98
Rate for Payer: Aetna of CA Government/Medicare	$5.98
Rate for Payer: Cash Price	$5.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.97
Rate for Payer: Health Smart Auto/Commercial	$5.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.98
Rate for Payer: LLUH Dept of Risk Management WC	$5.48
Rate for Payer: Multiplan Commercial	$7.47

GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121917]

Facility

$9.96

Service Code	HCPCS A9585
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$5.48
Max. Negotiated Rate	$7.97
Rate for Payer: Cash Price	$5.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.97
Rate for Payer: Health Smart Auto/Commercial	$5.98
Rate for Payer: LLUH Dept of Risk Management WC	$5.48
Rate for Payer: Multiplan Commercial	$7.47

GADOBUTROL 2 MMOL/2 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [205457]

Facility

$9.96

Service Code	HCPCS A9585
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$5.48
Max. Negotiated Rate	$7.97
Rate for Payer: Cash Price	$5.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.97
Rate for Payer: Health Smart Auto/Commercial	$5.98
Rate for Payer: LLUH Dept of Risk Management WC	$5.48
Rate for Payer: Multiplan Commercial	$7.47

GADOBUTROL 2 MMOL/2 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [205457]

Facility

$9.96

Service Code	HCPCS A9585
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$5.48
Max. Negotiated Rate	$7.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.98
Rate for Payer: Aetna of CA Government/Medicare	$5.98
Rate for Payer: Cash Price	$5.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.97
Rate for Payer: Health Smart Auto/Commercial	$5.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.98
Rate for Payer: LLUH Dept of Risk Management WC	$5.48
Rate for Payer: Multiplan Commercial	$7.47

GADOBUTROL 7.5 MMOL/7.5 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121916]

Facility

$9.96

Service Code	HCPCS A9585
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$5.48
Max. Negotiated Rate	$7.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.98
Rate for Payer: Aetna of CA Government/Medicare	$5.98
Rate for Payer: Cash Price	$5.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.97
Rate for Payer: Health Smart Auto/Commercial	$5.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.98
Rate for Payer: LLUH Dept of Risk Management WC	$5.48
Rate for Payer: Multiplan Commercial	$7.47

GADOBUTROL 7.5 MMOL/7.5 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121916]

Facility

$9.96

Service Code	HCPCS A9585
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$5.48
Max. Negotiated Rate	$7.97
Rate for Payer: Cash Price	$5.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.97
Rate for Payer: Health Smart Auto/Commercial	$5.98
Rate for Payer: LLUH Dept of Risk Management WC	$5.48
Rate for Payer: Multiplan Commercial	$7.47

GADODIAMIDE 10 MMOL/20 ML (287 MG/ML) INTRAVENOUS SOLUTION [119868]

Facility

$6.18

Service Code	HCPCS A9579
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$4.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.71
Rate for Payer: Aetna of CA Government/Medicare	$3.71
Rate for Payer: Cash Price	$3.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.94
Rate for Payer: Health Smart Auto/Commercial	$3.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.71
Rate for Payer: LLUH Dept of Risk Management WC	$3.40
Rate for Payer: Multiplan Commercial	$4.63

GADODIAMIDE 10 MMOL/20 ML (287 MG/ML) INTRAVENOUS SOLUTION [119868]

Facility

$6.18

Service Code	HCPCS A9579
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$4.94
Rate for Payer: Cash Price	$3.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.94
Rate for Payer: Health Smart Auto/Commercial	$3.71
Rate for Payer: LLUH Dept of Risk Management WC	$3.40
Rate for Payer: Multiplan Commercial	$4.63

GADODIAMIDE 5 MMOL/10 ML (287 MG/ML) INTRAVENOUS SOLUTION [11929]

Facility

$6.82

Service Code	HCPCS A9579
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$3.75
Max. Negotiated Rate	$5.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.09
Rate for Payer: Aetna of CA Government/Medicare	$4.09
Rate for Payer: Cash Price	$3.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.46
Rate for Payer: Health Smart Auto/Commercial	$4.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.09
Rate for Payer: LLUH Dept of Risk Management WC	$3.75
Rate for Payer: Multiplan Commercial	$5.12

GADODIAMIDE 5 MMOL/10 ML (287 MG/ML) INTRAVENOUS SOLUTION [11929]

Facility

$6.82

Service Code	HCPCS A9579
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$3.75
Max. Negotiated Rate	$5.46
Rate for Payer: Cash Price	$3.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.46
Rate for Payer: Health Smart Auto/Commercial	$4.09
Rate for Payer: LLUH Dept of Risk Management WC	$3.75
Rate for Payer: Multiplan Commercial	$5.12

GADODIAMIDE 7.5 MMOL/15 ML (287 MG/ML) INTRAVENOUS SOLUTION [119867]

Facility

$6.67

Service Code	HCPCS A9579
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$5.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.00
Rate for Payer: Aetna of CA Government/Medicare	$4.00
Rate for Payer: Cash Price	$3.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.34
Rate for Payer: Health Smart Auto/Commercial	$4.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.00
Rate for Payer: LLUH Dept of Risk Management WC	$3.67
Rate for Payer: Multiplan Commercial	$5.00

GADODIAMIDE 7.5 MMOL/15 ML (287 MG/ML) INTRAVENOUS SOLUTION [119867]

Facility

$6.67

Service Code	HCPCS A9579
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$5.34
Rate for Payer: Cash Price	$3.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.34
Rate for Payer: Health Smart Auto/Commercial	$4.00
Rate for Payer: LLUH Dept of Risk Management WC	$3.67
Rate for Payer: Multiplan Commercial	$5.00

Know your out-of-pocket cost for care.

All Charges