Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]

Facility

$13.56

Service Code	HCPCS A9573
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.46
Max. Negotiated Rate	$10.85
Rate for Payer: Cash Price	$7.46
Rate for Payer: Cash Price	$7.37
Rate for Payer: Cash Price	$7.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.71
Rate for Payer: Health Smart Auto/Commercial	$8.03
Rate for Payer: Health Smart Auto/Commercial	$8.08
Rate for Payer: Health Smart Auto/Commercial	$8.14
Rate for Payer: LLUH Dept of Risk Management WC	$7.46
Rate for Payer: LLUH Dept of Risk Management WC	$7.36
Rate for Payer: LLUH Dept of Risk Management WC	$7.40
Rate for Payer: Multiplan Commercial	$10.04
Rate for Payer: Multiplan Commercial	$10.10
Rate for Payer: Multiplan Commercial	$10.17

GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]

Facility

$13.56

Service Code	HCPCS A9573
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.46
Max. Negotiated Rate	$10.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.08
Rate for Payer: Aetna of CA Government/Medicare	$8.03
Rate for Payer: Aetna of CA Government/Medicare	$8.14
Rate for Payer: Aetna of CA Government/Medicare	$8.08
Rate for Payer: Cash Price	$7.37
Rate for Payer: Cash Price	$7.46
Rate for Payer: Cash Price	$7.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.77
Rate for Payer: Health Smart Auto/Commercial	$8.03
Rate for Payer: Health Smart Auto/Commercial	$8.08
Rate for Payer: Health Smart Auto/Commercial	$8.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.14
Rate for Payer: LLUH Dept of Risk Management WC	$7.40
Rate for Payer: LLUH Dept of Risk Management WC	$7.36
Rate for Payer: LLUH Dept of Risk Management WC	$7.46
Rate for Payer: Multiplan Commercial	$10.04
Rate for Payer: Multiplan Commercial	$10.10
Rate for Payer: Multiplan Commercial	$10.17

GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) INTRAVENOUS SOLUTION [201457]

Facility

$6.04

Service Code	HCPCS A9575
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$4.83
Rate for Payer: Cash Price	$3.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.83
Rate for Payer: Health Smart Auto/Commercial	$3.62
Rate for Payer: LLUH Dept of Risk Management WC	$3.32
Rate for Payer: Multiplan Commercial	$4.53

GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) INTRAVENOUS SOLUTION [201457]

Facility

$6.04

Service Code	HCPCS A9575
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$4.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.62
Rate for Payer: Aetna of CA Government/Medicare	$3.62
Rate for Payer: Cash Price	$3.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.83
Rate for Payer: Health Smart Auto/Commercial	$3.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.62
Rate for Payer: LLUH Dept of Risk Management WC	$3.32
Rate for Payer: Multiplan Commercial	$4.53

GADOTERATE MEGLUMINE 0.5 MMOL/ML INTRAVENOUS SYRINGE [203433]

Facility

$6.52

Service Code	HCPCS A9575
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$3.59
Max. Negotiated Rate	$5.22
Rate for Payer: Cash Price	$3.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.22
Rate for Payer: Health Smart Auto/Commercial	$3.91
Rate for Payer: LLUH Dept of Risk Management WC	$3.59
Rate for Payer: Multiplan Commercial	$4.89

GADOTERATE MEGLUMINE 0.5 MMOL/ML INTRAVENOUS SYRINGE [203433]

Facility

$6.52

Service Code	HCPCS A9575
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$3.59
Max. Negotiated Rate	$5.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.91
Rate for Payer: Aetna of CA Government/Medicare	$3.91
Rate for Payer: Cash Price	$3.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.22
Rate for Payer: Health Smart Auto/Commercial	$3.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.91
Rate for Payer: LLUH Dept of Risk Management WC	$3.59
Rate for Payer: Multiplan Commercial	$4.89

GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION [93574]

Facility

$17.04

Service Code	HCPCS A9581
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$9.37
Max. Negotiated Rate	$13.63
Rate for Payer: Cash Price	$9.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.63
Rate for Payer: Health Smart Auto/Commercial	$10.22
Rate for Payer: LLUH Dept of Risk Management WC	$9.37
Rate for Payer: Multiplan Commercial	$12.78

GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION [93574]

Facility

$17.04

Service Code	HCPCS A9581
Hospital Charge Code	901700036
Hospital Revenue Code	255
Min. Negotiated Rate	$9.37
Max. Negotiated Rate	$13.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.22
Rate for Payer: Aetna of CA Government/Medicare	$10.22
Rate for Payer: Cash Price	$9.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.63
Rate for Payer: Health Smart Auto/Commercial	$10.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.22
Rate for Payer: LLUH Dept of Risk Management WC	$9.37
Rate for Payer: Multiplan Commercial	$12.78

GALANTAMINE ER 16 MG 24 HR CAPSULE,EXTENDED RELEASE [41139]

Facility

$5.50

Service Code	NDC 0378-8106-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$4.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.30
Rate for Payer: Aetna of CA Government/Medicare	$3.30
Rate for Payer: Cash Price	$3.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.40
Rate for Payer: Health Smart Auto/Commercial	$3.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.30
Rate for Payer: LLUH Dept of Risk Management WC	$3.02
Rate for Payer: Multiplan Commercial	$4.12

GALANTAMINE ER 16 MG 24 HR CAPSULE,EXTENDED RELEASE [41139]

Facility

$5.50

Service Code	NDC 0378-8106-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$4.40
Rate for Payer: Cash Price	$3.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.40
Rate for Payer: Health Smart Auto/Commercial	$3.30
Rate for Payer: LLUH Dept of Risk Management WC	$3.02
Rate for Payer: Multiplan Commercial	$4.12

GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]

Facility

$596.88

Service Code	HCPCS J1458
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$328.28
Max. Negotiated Rate	$477.50
Rate for Payer: Cash Price	$328.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$477.50
Rate for Payer: Health Smart Auto/Commercial	$358.13
Rate for Payer: LLUH Dept of Risk Management WC	$328.28
Rate for Payer: Multiplan Commercial	$447.66

GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]

Facility

$596.88

Service Code	HCPCS J1458
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$328.28
Max. Negotiated Rate	$477.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$358.13
Rate for Payer: Aetna of CA Government/Medicare	$358.13
Rate for Payer: Cash Price	$328.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$477.50
Rate for Payer: Health Smart Auto/Commercial	$358.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$358.13
Rate for Payer: LLUH Dept of Risk Management WC	$328.28
Rate for Payer: Multiplan Commercial	$447.66

GANCICLOVIR 0.15 % EYE GEL [104575]

Facility

$114.51

Service Code	NDC 24208-535-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$62.98
Max. Negotiated Rate	$91.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$68.71
Rate for Payer: Aetna of CA Government/Medicare	$68.71
Rate for Payer: Cash Price	$62.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$91.61
Rate for Payer: Health Smart Auto/Commercial	$68.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$68.71
Rate for Payer: LLUH Dept of Risk Management WC	$62.98
Rate for Payer: Multiplan Commercial	$85.88

GANCICLOVIR 0.15 % EYE GEL [104575]

Facility

$114.51

Service Code	NDC 24208-535-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$62.98
Max. Negotiated Rate	$91.61
Rate for Payer: Cash Price	$62.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$91.61
Rate for Payer: Health Smart Auto/Commercial	$68.71
Rate for Payer: LLUH Dept of Risk Management WC	$62.98
Rate for Payer: Multiplan Commercial	$85.88

GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]

Facility

$82.08

Service Code	HCPCS J1570
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$45.14
Max. Negotiated Rate	$65.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$49.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$70.03
Rate for Payer: Aetna of CA Government/Medicare	$70.03
Rate for Payer: Aetna of CA Government/Medicare	$49.25
Rate for Payer: Cash Price	$64.20
Rate for Payer: Cash Price	$45.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$65.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$93.38
Rate for Payer: Health Smart Auto/Commercial	$49.25
Rate for Payer: Health Smart Auto/Commercial	$70.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$70.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$49.25
Rate for Payer: LLUH Dept of Risk Management WC	$64.20
Rate for Payer: LLUH Dept of Risk Management WC	$45.14
Rate for Payer: Multiplan Commercial	$61.56
Rate for Payer: Multiplan Commercial	$87.54

GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]

Facility

$116.72

Service Code	HCPCS J1570
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$64.20
Max. Negotiated Rate	$93.38
Rate for Payer: Cash Price	$64.20
Rate for Payer: Cash Price	$45.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$65.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$93.38
Rate for Payer: Health Smart Auto/Commercial	$70.03
Rate for Payer: Health Smart Auto/Commercial	$49.25
Rate for Payer: LLUH Dept of Risk Management WC	$64.20
Rate for Payer: LLUH Dept of Risk Management WC	$45.14
Rate for Payer: Multiplan Commercial	$87.54
Rate for Payer: Multiplan Commercial	$61.56

GELATIN ABSORBABLE EYE FILM [28028]

Facility

$268.54

Service Code	NDC 0009-0297-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$147.70
Max. Negotiated Rate	$214.83
Rate for Payer: Cash Price	$147.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$214.83
Rate for Payer: Health Smart Auto/Commercial	$161.12
Rate for Payer: LLUH Dept of Risk Management WC	$147.70
Rate for Payer: Multiplan Commercial	$201.41

GELATIN ABSORBABLE EYE FILM [28028]

Facility

$268.54

Service Code	NDC 0009-0297-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$147.70
Max. Negotiated Rate	$214.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$161.12
Rate for Payer: Aetna of CA Government/Medicare	$161.12
Rate for Payer: Cash Price	$147.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$214.83
Rate for Payer: Health Smart Auto/Commercial	$161.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$161.12
Rate for Payer: LLUH Dept of Risk Management WC	$147.70
Rate for Payer: Multiplan Commercial	$201.41

GELATIN ABSORBABLE MUCOSAL POWDER [28017]

Facility

$100.68

Service Code	NDC 0009-0433-04
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$55.37
Max. Negotiated Rate	$80.54
Rate for Payer: Cash Price	$55.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$80.54
Rate for Payer: Health Smart Auto/Commercial	$60.41
Rate for Payer: LLUH Dept of Risk Management WC	$55.37
Rate for Payer: Multiplan Commercial	$75.51

GELATIN ABSORBABLE MUCOSAL POWDER [28017]

Facility

$100.68

Service Code	NDC 0009-0433-04
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$55.37
Max. Negotiated Rate	$80.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$60.41
Rate for Payer: Aetna of CA Government/Medicare	$60.41
Rate for Payer: Cash Price	$55.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$80.54
Rate for Payer: Health Smart Auto/Commercial	$60.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$60.41
Rate for Payer: LLUH Dept of Risk Management WC	$55.37
Rate for Payer: Multiplan Commercial	$75.51

GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]

Facility

$212.32

Service Code	NDC 85412-863-09
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$116.78
Max. Negotiated Rate	$169.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$127.39
Rate for Payer: Aetna of CA Government/Medicare	$127.39
Rate for Payer: Cash Price	$116.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$169.86
Rate for Payer: Health Smart Auto/Commercial	$127.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$127.39
Rate for Payer: LLUH Dept of Risk Management WC	$116.78
Rate for Payer: Multiplan Commercial	$159.24

GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]

Facility

$212.32

Service Code	NDC 85412-863-09
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$116.78
Max. Negotiated Rate	$169.86
Rate for Payer: Cash Price	$116.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$169.86
Rate for Payer: Health Smart Auto/Commercial	$127.39
Rate for Payer: LLUH Dept of Risk Management WC	$116.78
Rate for Payer: Multiplan Commercial	$159.24

GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]

Facility

$212.50

Service Code	NDC 85412-863-04
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$116.88
Max. Negotiated Rate	$170.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$127.50
Rate for Payer: Aetna of CA Government/Medicare	$127.50
Rate for Payer: Cash Price	$116.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$170.00
Rate for Payer: Health Smart Auto/Commercial	$127.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$127.50
Rate for Payer: LLUH Dept of Risk Management WC	$116.88
Rate for Payer: Multiplan Commercial	$159.38

GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]

Facility

$212.50

Service Code	NDC 85412-863-04
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$116.88
Max. Negotiated Rate	$170.00
Rate for Payer: Cash Price	$116.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$170.00
Rate for Payer: Health Smart Auto/Commercial	$127.50
Rate for Payer: LLUH Dept of Risk Management WC	$116.88
Rate for Payer: Multiplan Commercial	$159.38

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE [28025]

Facility

$55.39

Service Code	NDC 0009-0342-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$30.46
Max. Negotiated Rate	$44.31
Rate for Payer: Cash Price	$30.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.31
Rate for Payer: Health Smart Auto/Commercial	$33.23
Rate for Payer: LLUH Dept of Risk Management WC	$30.46
Rate for Payer: Multiplan Commercial	$41.54

Know your out-of-pocket cost for care.

All Charges