Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

GEMFIBROZIL 600 MG TABLET [3378]

Facility

$0.31

Service Code	NDC 60687-224-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

GEMFIBROZIL 600 MG TABLET [3378]

Facility

$0.21

Service Code	NDC 69097-821-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.17
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	$0.16

GEMFIBROZIL 600 MG TABLET [3378]

Facility

$0.21

Service Code	NDC 65862-624-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
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	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.17
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	$0.16

GEMFIBROZIL 600 MG TABLET [3378]

Facility

$0.21

Service Code	NDC 69097-821-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
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	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.17
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	$0.16

GEMFIBROZIL 600 MG TABLET [3378]

Facility

$0.31

Service Code	NDC 60687-224-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

GEMFIBROZIL 600 MG TABLET [3378]

Facility

$0.31

Service Code	NDC 60687-224-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

GEMFIBROZIL 600 MG TABLET [3378]

Facility

$0.31

Service Code	NDC 60687-224-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

GEMFIBROZIL 600 MG TABLET [3378]

Facility

$0.21

Service Code	NDC 65862-624-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.17
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	$0.16

GENTAMICIN 0.1 % TOPICAL CREAM [3423]

Facility

$3.16

Service Code	NDC 45802-056-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.53
Rate for Payer: Cash Price	$1.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.53
Rate for Payer: Health Smart Auto/Commercial	$1.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.74
Rate for Payer: Multiplan Commercial	$2.37

GENTAMICIN 0.1 % TOPICAL CREAM [3423]

Facility

$3.16

Service Code	NDC 0713-0683-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.90
Rate for Payer: Aetna of CA Government/Medicare	$1.90
Rate for Payer: Cash Price	$1.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.53
Rate for Payer: Health Smart Auto/Commercial	$1.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.74
Rate for Payer: Multiplan Commercial	$2.37

GENTAMICIN 0.1 % TOPICAL CREAM [3423]

Facility

$3.16

Service Code	NDC 45802-056-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.90
Rate for Payer: Aetna of CA Government/Medicare	$1.90
Rate for Payer: Cash Price	$1.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.53
Rate for Payer: Health Smart Auto/Commercial	$1.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.74
Rate for Payer: Multiplan Commercial	$2.37

GENTAMICIN 0.1 % TOPICAL CREAM [3423]

Facility

$3.16

Service Code	NDC 0713-0683-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.53
Rate for Payer: Cash Price	$1.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.53
Rate for Payer: Health Smart Auto/Commercial	$1.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.74
Rate for Payer: Multiplan Commercial	$2.37

GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]

Facility

$3.16

Service Code	NDC 45802-046-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.53
Rate for Payer: Cash Price	$1.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.53
Rate for Payer: Health Smart Auto/Commercial	$1.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.74
Rate for Payer: Multiplan Commercial	$2.37

GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]

Facility

$3.16

Service Code	NDC 45802-046-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.90
Rate for Payer: Aetna of CA Government/Medicare	$1.90
Rate for Payer: Cash Price	$1.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.53
Rate for Payer: Health Smart Auto/Commercial	$1.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.74
Rate for Payer: Multiplan Commercial	$2.37

GENTAMICIN 0.3 % EYE DROPS [3428]

Facility

$8.57

Service Code	NDC 24208-580-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.71
Max. Negotiated Rate	$6.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.14
Rate for Payer: Aetna of CA Government/Medicare	$5.14
Rate for Payer: Cash Price	$4.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.86
Rate for Payer: Health Smart Auto/Commercial	$5.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.14
Rate for Payer: LLUH Dept of Risk Management WC	$4.71
Rate for Payer: Multiplan Commercial	$6.43

GENTAMICIN 0.3 % EYE DROPS [3428]

Facility

$8.57

Service Code	NDC 24208-580-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.71
Max. Negotiated Rate	$6.86
Rate for Payer: Cash Price	$4.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.86
Rate for Payer: Health Smart Auto/Commercial	$5.14
Rate for Payer: LLUH Dept of Risk Management WC	$4.71
Rate for Payer: Multiplan Commercial	$6.43

GENTAMICIN 120 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [116094]

Facility

$0.05

Service Code	HCPCS J1580
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

GENTAMICIN 120 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [116094]

Facility

$0.05

Service Code	HCPCS J1580
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]

Facility

$2.17

Service Code	HCPCS J1580
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$1.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.20
Rate for Payer: Aetna of CA Government/Medicare	$1.20
Rate for Payer: Aetna of CA Government/Medicare	$1.30
Rate for Payer: Cash Price	$1.10
Rate for Payer: Cash Price	$1.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$1.30
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.30
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: LLUH Dept of Risk Management WC	$1.19
Rate for Payer: Multiplan Commercial	$1.63
Rate for Payer: Multiplan Commercial	$1.50

GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]

Facility

$2.00

Service Code	HCPCS J1580
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.60
Rate for Payer: Cash Price	$1.10
Rate for Payer: Cash Price	$1.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: Health Smart Auto/Commercial	$1.30
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: LLUH Dept of Risk Management WC	$1.19
Rate for Payer: Multiplan Commercial	$1.50
Rate for Payer: Multiplan Commercial	$1.63

GENTAMICIN 80 MG/50 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [15911]

Facility

$0.10

Service Code	HCPCS J1580
Hospital Charge Code	901700025
Hospital Revenue Code	636
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

GENTAMICIN 80 MG/50 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [15911]

Facility

$0.10

Service Code	HCPCS J1580
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
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: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

GENTAMICIN ORAL SOLUTION (IV FORM) 10 MG/ML [4080431]

Facility

$2.40

Service Code	NDC 9994-0804-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

GENTAMICIN ORAL SOLUTION (IV FORM) 10 MG/ML [4080431]

Facility

$2.40

Service Code	NDC 9994-0804-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

GENTAMICIN (PF) 20 MG/2 ML MED NEB [4080723]

Facility

$3.70

Service Code	HCPCS J1580
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$2.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.22
Rate for Payer: Aetna of CA Government/Medicare	$2.22
Rate for Payer: Cash Price	$2.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.96
Rate for Payer: Health Smart Auto/Commercial	$2.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.22
Rate for Payer: LLUH Dept of Risk Management WC	$2.04
Rate for Payer: Multiplan Commercial	$2.77

Know your out-of-pocket cost for care.

All Charges