Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

GELATIN ABSORBABLE IMPLANT FILM [111340]

Facility

$2,441.98

Service Code	NDC 0009-0283-01
Hospital Charge Code	1780004
Hospital Revenue Code	250
Min. Negotiated Rate	$1,343.09
Max. Negotiated Rate	$1,831.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,465.19
Rate for Payer: Aetna of CA Government/Medicare	$1,465.19
Rate for Payer: Cash Price	$1,098.89
Rate for Payer: Health Smart Auto/Commercial	$1,465.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,465.19
Rate for Payer: LLUH Dept of Risk Management WC	$1,343.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,831.48

GELATIN ABSORBABLE MUCOSAL POWDER [28017]

Facility

$91.32

Service Code	NDC 0009-0433-04
Hospital Charge Code	1743583
Hospital Revenue Code	250
Min. Negotiated Rate	$50.23
Max. Negotiated Rate	$73.06
Rate for Payer: Cash Price	$41.09
Rate for Payer: Cigna of CA HMO/PPO	$73.06
Rate for Payer: Health Smart Auto/Commercial	$54.79
Rate for Payer: LLUH Dept of Risk Management WC	$50.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$68.49

GELATIN ABSORBABLE MUCOSAL POWDER [28017]

Facility

$91.32

Service Code	NDC 0009-0433-04
Hospital Charge Code	1743583
Hospital Revenue Code	250
Min. Negotiated Rate	$50.23
Max. Negotiated Rate	$68.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$54.79
Rate for Payer: Aetna of CA Government/Medicare	$54.79
Rate for Payer: Cash Price	$41.09
Rate for Payer: Health Smart Auto/Commercial	$54.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$54.79
Rate for Payer: LLUH Dept of Risk Management WC	$50.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$68.49

GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]

Facility

$212.50

Service Code	NDC 85412-863-04
Hospital Charge Code	1796131
Hospital Revenue Code	250
Min. Negotiated Rate	$116.88
Max. Negotiated Rate	$170.00
Rate for Payer: Cash Price	$95.63
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$159.38

GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]

Facility

$212.32

Service Code	NDC 85412-863-09
Hospital Charge Code	1796131
Hospital Revenue Code	250
Min. Negotiated Rate	$116.78
Max. Negotiated Rate	$169.86
Rate for Payer: Health Smart Auto/Commercial	$127.39
Rate for Payer: Cash Price	$95.54
Rate for Payer: Cigna of CA HMO/PPO	$169.86
Rate for Payer: LLUH Dept of Risk Management WC	$116.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$159.24

GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]

Facility

$212.50

Service Code	NDC 85412-863-04
Hospital Charge Code	1796131
Hospital Revenue Code	250
Min. Negotiated Rate	$116.88
Max. Negotiated Rate	$159.38
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	$95.63
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 Beech St/Commercial/PHCS	$159.38

GELATIN GELFOAM PLUS WITH THROMBIN 2500 UNITS KIT [4080737]

Facility

$212.32

Service Code	NDC 85412-863-09
Hospital Charge Code	1796131
Hospital Revenue Code	250
Min. Negotiated Rate	$116.78
Max. Negotiated Rate	$159.24
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	$95.54
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 Beech St/Commercial/PHCS	$159.24

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

Facility

$50.24

Service Code	NDC 0009-0342-01
Hospital Charge Code	1743565
Hospital Revenue Code	250
Min. Negotiated Rate	$27.63
Max. Negotiated Rate	$37.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.14
Rate for Payer: Aetna of CA Government/Medicare	$30.14
Rate for Payer: Cash Price	$22.61
Rate for Payer: Health Smart Auto/Commercial	$30.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.14
Rate for Payer: LLUH Dept of Risk Management WC	$27.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.68

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

Facility

$50.24

Service Code	NDC 0009-0342-01
Hospital Charge Code	1743565
Hospital Revenue Code	250
Min. Negotiated Rate	$27.63
Max. Negotiated Rate	$40.19
Rate for Payer: Cash Price	$22.61
Rate for Payer: Cigna of CA HMO/PPO	$40.19
Rate for Payer: Health Smart Auto/Commercial	$30.14
Rate for Payer: LLUH Dept of Risk Management WC	$27.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.68

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 200 TOPICAL SPONGE [28026]

Facility

$96.33

Service Code	NDC 0009-0349-03
Hospital Charge Code	ERX28026
Hospital Revenue Code	250
Min. Negotiated Rate	$52.98
Max. Negotiated Rate	$77.06
Rate for Payer: Cash Price	$43.35
Rate for Payer: Cigna of CA HMO/PPO	$77.06
Rate for Payer: Health Smart Auto/Commercial	$57.80
Rate for Payer: LLUH Dept of Risk Management WC	$52.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$72.25

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 200 TOPICAL SPONGE [28026]

Facility

$96.33

Service Code	NDC 0009-0349-03
Hospital Charge Code	ERX28026
Hospital Revenue Code	250
Min. Negotiated Rate	$52.98
Max. Negotiated Rate	$72.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$57.80
Rate for Payer: Aetna of CA Government/Medicare	$57.80
Rate for Payer: Cash Price	$43.35
Rate for Payer: Health Smart Auto/Commercial	$57.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$57.80
Rate for Payer: LLUH Dept of Risk Management WC	$52.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$72.25

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 4 TOPICAL SPONGE [28023]

Facility

$16.16

Service Code	NDC 0009-0396-05
Hospital Charge Code	ERX28023
Hospital Revenue Code	250
Min. Negotiated Rate	$8.89
Max. Negotiated Rate	$12.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.70
Rate for Payer: Aetna of CA Government/Medicare	$9.70
Rate for Payer: Cash Price	$7.27
Rate for Payer: Health Smart Auto/Commercial	$9.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.70
Rate for Payer: LLUH Dept of Risk Management WC	$8.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.12

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 4 TOPICAL SPONGE [28023]

Facility

$16.16

Service Code	NDC 0009-0396-05
Hospital Charge Code	ERX28023
Hospital Revenue Code	250
Min. Negotiated Rate	$8.89
Max. Negotiated Rate	$12.93
Rate for Payer: Cash Price	$7.27
Rate for Payer: Cigna of CA HMO/PPO	$12.93
Rate for Payer: Health Smart Auto/Commercial	$9.70
Rate for Payer: LLUH Dept of Risk Management WC	$8.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.12

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 50 TOPICAL SPONGE [28024]

Facility

$33.61

Service Code	NDC 0009-0323-01
Hospital Charge Code	1743564
Hospital Revenue Code	250
Min. Negotiated Rate	$18.49
Max. Negotiated Rate	$25.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.17
Rate for Payer: Aetna of CA Government/Medicare	$20.17
Rate for Payer: Cash Price	$15.12
Rate for Payer: Health Smart Auto/Commercial	$20.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.17
Rate for Payer: LLUH Dept of Risk Management WC	$18.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.21

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 50 TOPICAL SPONGE [28024]

Facility

$33.61

Service Code	NDC 0009-0323-01
Hospital Charge Code	1743564
Hospital Revenue Code	250
Min. Negotiated Rate	$18.49
Max. Negotiated Rate	$26.89
Rate for Payer: Cash Price	$15.12
Rate for Payer: Cigna of CA HMO/PPO	$26.89
Rate for Payer: Health Smart Auto/Commercial	$20.17
Rate for Payer: LLUH Dept of Risk Management WC	$18.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.21

GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [220785]

Facility

$15.84

Service Code	CPT J9196
Hospital Charge Code	NDG220785
Hospital Revenue Code	636
Min. Negotiated Rate	$8.71
Max. Negotiated Rate	$11.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.50
Rate for Payer: Aetna of CA Government/Medicare	$9.50
Rate for Payer: Cash Price	$7.13
Rate for Payer: Health Smart Auto/Commercial	$9.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.50
Rate for Payer: LLUH Dept of Risk Management WC	$8.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.88

GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [220785]

Facility

$15.84

Service Code	CPT J9196
Hospital Charge Code	NDG220785
Hospital Revenue Code	636
Min. Negotiated Rate	$8.71
Max. Negotiated Rate	$12.67
Rate for Payer: Cash Price	$7.13
Rate for Payer: Cigna of CA HMO/PPO	$12.67
Rate for Payer: Health Smart Auto/Commercial	$9.50
Rate for Payer: LLUH Dept of Risk Management WC	$8.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.88

GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [220785]

Facility

$6.65

Service Code	CPT J9196
Hospital Charge Code	NDG220785B
Hospital Revenue Code	636
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$4.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.99
Rate for Payer: Aetna of CA Government/Medicare	$3.99
Rate for Payer: Cash Price	$2.99
Rate for Payer: Health Smart Auto/Commercial	$3.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.99
Rate for Payer: LLUH Dept of Risk Management WC	$3.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.99

GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [220785]

Facility

$6.65

Service Code	CPT J9196
Hospital Charge Code	NDG220785B
Hospital Revenue Code	636
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$5.32
Rate for Payer: Health Smart Auto/Commercial	$3.99
Rate for Payer: Cash Price	$2.99
Rate for Payer: Cigna of CA HMO/PPO	$5.32
Rate for Payer: LLUH Dept of Risk Management WC	$3.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.99

GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION [191075]

Facility

$2.07

Service Code	CPT J9201
Hospital Charge Code	NDG191075
Hospital Revenue Code	636
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$1.66
Rate for Payer: Cash Price	$0.93
Rate for Payer: Cigna of CA HMO/PPO	$1.66
Rate for Payer: Health Smart Auto/Commercial	$1.24
Rate for Payer: LLUH Dept of Risk Management WC	$1.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.55

GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION [191075]

Facility

$2.07

Service Code	CPT J9201
Hospital Charge Code	NDG191075
Hospital Revenue Code	636
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$1.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.24
Rate for Payer: Aetna of CA Government/Medicare	$1.24
Rate for Payer: Cash Price	$0.93
Rate for Payer: Health Smart Auto/Commercial	$1.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.24
Rate for Payer: LLUH Dept of Risk Management WC	$1.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.55

GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION [17122]

Facility

$55.12

Service Code	CPT J9201
Hospital Charge Code	1755609
Hospital Revenue Code	636
Min. Negotiated Rate	$30.32
Max. Negotiated Rate	$41.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.84
Rate for Payer: Aetna of CA Government/Medicare	$33.84
Rate for Payer: Aetna of CA Government/Medicare	$33.07
Rate for Payer: Cash Price	$25.38
Rate for Payer: Cash Price	$24.80
Rate for Payer: Health Smart Auto/Commercial	$33.07
Rate for Payer: Health Smart Auto/Commercial	$33.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.84
Rate for Payer: LLUH Dept of Risk Management WC	$30.32
Rate for Payer: LLUH Dept of Risk Management WC	$31.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.30

GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION [17122]

Facility

$55.12

Service Code	CPT J9201
Hospital Charge Code	1755609
Hospital Revenue Code	636
Min. Negotiated Rate	$30.32
Max. Negotiated Rate	$44.10
Rate for Payer: Cash Price	$24.80
Rate for Payer: Cash Price	$25.38
Rate for Payer: Cigna of CA HMO/PPO	$45.12
Rate for Payer: Cigna of CA HMO/PPO	$44.10
Rate for Payer: Health Smart Auto/Commercial	$33.84
Rate for Payer: Health Smart Auto/Commercial	$33.07
Rate for Payer: LLUH Dept of Risk Management WC	$31.02
Rate for Payer: LLUH Dept of Risk Management WC	$30.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.30

GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION [400398]

Facility

$56.40

Service Code	CPT J9201
Hospital Charge Code	ERX400398
Hospital Revenue Code	636
Min. Negotiated Rate	$31.02
Max. Negotiated Rate	$45.12
Rate for Payer: Cash Price	$25.38
Rate for Payer: Cash Price	$24.80
Rate for Payer: Cigna of CA HMO/PPO	$45.12
Rate for Payer: Cigna of CA HMO/PPO	$44.10
Rate for Payer: Health Smart Auto/Commercial	$33.84
Rate for Payer: Health Smart Auto/Commercial	$33.07
Rate for Payer: LLUH Dept of Risk Management WC	$31.02
Rate for Payer: LLUH Dept of Risk Management WC	$30.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.34

GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION [400398]

Facility

$55.12

Service Code	CPT J9201
Hospital Charge Code	ERX400398
Hospital Revenue Code	636
Min. Negotiated Rate	$30.32
Max. Negotiated Rate	$41.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.84
Rate for Payer: Aetna of CA Government/Medicare	$33.07
Rate for Payer: Aetna of CA Government/Medicare	$33.84
Rate for Payer: Cash Price	$24.80
Rate for Payer: Cash Price	$25.38
Rate for Payer: Health Smart Auto/Commercial	$33.07
Rate for Payer: Health Smart Auto/Commercial	$33.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.84
Rate for Payer: LLUH Dept of Risk Management WC	$30.32
Rate for Payer: LLUH Dept of Risk Management WC	$31.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.30

Know your out-of-pocket cost for care.

All Charges