Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]

Facility

$3.16

Service Code	NDC 45802-046-35
Hospital Charge Code	1743222
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.53
Rate for Payer: Cash Price	$1.42
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$2.37

GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]

Facility

$3.16

Service Code	NDC 52565-090-15
Hospital Charge Code	1743222
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.53
Rate for Payer: Cash Price	$1.42
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$2.37

GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]

Facility

$3.16

Service Code	NDC 45802-046-35
Hospital Charge Code	1743222
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.37
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	$1.42
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 Beech St/Commercial/PHCS	$2.37

GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]

Facility

$2.80

Service Code	NDC 52565-090-30
Hospital Charge Code	NDG3424
Hospital Revenue Code	259
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$2.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.68
Rate for Payer: Aetna of CA Government/Medicare	$1.68
Rate for Payer: Cash Price	$1.26
Rate for Payer: Health Smart Auto/Commercial	$1.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.68
Rate for Payer: LLUH Dept of Risk Management WC	$1.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.10

GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]

Facility

$3.16

Service Code	NDC 52565-090-15
Hospital Charge Code	1743222
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.37
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	$1.42
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 Beech St/Commercial/PHCS	$2.37

GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT [3427]

Facility

$10.68

Service Code	NDC 17478-284-35
Hospital Charge Code	1740131
Hospital Revenue Code	259
Min. Negotiated Rate	$5.87
Max. Negotiated Rate	$8.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.41
Rate for Payer: Aetna of CA Government/Medicare	$6.41
Rate for Payer: Cash Price	$4.81
Rate for Payer: Health Smart Auto/Commercial	$6.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.41
Rate for Payer: LLUH Dept of Risk Management WC	$5.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.01

GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT [3427]

Facility

$10.68

Service Code	NDC 17478-284-35
Hospital Charge Code	1740131
Hospital Revenue Code	259
Min. Negotiated Rate	$5.87
Max. Negotiated Rate	$8.54
Rate for Payer: Cash Price	$4.81
Rate for Payer: Cigna of CA HMO/PPO	$8.54
Rate for Payer: Health Smart Auto/Commercial	$6.41
Rate for Payer: LLUH Dept of Risk Management WC	$5.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.01

GENTAMICIN 0.3 % EYE DROPS [3428]

Facility

$8.57

Service Code	NDC 24208-580-60
Hospital Charge Code	1740133
Hospital Revenue Code	259
Min. Negotiated Rate	$4.71
Max. Negotiated Rate	$6.43
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	$3.86
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 Beech St/Commercial/PHCS	$6.43

GENTAMICIN 0.3 % EYE DROPS [3428]

Facility

$8.57

Service Code	NDC 24208-580-60
Hospital Charge Code	1740133
Hospital Revenue Code	259
Min. Negotiated Rate	$4.71
Max. Negotiated Rate	$6.86
Rate for Payer: Cash Price	$3.86
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$6.43

GENTAMICIN 0.3 % EYE DROPS [3428]

Facility

$1.05

Service Code	NDC 60758-188-05
Hospital Charge Code	1740133
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.84
Rate for Payer: Cash Price	$0.47
Rate for Payer: Cigna of CA HMO/PPO	$0.84
Rate for Payer: Health Smart Auto/Commercial	$0.63
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.79

GENTAMICIN 0.3 % EYE DROPS [3428]

Facility

$1.05

Service Code	NDC 60758-188-05
Hospital Charge Code	1740133
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.63
Rate for Payer: Aetna of CA Government/Medicare	$0.63
Rate for Payer: Cash Price	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.63
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.79

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

Facility

$0.05

Service Code	CPT J1580
Hospital Charge Code	NDG116094
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.04

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

Facility

$0.05

Service Code	CPT J1580
Hospital Charge Code	NDG116094
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	$0.02
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 Beech St/Commercial/PHCS	$0.04

GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]

Facility

$1.75

Service Code	CPT J1580
Hospital Charge Code	NDG3426
Hospital Revenue Code	636
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.05
Rate for Payer: Aetna of CA Government/Medicare	$1.05
Rate for Payer: Cash Price	$0.79
Rate for Payer: Health Smart Auto/Commercial	$1.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.31

GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]

Facility

$1.75

Service Code	CPT J1580
Hospital Charge Code	NDG3426
Hospital Revenue Code	636
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.40
Rate for Payer: Cash Price	$0.79
Rate for Payer: Cigna of CA HMO/PPO	$1.40
Rate for Payer: Health Smart Auto/Commercial	$1.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.31

GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]

Facility

$1.32

Service Code	CPT J1580
Hospital Charge Code	1752221
Hospital Revenue Code	636
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$0.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Cash Price	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.99

GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]

Facility

$1.32

Service Code	CPT J1580
Hospital Charge Code	1752221
Hospital Revenue Code	636
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Cash Price	$0.59
Rate for Payer: Cigna of CA HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.99

GENTAMICIN 4 MG/ML SERIAL DILUTION FOR MIXTURES [4080887]

Facility

$0.52

Service Code	CPT J1580
Hospital Charge Code	NDC4080887
Hospital Revenue Code	636
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.39

GENTAMICIN 4 MG/ML SERIAL DILUTION FOR MIXTURES [4080887]

Facility

$0.52

Service Code	CPT J1580
Hospital Charge Code	NDC4080887
Hospital Revenue Code	636
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.39

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

Facility

$0.10

Service Code	CPT J1580
Hospital Charge Code	1753545
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.08

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

Facility

$0.10

Service Code	CPT J1580
Hospital Charge Code	1753545
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: 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 Beech St/Commercial/PHCS	$0.08

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

Facility

$2.40

Service Code	NDC 9994-0804-31
Hospital Charge Code	1715981
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.80
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	$1.08
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 Beech St/Commercial/PHCS	$1.80

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

Facility

$2.40

Service Code	NDC 9994-0804-31
Hospital Charge Code	1715981
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.80

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

Facility

$3.25

Service Code	CPT J1580
Hospital Charge Code	1752042
Hospital Revenue Code	636
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$2.60
Rate for Payer: Cash Price	$1.46
Rate for Payer: Cigna of CA HMO/PPO	$2.60
Rate for Payer: Health Smart Auto/Commercial	$1.95
Rate for Payer: LLUH Dept of Risk Management WC	$1.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.44

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

Facility

$3.25

Service Code	CPT J1580
Hospital Charge Code	1752042
Hospital Revenue Code	636
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$2.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.95
Rate for Payer: Aetna of CA Government/Medicare	$1.95
Rate for Payer: Cash Price	$1.46
Rate for Payer: Health Smart Auto/Commercial	$1.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.95
Rate for Payer: LLUH Dept of Risk Management WC	$1.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.44

Know your out-of-pocket cost for care.

All Charges