Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

KIT FOR TC 99M-LABELED RED BLOOD CELLS INTRAVENOUS SOLUTION [225270]

Facility

$181.13

Service Code	HCPCS A9560
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$99.62
Max. Negotiated Rate	$144.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$108.68
Rate for Payer: Aetna of CA Government/Medicare	$108.68
Rate for Payer: Cash Price	$99.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$144.90
Rate for Payer: Health Smart Auto/Commercial	$108.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$108.68
Rate for Payer: LLUH Dept of Risk Management WC	$99.62
Rate for Payer: Multiplan Commercial	$135.85

KIT FOR TC 99M-LABELED RED BLOOD CELLS INTRAVENOUS SOLUTION [225270]

Facility

$181.13

Service Code	HCPCS A9560
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$99.62
Max. Negotiated Rate	$144.90
Rate for Payer: Cash Price	$99.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$144.90
Rate for Payer: Health Smart Auto/Commercial	$108.68
Rate for Payer: LLUH Dept of Risk Management WC	$99.62
Rate for Payer: Multiplan Commercial	$135.85

KIT FOR THE PREPARATION OF TC-99M-MEBROFENIN 45 MG IV SOLUTION [121131]

Facility

$90.00

Service Code	HCPCS A9537
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$72.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$72.00
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Commercial	$67.50

KIT FOR THE PREPARATION OF TC-99M-MEBROFENIN 45 MG IV SOLUTION [121131]

Facility

$90.00

Service Code	HCPCS A9537
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$54.00
Rate for Payer: Aetna of CA Government/Medicare	$54.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$72.00
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Commercial	$67.50

KIT FOR THE PREPARATION OF TC-99M-TETROFOSMIN 0.23 MG IV SOLUTION [98467]

Facility

$818.62

Service Code	HCPCS A9502
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$450.24
Max. Negotiated Rate	$654.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$491.17
Rate for Payer: Aetna of CA Government/Medicare	$491.17
Rate for Payer: Cash Price	$450.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$654.90
Rate for Payer: Health Smart Auto/Commercial	$491.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$491.17
Rate for Payer: LLUH Dept of Risk Management WC	$450.24
Rate for Payer: Multiplan Commercial	$613.97

KIT FOR THE PREPARATION OF TC-99M-TETROFOSMIN 0.23 MG IV SOLUTION [98467]

Facility

$818.62

Service Code	HCPCS A9502
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$450.24
Max. Negotiated Rate	$654.90
Rate for Payer: Cash Price	$450.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$654.90
Rate for Payer: Health Smart Auto/Commercial	$491.17
Rate for Payer: LLUH Dept of Risk Management WC	$450.24
Rate for Payer: Multiplan Commercial	$613.97

KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [223025]

Facility

$755.82

Service Code	HCPCS A9520
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$415.70
Max. Negotiated Rate	$604.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$453.49
Rate for Payer: Aetna of CA Government/Medicare	$453.49
Rate for Payer: Cash Price	$415.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$604.66
Rate for Payer: Health Smart Auto/Commercial	$453.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$453.49
Rate for Payer: LLUH Dept of Risk Management WC	$415.70
Rate for Payer: Multiplan Commercial	$566.87

KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [223025]

Facility

$755.82

Service Code	HCPCS A9520
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$415.70
Max. Negotiated Rate	$604.66
Rate for Payer: Cash Price	$415.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$604.66
Rate for Payer: Health Smart Auto/Commercial	$453.49
Rate for Payer: LLUH Dept of Risk Management WC	$415.70
Rate for Payer: Multiplan Commercial	$566.87

KIT PREPARATION OF TC 99M-SESTAMIBI COMBO NO.1 IV SOLUTION [121547]

Facility

$36.00

Service Code	HCPCS A9500
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$28.80
Rate for Payer: Cash Price	$19.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.80
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: Multiplan Commercial	$27.00

KIT PREPARATION OF TC 99M-SESTAMIBI COMBO NO.1 IV SOLUTION [121547]

Facility

$36.00

Service Code	HCPCS A9500
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.60
Rate for Payer: Aetna of CA Government/Medicare	$21.60
Rate for Payer: Cash Price	$19.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.80
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: Multiplan Commercial	$27.00

KIT PREPARATION OF TC-99M-SODIUM PYROPHOSPHATE 12 MG IV SOLUTION [121139]

Facility

$28.62

Service Code	HCPCS A9538
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$15.74
Max. Negotiated Rate	$22.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.17
Rate for Payer: Aetna of CA Government/Medicare	$17.17
Rate for Payer: Cash Price	$15.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.90
Rate for Payer: Health Smart Auto/Commercial	$17.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.17
Rate for Payer: LLUH Dept of Risk Management WC	$15.74
Rate for Payer: Multiplan Commercial	$21.46

KIT PREPARATION OF TC-99M-SODIUM PYROPHOSPHATE 12 MG IV SOLUTION [121139]

Facility

$28.62

Service Code	HCPCS A9538
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$15.74
Max. Negotiated Rate	$22.90
Rate for Payer: Cash Price	$15.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.90
Rate for Payer: Health Smart Auto/Commercial	$17.17
Rate for Payer: LLUH Dept of Risk Management WC	$15.74
Rate for Payer: Multiplan Commercial	$21.46

K-PHOS NEUTRAL ORAL SUSP CMPD 25 MG/ML (0.1 MEQ/ML) [4080284]

Facility

$0.49

Service Code	NDC 9994-0802-84
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37

K-PHOS NEUTRAL ORAL SUSP CMPD 25 MG/ML (0.1 MEQ/ML) [4080284]

Facility

$0.49

Service Code	NDC 9994-0802-84
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37

LABETALOL 100 MG TABLET [10373]

Facility

$0.49

Service Code	NDC 68001-381-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37

LABETALOL 100 MG TABLET [10373]

Facility

$0.54

Service Code	NDC 60687-439-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

LABETALOL 100 MG TABLET [10373]

Facility

$0.49

Service Code	NDC 68001-381-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37

LABETALOL 100 MG TABLET [10373]

Facility

$0.54

Service Code	NDC 60687-439-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

LABETALOL 100 MG TABLET [10373]

Facility

$0.54

Service Code	NDC 60687-439-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

LABETALOL 100 MG TABLET [10373]

Facility

$0.54

Service Code	NDC 60687-439-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

LABETALOL 200 MG TABLET [10374]

Facility

$0.34

Service Code	NDC 68382-799-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

LABETALOL 200 MG TABLET [10374]

Facility

$0.68

Service Code	NDC 68001-382-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.51

LABETALOL 200 MG TABLET [10374]

Facility

$0.34

Service Code	NDC 68382-799-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

LABETALOL 200 MG TABLET [10374]

Facility

$0.34

Service Code	NDC 70377-061-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

LABETALOL 200 MG TABLET [10374]

Facility

$0.68

Service Code	NDC 68001-382-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.51

Know your out-of-pocket cost for care.

All Charges