Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

KIT FOR PREPARATION OF GA-68-GOZETOTIDE 25 MCG INTRAVENOUS SOLUTION [233443]

Facility

$5,640.00

Service Code	CPT A9596
Hospital Charge Code	ERX233443
Hospital Revenue Code	636
Min. Negotiated Rate	$3,102.00
Max. Negotiated Rate	$4,230.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3,384.00
Rate for Payer: Aetna of CA Government/Medicare	$3,384.00
Rate for Payer: Cash Price	$2,538.00
Rate for Payer: Health Smart Auto/Commercial	$3,384.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3,384.00
Rate for Payer: LLUH Dept of Risk Management WC	$3,102.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,230.00

KIT FOR PREPARATION OF GA-68-GOZETOTIDE 25 MCG INTRAVENOUS SOLUTION [233443]

Facility

$5,640.00

Service Code	CPT A9596
Hospital Charge Code	ERX233443
Hospital Revenue Code	636
Min. Negotiated Rate	$3,102.00
Max. Negotiated Rate	$4,512.00
Rate for Payer: Cash Price	$2,538.00
Rate for Payer: Cigna of CA HMO/PPO	$4,512.00
Rate for Payer: Health Smart Auto/Commercial	$3,384.00
Rate for Payer: LLUH Dept of Risk Management WC	$3,102.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,230.00

KIT FOR PREPARATION OF TC-99M-MEDRONATE SODIUM 25 MG IV SOLUTION [121677]

Facility

$15.60

Service Code	CPT A9503
Hospital Charge Code	ERX121677
Hospital Revenue Code	343
Min. Negotiated Rate	$8.58
Max. Negotiated Rate	$12.48
Rate for Payer: Cash Price	$7.02
Rate for Payer: Cigna of CA HMO/PPO	$12.48
Rate for Payer: Health Smart Auto/Commercial	$9.36
Rate for Payer: LLUH Dept of Risk Management WC	$8.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.70

KIT FOR PREPARATION OF TC-99M-MEDRONATE SODIUM 25 MG IV SOLUTION [121677]

Facility

$15.60

Service Code	CPT A9503
Hospital Charge Code	ERX121677
Hospital Revenue Code	343
Min. Negotiated Rate	$8.58
Max. Negotiated Rate	$11.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.36
Rate for Payer: Aetna of CA Government/Medicare	$9.36
Rate for Payer: Cash Price	$7.02
Rate for Payer: Health Smart Auto/Commercial	$9.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.36
Rate for Payer: LLUH Dept of Risk Management WC	$8.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.70

KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) 1 MG INTRAVENOUS SOLUTION [225273]

Facility

$498.77

Service Code	CPT A9562
Hospital Charge Code	ERX225273
Hospital Revenue Code	343
Min. Negotiated Rate	$274.32
Max. Negotiated Rate	$399.02
Rate for Payer: Cash Price	$224.45
Rate for Payer: Cigna of CA HMO/PPO	$399.02
Rate for Payer: Health Smart Auto/Commercial	$299.26
Rate for Payer: LLUH Dept of Risk Management WC	$274.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$374.08

KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) 1 MG INTRAVENOUS SOLUTION [225273]

Facility

$498.77

Service Code	CPT A9562
Hospital Charge Code	ERX225273
Hospital Revenue Code	343
Min. Negotiated Rate	$274.32
Max. Negotiated Rate	$374.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$299.26
Rate for Payer: Aetna of CA Government/Medicare	$299.26
Rate for Payer: Cash Price	$224.45
Rate for Payer: Health Smart Auto/Commercial	$299.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$299.26
Rate for Payer: LLUH Dept of Risk Management WC	$274.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$374.08

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

Facility

$181.13

Service Code	CPT A9560
Hospital Charge Code	ERX225270
Hospital Revenue Code	343
Min. Negotiated Rate	$99.62
Max. Negotiated Rate	$144.90
Rate for Payer: Cash Price	$81.51
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$135.85

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

Facility

$181.13

Service Code	CPT A9560
Hospital Charge Code	ERX225270
Hospital Revenue Code	343
Min. Negotiated Rate	$99.62
Max. Negotiated Rate	$135.85
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	$81.51
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 Beech St/Commercial/PHCS	$135.85

KIT FOR THE PREPARATION OF GA-68-DOTATATE 40 MCG INTRAVENOUS SOLN [215477]

Facility

$3,600.00

Service Code	CPT A9587
Hospital Charge Code	ERX215477
Hospital Revenue Code	343
Min. Negotiated Rate	$1,980.00
Max. Negotiated Rate	$2,700.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,160.00
Rate for Payer: Aetna of CA Government/Medicare	$2,160.00
Rate for Payer: Cash Price	$1,620.00
Rate for Payer: Health Smart Auto/Commercial	$2,160.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,160.00
Rate for Payer: LLUH Dept of Risk Management WC	$1,980.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,700.00

KIT FOR THE PREPARATION OF GA-68-DOTATATE 40 MCG INTRAVENOUS SOLN [215477]

Facility

$3,600.00

Service Code	CPT A9587
Hospital Charge Code	ERX215477
Hospital Revenue Code	343
Min. Negotiated Rate	$1,980.00
Max. Negotiated Rate	$2,880.00
Rate for Payer: Cash Price	$1,620.00
Rate for Payer: Cigna of CA HMO/PPO	$2,880.00
Rate for Payer: Health Smart Auto/Commercial	$2,160.00
Rate for Payer: LLUH Dept of Risk Management WC	$1,980.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,700.00

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

Facility

$90.00

Service Code	CPT A9537
Hospital Charge Code	ERX121131
Hospital Revenue Code	343
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$72.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$67.50

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

Facility

$90.00

Service Code	CPT A9537
Hospital Charge Code	ERX121131
Hospital Revenue Code	343
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$67.50
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	$40.50
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 Beech St/Commercial/PHCS	$67.50

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

Facility

$755.82

Service Code	CPT A9520
Hospital Charge Code	ERX223025
Hospital Revenue Code	343
Min. Negotiated Rate	$415.70
Max. Negotiated Rate	$604.66
Rate for Payer: Cash Price	$340.12
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$566.86

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

Facility

$755.82

Service Code	CPT A9520
Hospital Charge Code	ERX223025
Hospital Revenue Code	343
Min. Negotiated Rate	$415.70
Max. Negotiated Rate	$566.86
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	$340.12
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 Beech St/Commercial/PHCS	$566.86

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	1715213
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.37
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	$0.22
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 Beech St/Commercial/PHCS	$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	1715213
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.37

LABETALOL 100 MG TABLET [10373]

Facility

$0.54

Service Code	NDC 60687-439-11
Hospital Charge Code	1711384
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
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	$0.24
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 Beech St/Commercial/PHCS	$0.41

LABETALOL 100 MG TABLET [10373]

Facility

$0.54

Service Code	NDC 60687-439-11
Hospital Charge Code	1711384
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.41

LABETALOL 100 MG TABLET [10373]

Facility

$0.49

Service Code	NDC 68001-381-00
Hospital Charge Code	1711384
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.37

LABETALOL 100 MG TABLET [10373]

Facility

$0.49

Service Code	NDC 68001-381-00
Hospital Charge Code	1711384
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.37
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	$0.22
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 Beech St/Commercial/PHCS	$0.37

LABETALOL 100 MG TABLET [10373]

Facility

$0.54

Service Code	NDC 60687-439-01
Hospital Charge Code	1711384
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.41

LABETALOL 100 MG TABLET [10373]

Facility

$0.49

Service Code	NDC 0185-0010-01
Hospital Charge Code	1711384
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.37
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	$0.22
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 Beech St/Commercial/PHCS	$0.37

LABETALOL 100 MG TABLET [10373]

Facility

$0.54

Service Code	NDC 60687-439-01
Hospital Charge Code	1711384
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
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	$0.24
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 Beech St/Commercial/PHCS	$0.41

LABETALOL 100 MG TABLET [10373]

Facility

$0.49

Service Code	NDC 0185-0010-01
Hospital Charge Code	1711384
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.37

LABETALOL 200 MG TABLET [10374]

Facility

$0.34

Service Code	NDC 68382-799-01
Hospital Charge Code	1711385
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
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	$0.15
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 Beech St/Commercial/PHCS	$0.26

Know your out-of-pocket cost for care.

All Charges