Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION [12935]

Facility

$306.03

Service Code	HCPCS J7525
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$168.32
Max. Negotiated Rate	$244.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$183.62
Rate for Payer: Aetna of CA Government/Medicare	$183.62
Rate for Payer: Cash Price	$168.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$244.82
Rate for Payer: Health Smart Auto/Commercial	$183.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$183.62
Rate for Payer: LLUH Dept of Risk Management WC	$168.32
Rate for Payer: Multiplan Commercial	$229.52

TACROLIMUS ORAL SUSPENSION COMPOUND 0.5 MG/ML [4080345]

Facility

$2.61

Service Code	NDC 9994-0803-45
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$2.09
Rate for Payer: Cash Price	$1.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.09
Rate for Payer: Health Smart Auto/Commercial	$1.57
Rate for Payer: LLUH Dept of Risk Management WC	$1.44
Rate for Payer: Multiplan Commercial	$1.96

TACROLIMUS ORAL SUSPENSION COMPOUND 0.5 MG/ML [4080345]

Facility

$2.61

Service Code	NDC 9994-0803-45
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$2.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.57
Rate for Payer: Aetna of CA Government/Medicare	$1.57
Rate for Payer: Cash Price	$1.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.09
Rate for Payer: Health Smart Auto/Commercial	$1.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.57
Rate for Payer: LLUH Dept of Risk Management WC	$1.44
Rate for Payer: Multiplan Commercial	$1.96

TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR [211104]

Facility

$6.37

Service Code	HCPCS J7508
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.10
Rate for Payer: Cash Price	$3.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.10
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Commercial	$4.78

TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR [211104]

Facility

$6.37

Service Code	HCPCS J7508
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.82
Rate for Payer: Aetna of CA Government/Medicare	$3.82
Rate for Payer: Cash Price	$3.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.10
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Commercial	$4.78

TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR [211105]

Facility

$8.49

Service Code	HCPCS J7508
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$6.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.09
Rate for Payer: Aetna of CA Government/Medicare	$5.09
Rate for Payer: Cash Price	$4.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.79
Rate for Payer: Health Smart Auto/Commercial	$5.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.09
Rate for Payer: LLUH Dept of Risk Management WC	$4.67
Rate for Payer: Multiplan Commercial	$6.37

TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR [211105]

Facility

$8.49

Service Code	HCPCS J7508
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.79
Rate for Payer: Health Smart Auto/Commercial	$5.09
Rate for Payer: LLUH Dept of Risk Management WC	$4.67
Rate for Payer: Multiplan Commercial	$6.37

TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR [211106]

Facility

$33.95

Service Code	HCPCS J7508
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$18.67
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$18.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.16
Rate for Payer: Health Smart Auto/Commercial	$20.37
Rate for Payer: LLUH Dept of Risk Management WC	$18.67
Rate for Payer: Multiplan Commercial	$25.46

TACROLIMUS XR 4 MG TABLET,EXTENDED RELEASE 24 HR [211106]

Facility

$33.95

Service Code	HCPCS J7508
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$18.67
Max. Negotiated Rate	$27.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.37
Rate for Payer: Aetna of CA Government/Medicare	$20.37
Rate for Payer: Cash Price	$18.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.16
Rate for Payer: Health Smart Auto/Commercial	$20.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.37
Rate for Payer: LLUH Dept of Risk Management WC	$18.67
Rate for Payer: Multiplan Commercial	$25.46

TADALAFIL 20 MG TABLET [36986]

Facility

$0.44

Service Code	NDC 43547-051-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

TADALAFIL 20 MG TABLET [36986]

Facility

$3.88

Service Code	NDC 50268-739-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.13
Max. Negotiated Rate	$3.10
Rate for Payer: Cash Price	$2.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.10
Rate for Payer: Health Smart Auto/Commercial	$2.33
Rate for Payer: LLUH Dept of Risk Management WC	$2.13
Rate for Payer: Multiplan Commercial	$2.91

TADALAFIL 20 MG TABLET [36986]

Facility

$3.88

Service Code	NDC 50268-739-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.13
Max. Negotiated Rate	$3.10
Rate for Payer: Cash Price	$2.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.10
Rate for Payer: Health Smart Auto/Commercial	$2.33
Rate for Payer: LLUH Dept of Risk Management WC	$2.13
Rate for Payer: Multiplan Commercial	$2.91

TADALAFIL 20 MG TABLET [36986]

Facility

$3.88

Service Code	NDC 50268-739-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.13
Max. Negotiated Rate	$3.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.33
Rate for Payer: Aetna of CA Government/Medicare	$2.33
Rate for Payer: Cash Price	$2.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.10
Rate for Payer: Health Smart Auto/Commercial	$2.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.33
Rate for Payer: LLUH Dept of Risk Management WC	$2.13
Rate for Payer: Multiplan Commercial	$2.91

TADALAFIL 20 MG TABLET [36986]

Facility

$3.88

Service Code	NDC 50268-739-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.13
Max. Negotiated Rate	$3.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.33
Rate for Payer: Aetna of CA Government/Medicare	$2.33
Rate for Payer: Cash Price	$2.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.10
Rate for Payer: Health Smart Auto/Commercial	$2.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.33
Rate for Payer: LLUH Dept of Risk Management WC	$2.13
Rate for Payer: Multiplan Commercial	$2.91

TADALAFIL 20 MG TABLET [36986]

Facility

$0.44

Service Code	NDC 43547-051-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION) [214774]

Facility

$1.00

Service Code	NDC 27241-123-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.60
Rate for Payer: Aetna of CA Government/Medicare	$0.60
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION) [214774]

Facility

$0.60

Service Code	NDC 33342-278-09
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION) [214774]

Facility

$1.00

Service Code	NDC 69097-526-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.60
Rate for Payer: Aetna of CA Government/Medicare	$0.60
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION) [214774]

Facility

$1.00

Service Code	NDC 27241-123-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION) [214774]

Facility

$1.00

Service Code	NDC 69097-526-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

TADALAFIL 20 MG TABLET (PULMONARY HYPERTENSION) [214774]

Facility

$0.60

Service Code	NDC 33342-278-09
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

TADALAFIL 5 MG TABLET [37400]

Facility

$0.36

Service Code	NDC 43598-575-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

TADALAFIL 5 MG TABLET [37400]

Facility

$0.36

Service Code	NDC 43598-575-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

TADALAFIL ORAL SUSPENSION COMPOUND 5 MG/ML [4081077]

Facility

$0.25

Service Code	NDC 99994-0810-77
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

TADALAFIL ORAL SUSPENSION COMPOUND 5 MG/ML [4081077]

Facility

$0.25

Service Code	NDC 99994-0810-77
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

Know your out-of-pocket cost for care.

All Charges