Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TALIMOGENE LAHERPAREPVEC 10EXP6 (1 MILLION) PFU/ML SUSP FOR INJECTION [211748]

Facility

$83.84

Service Code	HCPCS J9325
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$46.11
Max. Negotiated Rate	$67.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$50.30
Rate for Payer: Aetna of CA Government/Medicare	$50.30
Rate for Payer: Cash Price	$46.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$67.07
Rate for Payer: Health Smart Auto/Commercial	$50.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$50.30
Rate for Payer: LLUH Dept of Risk Management WC	$46.11
Rate for Payer: Multiplan Commercial	$62.88

TALIMOGENE LAHERPAREPVEC 10EXP6 (1 MILLION) PFU/ML SUSP FOR INJECTION [211748]

Facility

$83.84

Service Code	HCPCS J9325
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$46.11
Max. Negotiated Rate	$67.07
Rate for Payer: Cash Price	$46.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$67.07
Rate for Payer: Health Smart Auto/Commercial	$50.30
Rate for Payer: LLUH Dept of Risk Management WC	$46.11
Rate for Payer: Multiplan Commercial	$62.88

TAMOXIFEN 10 MG TABLET [7711]

Facility

$0.46

Service Code	HCPCS S0187
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.35

TAMOXIFEN 10 MG TABLET [7711]

Facility

$0.46

Service Code	HCPCS S0187
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.35

TAMOXIFEN 20 MG TABLET [11498]

Facility

$0.46

Service Code	NDC 59651-300-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.35

TAMOXIFEN 20 MG TABLET [11498]

Facility

$0.46

Service Code	NDC 59651-300-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.35

TAMSULOSIN 0.4 MG CAPSULE [103890]

Facility

$0.71

Service Code	NDC 68084-299-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

TAMSULOSIN 0.4 MG CAPSULE [103890]

Facility

$0.33

Service Code	NDC 68382-132-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
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	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
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	$0.18
Rate for Payer: Multiplan Commercial	$0.25

TAMSULOSIN 0.4 MG CAPSULE [103890]

Facility

$0.33

Service Code	NDC 68382-132-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.25

TAMSULOSIN 0.4 MG CAPSULE [103890]

Facility

$0.29

Service Code	NDC 62756-160-88
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

TAMSULOSIN 0.4 MG CAPSULE [103890]

Facility

$0.71

Service Code	NDC 68084-299-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

TAMSULOSIN 0.4 MG CAPSULE [103890]

Facility

$0.71

Service Code	NDC 68084-299-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

TAMSULOSIN 0.4 MG CAPSULE [103890]

Facility

$0.09

Service Code	NDC 65862-598-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

TAMSULOSIN 0.4 MG CAPSULE [103890]

Facility

$0.29

Service Code	NDC 62756-160-88
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

TAMSULOSIN 0.4 MG CAPSULE [103890]

Facility

$0.09

Service Code	NDC 65862-598-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

TAMSULOSIN 0.4 MG CAPSULE [103890]

Facility

$0.71

Service Code	NDC 68084-299-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

TAPENTADOL 50 MG TABLET [98253]

Facility

$14.61

Service Code	NDC 24510-050-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.04
Max. Negotiated Rate	$11.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.77
Rate for Payer: Aetna of CA Government/Medicare	$8.77
Rate for Payer: Cash Price	$8.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.69
Rate for Payer: Health Smart Auto/Commercial	$8.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.77
Rate for Payer: LLUH Dept of Risk Management WC	$8.04
Rate for Payer: Multiplan Commercial	$10.96

TAPENTADOL 50 MG TABLET [98253]

Facility

$14.61

Service Code	NDC 24510-050-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.04
Max. Negotiated Rate	$11.69
Rate for Payer: Cash Price	$8.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.69
Rate for Payer: Health Smart Auto/Commercial	$8.77
Rate for Payer: LLUH Dept of Risk Management WC	$8.04
Rate for Payer: Multiplan Commercial	$10.96

TAZEMETOSTAT 200 MG TABLET [226994]

Facility

$103.88

Service Code	NDC 72607-100-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$57.13
Max. Negotiated Rate	$83.10
Rate for Payer: Cash Price	$57.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$83.10
Rate for Payer: Health Smart Auto/Commercial	$62.33
Rate for Payer: LLUH Dept of Risk Management WC	$57.13
Rate for Payer: Multiplan Commercial	$77.91

TAZEMETOSTAT 200 MG TABLET [226994]

Facility

$103.88

Service Code	NDC 72607-100-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$57.13
Max. Negotiated Rate	$83.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$62.33
Rate for Payer: Aetna of CA Government/Medicare	$62.33
Rate for Payer: Cash Price	$57.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$83.10
Rate for Payer: Health Smart Auto/Commercial	$62.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$62.33
Rate for Payer: LLUH Dept of Risk Management WC	$57.13
Rate for Payer: Multiplan Commercial	$77.91

TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION [236039]

Facility

$819.41

Service Code	HCPCS J9380
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$450.68
Max. Negotiated Rate	$655.53
Rate for Payer: Cash Price	$450.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$655.53
Rate for Payer: Health Smart Auto/Commercial	$491.65
Rate for Payer: LLUH Dept of Risk Management WC	$450.68
Rate for Payer: Multiplan Commercial	$614.56

TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION [236039]

Facility

$819.41

Service Code	HCPCS J9380
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$450.68
Max. Negotiated Rate	$655.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$491.65
Rate for Payer: Aetna of CA Government/Medicare	$491.65
Rate for Payer: Cash Price	$450.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$655.53
Rate for Payer: Health Smart Auto/Commercial	$491.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$491.65
Rate for Payer: LLUH Dept of Risk Management WC	$450.68
Rate for Payer: Multiplan Commercial	$614.56

TELMISARTAN 40 MG TABLET [24335]

Facility

$5.61

Service Code	NDC 0597-0040-37
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$4.49
Rate for Payer: Cash Price	$3.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.49
Rate for Payer: Health Smart Auto/Commercial	$3.37
Rate for Payer: LLUH Dept of Risk Management WC	$3.09
Rate for Payer: Multiplan Commercial	$4.21

TELMISARTAN 40 MG TABLET [24335]

Facility

$5.61

Service Code	NDC 0597-0040-37
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$4.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.37
Rate for Payer: Aetna of CA Government/Medicare	$3.37
Rate for Payer: Cash Price	$3.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.49
Rate for Payer: Health Smart Auto/Commercial	$3.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.37
Rate for Payer: LLUH Dept of Risk Management WC	$3.09
Rate for Payer: Multiplan Commercial	$4.21

TELMISARTAN 80 MG TABLET [24336]

Facility

$5.61

Service Code	NDC 0597-0041-37
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$4.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.37
Rate for Payer: Aetna of CA Government/Medicare	$3.37
Rate for Payer: Cash Price	$3.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.49
Rate for Payer: Health Smart Auto/Commercial	$3.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.37
Rate for Payer: LLUH Dept of Risk Management WC	$3.09
Rate for Payer: Multiplan Commercial	$4.21

Know your out-of-pocket cost for care.

All Charges