Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: 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

TEMAZEPAM 15 MG CAPSULE [7753]

Facility

$0.10

Service Code	NDC 67877-146-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.08

TEMAZEPAM 15 MG CAPSULE [7753]

Facility

$0.10

Service Code	NDC 67877-146-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
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	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
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 Commercial	$0.08

TEMAZEPAM 15 MG CAPSULE [7753]

Facility

$0.11

Service Code	NDC 67877-146-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

TEMAZEPAM 15 MG CAPSULE [7753]

Facility

$0.11

Service Code	NDC 0228-2076-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

TEMAZEPAM 15 MG CAPSULE [7753]

Facility

$0.11

Service Code	NDC 0228-2076-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

TEMAZEPAM 15 MG CAPSULE [7753]

Facility

$0.11

Service Code	NDC 67877-146-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

TEMAZEPAM 30 MG CAPSULE [7754]

Facility

$0.14

Service Code	NDC 0378-5050-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

TEMAZEPAM 30 MG CAPSULE [7754]

Facility

$0.14

Service Code	NDC 0378-5050-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

TEMAZEPAM 7.5 MG CAPSULE [11500]

Facility

$4.20

Service Code	NDC 0904-6436-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.52
Rate for Payer: Aetna of CA Government/Medicare	$2.52
Rate for Payer: Cash Price	$2.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Commercial	$3.15

TEMAZEPAM 7.5 MG CAPSULE [11500]

Facility

$4.20

Service Code	NDC 0904-6436-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$3.36
Rate for Payer: Cash Price	$2.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.36
Rate for Payer: Health Smart Auto/Commercial	$2.52
Rate for Payer: LLUH Dept of Risk Management WC	$2.31
Rate for Payer: Multiplan Commercial	$3.15

TEMOZOLOMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080346]

Facility

$26.03

Service Code	HCPCS J8700
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$14.32
Max. Negotiated Rate	$20.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.62
Rate for Payer: Aetna of CA Government/Medicare	$15.62
Rate for Payer: Cash Price	$14.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.82
Rate for Payer: Health Smart Auto/Commercial	$15.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.62
Rate for Payer: LLUH Dept of Risk Management WC	$14.32
Rate for Payer: Multiplan Commercial	$19.52

TEMOZOLOMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080346]

Facility

$26.03

Service Code	HCPCS J8700
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$14.32
Max. Negotiated Rate	$20.82
Rate for Payer: Cash Price	$14.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.82
Rate for Payer: Health Smart Auto/Commercial	$15.62
Rate for Payer: LLUH Dept of Risk Management WC	$14.32
Rate for Payer: Multiplan Commercial	$19.52

TENOFOVIR ALAFENAMIDE 25 MG TABLET [216415]

Facility

$61.07

Service Code	NDC 61958-2301-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$33.59
Max. Negotiated Rate	$48.86
Rate for Payer: Cash Price	$33.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.86
Rate for Payer: Health Smart Auto/Commercial	$36.64
Rate for Payer: LLUH Dept of Risk Management WC	$33.59
Rate for Payer: Multiplan Commercial	$45.80

TENOFOVIR ALAFENAMIDE 25 MG TABLET [216415]

Facility

$61.07

Service Code	NDC 61958-2301-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$33.59
Max. Negotiated Rate	$48.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.64
Rate for Payer: Aetna of CA Government/Medicare	$36.64
Rate for Payer: Cash Price	$33.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.86
Rate for Payer: Health Smart Auto/Commercial	$36.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.64
Rate for Payer: LLUH Dept of Risk Management WC	$33.59
Rate for Payer: Multiplan Commercial	$45.80

TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [31684]

Facility

$2.82

Service Code	NDC 50268-758-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.26
Rate for Payer: Cash Price	$1.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.26
Rate for Payer: Health Smart Auto/Commercial	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.55
Rate for Payer: Multiplan Commercial	$2.12

TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [31684]

Facility

$1.15

Service Code	NDC 69097-533-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.92
Rate for Payer: Cash Price	$0.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.92
Rate for Payer: Health Smart Auto/Commercial	$0.69
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: Multiplan Commercial	$0.86

TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [31684]

Facility

$2.82

Service Code	NDC 50268-758-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.69
Rate for Payer: Aetna of CA Government/Medicare	$1.69
Rate for Payer: Cash Price	$1.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.26
Rate for Payer: Health Smart Auto/Commercial	$1.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.55
Rate for Payer: Multiplan Commercial	$2.12

TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [31684]

Facility

$2.82

Service Code	NDC 50268-758-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.69
Rate for Payer: Aetna of CA Government/Medicare	$1.69
Rate for Payer: Cash Price	$1.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.26
Rate for Payer: Health Smart Auto/Commercial	$1.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.55
Rate for Payer: Multiplan Commercial	$2.12

TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [31684]

Facility

$2.82

Service Code	NDC 50268-758-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.26
Rate for Payer: Cash Price	$1.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.26
Rate for Payer: Health Smart Auto/Commercial	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.55
Rate for Payer: Multiplan Commercial	$2.12

TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [31684]

Facility

$1.15

Service Code	NDC 69097-533-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.69
Rate for Payer: Aetna of CA Government/Medicare	$0.69
Rate for Payer: Cash Price	$0.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.92
Rate for Payer: Health Smart Auto/Commercial	$0.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.69
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: Multiplan Commercial	$0.86

TERAZOSIN 1 MG CAPSULE [14550]

Facility

$0.22

Service Code	NDC 59746-383-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

TERAZOSIN 1 MG CAPSULE [14550]

Facility

$0.22

Service Code	NDC 59746-383-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

TERAZOSIN 2 MG CAPSULE [14551]

Facility

$0.21

Service Code	NDC 59746-384-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.16

TERAZOSIN 2 MG CAPSULE [14551]

Facility

$0.22

Service Code	NDC 59746-384-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

Know your out-of-pocket cost for care.

All Charges