Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: 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 5 MG CAPSULE [14553]

Facility

$0.22

Service Code	NDC 59746-385-06
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 5 MG CAPSULE [14553]

Facility

$1.01

Service Code	NDC 50268-766-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.81
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.81
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.76

TERAZOSIN 5 MG CAPSULE [14553]

Facility

$0.22

Service Code	NDC 59746-385-06
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 5 MG CAPSULE [14553]

Facility

$1.01

Service Code	NDC 50268-766-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.81
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.81
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.76

TERAZOSIN 5 MG CAPSULE [14553]

Facility

$1.01

Service Code	NDC 50268-766-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.81
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.76

TERAZOSIN 5 MG CAPSULE [14553]

Facility

$1.01

Service Code	NDC 50268-766-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.81
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.76

TERBINAFINE HCL 1 % TOPICAL CREAM [27023]

Facility

$0.50

Service Code	NDC 8770140471
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

TERBINAFINE HCL 1 % TOPICAL CREAM [27023]

Facility

$0.50

Service Code	NDC 8770140471
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

TERBINAFINE HCL 1 % TOPICAL CREAM [27023]

Facility

$0.40

Service Code	NDC 8770140472
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

TERBINAFINE HCL 1 % TOPICAL CREAM [27023]

Facility

$0.42

Service Code	NDC 24385-524-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.32

TERBINAFINE HCL 1 % TOPICAL CREAM [27023]

Facility

$0.40

Service Code	NDC 8770140472
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

TERBINAFINE HCL 1 % TOPICAL CREAM [27023]

Facility

$0.52

Service Code	NDC 51672-2080-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.39

TERBINAFINE HCL 1 % TOPICAL CREAM [27023]

Facility

$0.54

Service Code	NDC 24385-524-05
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

TERBINAFINE HCL 1 % TOPICAL CREAM [27023]

Facility

$0.52

Service Code	NDC 51672-2080-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.39

TERBINAFINE HCL 1 % TOPICAL CREAM [27023]

Facility

$0.54

Service Code	NDC 24385-524-05
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

TERBINAFINE HCL 1 % TOPICAL CREAM [27023]

Facility

$0.42

Service Code	NDC 24385-524-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.32

TERBINAFINE HCL 250 MG TABLET [12724]

Facility

$0.30

Service Code	NDC 65862-079-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

TERBINAFINE HCL 250 MG TABLET [12724]

Facility

$0.30

Service Code	NDC 65862-079-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

TERBUTALINE 1 MG/ML CONTINUOUS INFUSION (STRAIGHT DRUG) [4080921]

Facility

$23.64

Service Code	HCPCS J3105
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$18.91
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cash Price	$2.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.91
Rate for Payer: Health Smart Auto/Commercial	$14.18
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$13.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Commercial	$17.73
Rate for Payer: Multiplan Commercial	$3.60

TERBUTALINE 1 MG/ML CONTINUOUS INFUSION (STRAIGHT DRUG) [4080921]

Facility

$4.80

Service Code	HCPCS J3105
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.18
Rate for Payer: Aetna of CA Government/Medicare	$14.18
Rate for Payer: Aetna of CA Government/Medicare	$2.88
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cash Price	$2.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.91
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Health Smart Auto/Commercial	$14.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$13.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Commercial	$3.60
Rate for Payer: Multiplan Commercial	$17.73

TERBUTALINE 1 MG/ML MED NEB SOLUTION [192332]

Facility

$4.80

Service Code	HCPCS J3105
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.18
Rate for Payer: Aetna of CA Government/Medicare	$14.18
Rate for Payer: Aetna of CA Government/Medicare	$2.88
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cash Price	$2.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.91
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Health Smart Auto/Commercial	$14.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$13.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Commercial	$3.60
Rate for Payer: Multiplan Commercial	$17.73

TERBUTALINE 1 MG/ML MED NEB SOLUTION [192332]

Facility

$23.64

Service Code	HCPCS J3105
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$18.91
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cash Price	$2.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.91
Rate for Payer: Health Smart Auto/Commercial	$14.18
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$13.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Commercial	$17.73
Rate for Payer: Multiplan Commercial	$3.60

TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION [11507]

Facility

$4.80

Service Code	HCPCS J3105
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.18
Rate for Payer: Aetna of CA Government/Medicare	$1.30
Rate for Payer: Aetna of CA Government/Medicare	$2.88
Rate for Payer: Aetna of CA Government/Medicare	$14.18
Rate for Payer: Cash Price	$1.19
Rate for Payer: Cash Price	$2.64
Rate for Payer: Cash Price	$13.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.91
Rate for Payer: Health Smart Auto/Commercial	$1.30
Rate for Payer: Health Smart Auto/Commercial	$14.18
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$13.00
Rate for Payer: LLUH Dept of Risk Management WC	$1.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Commercial	$1.62
Rate for Payer: Multiplan Commercial	$17.73
Rate for Payer: Multiplan Commercial	$3.60

Know your out-of-pocket cost for care.

All Charges