Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TETRABENAZINE 25 MG TABLET [92777]

Facility

$455.76

Service Code	NDC 67386-422-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$250.67
Max. Negotiated Rate	$364.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$273.46
Rate for Payer: Aetna of CA Government/Medicare	$273.46
Rate for Payer: Cash Price	$250.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$364.61
Rate for Payer: Health Smart Auto/Commercial	$273.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$273.46
Rate for Payer: LLUH Dept of Risk Management WC	$250.67
Rate for Payer: Multiplan Commercial	$341.82

TETRABENAZINE 25 MG TABLET [92777]

Facility

$455.76

Service Code	NDC 67386-422-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$250.67
Max. Negotiated Rate	$364.61
Rate for Payer: Cash Price	$250.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$364.61
Rate for Payer: Health Smart Auto/Commercial	$273.46
Rate for Payer: LLUH Dept of Risk Management WC	$250.67
Rate for Payer: Multiplan Commercial	$341.82

TETRACAINE 0.5 % EYE DROPS [7795]

Facility

$7.20

Service Code	NDC 68682-920-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.96
Max. Negotiated Rate	$5.76
Rate for Payer: Cash Price	$3.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.76
Rate for Payer: Health Smart Auto/Commercial	$4.32
Rate for Payer: LLUH Dept of Risk Management WC	$3.96
Rate for Payer: Multiplan Commercial	$5.40

TETRACAINE 0.5 % EYE DROPS [7795]

Facility

$7.20

Service Code	NDC 68682-920-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.96
Max. Negotiated Rate	$5.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.32
Rate for Payer: Aetna of CA Government/Medicare	$4.32
Rate for Payer: Cash Price	$3.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.76
Rate for Payer: Health Smart Auto/Commercial	$4.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.32
Rate for Payer: LLUH Dept of Risk Management WC	$3.96
Rate for Payer: Multiplan Commercial	$5.40

TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]

Facility

$4.16

Service Code	NDC 0065-0741-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$3.33
Rate for Payer: Cash Price	$2.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.33
Rate for Payer: Health Smart Auto/Commercial	$2.50
Rate for Payer: LLUH Dept of Risk Management WC	$2.29
Rate for Payer: Multiplan Commercial	$3.12

TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]

Facility

$4.16

Service Code	NDC 0065-0741-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$3.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.50
Rate for Payer: Aetna of CA Government/Medicare	$2.50
Rate for Payer: Cash Price	$2.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.33
Rate for Payer: Health Smart Auto/Commercial	$2.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.50
Rate for Payer: LLUH Dept of Risk Management WC	$2.29
Rate for Payer: Multiplan Commercial	$3.12

TETRACYCLINE 500 MG CAPSULE [7797]

Facility

$2.96

Service Code	NDC 60219-1523-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.63
Max. Negotiated Rate	$2.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.78
Rate for Payer: Aetna of CA Government/Medicare	$1.78
Rate for Payer: Cash Price	$1.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.37
Rate for Payer: Health Smart Auto/Commercial	$1.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.78
Rate for Payer: LLUH Dept of Risk Management WC	$1.63
Rate for Payer: Multiplan Commercial	$2.22

TETRACYCLINE 500 MG CAPSULE [7797]

Facility

$3.94

Service Code	NDC 51991-907-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$3.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.36
Rate for Payer: Aetna of CA Government/Medicare	$2.36
Rate for Payer: Cash Price	$2.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.15
Rate for Payer: Health Smart Auto/Commercial	$2.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.36
Rate for Payer: LLUH Dept of Risk Management WC	$2.17
Rate for Payer: Multiplan Commercial	$2.96

TETRACYCLINE 500 MG CAPSULE [7797]

Facility

$2.04

Service Code	NDC 23155-767-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$1.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.22
Rate for Payer: Aetna of CA Government/Medicare	$1.22
Rate for Payer: Cash Price	$1.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.63
Rate for Payer: Health Smart Auto/Commercial	$1.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.22
Rate for Payer: LLUH Dept of Risk Management WC	$1.12
Rate for Payer: Multiplan Commercial	$1.53

TETRACYCLINE 500 MG CAPSULE [7797]

Facility

$2.04

Service Code	NDC 23155-767-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$1.63
Rate for Payer: Cash Price	$1.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.63
Rate for Payer: Health Smart Auto/Commercial	$1.22
Rate for Payer: LLUH Dept of Risk Management WC	$1.12
Rate for Payer: Multiplan Commercial	$1.53

TETRACYCLINE 500 MG CAPSULE [7797]

Facility

$3.94

Service Code	NDC 62135-266-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$3.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.36
Rate for Payer: Aetna of CA Government/Medicare	$2.36
Rate for Payer: Cash Price	$2.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.15
Rate for Payer: Health Smart Auto/Commercial	$2.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.36
Rate for Payer: LLUH Dept of Risk Management WC	$2.17
Rate for Payer: Multiplan Commercial	$2.96

TETRACYCLINE 500 MG CAPSULE [7797]

Facility

$3.94

Service Code	NDC 51991-907-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$3.15
Rate for Payer: Cash Price	$2.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.15
Rate for Payer: Health Smart Auto/Commercial	$2.36
Rate for Payer: LLUH Dept of Risk Management WC	$2.17
Rate for Payer: Multiplan Commercial	$2.96

TETRACYCLINE 500 MG CAPSULE [7797]

Facility

$2.96

Service Code	NDC 60219-1523-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.63
Max. Negotiated Rate	$2.37
Rate for Payer: Cash Price	$1.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.37
Rate for Payer: Health Smart Auto/Commercial	$1.78
Rate for Payer: LLUH Dept of Risk Management WC	$1.63
Rate for Payer: Multiplan Commercial	$2.22

TETRACYCLINE 500 MG CAPSULE [7797]

Facility

$3.94

Service Code	NDC 62135-266-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$3.15
Rate for Payer: Cash Price	$2.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.15
Rate for Payer: Health Smart Auto/Commercial	$2.36
Rate for Payer: LLUH Dept of Risk Management WC	$2.17
Rate for Payer: Multiplan Commercial	$2.96

TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]

Facility

$0.21

Service Code	NDC 9994-0803-48
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
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: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.16

TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]

Facility

$0.21

Service Code	NDC 9994-0803-48
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

THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]

Facility

$94.83

Service Code	HCPCS A9505
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$52.16
Max. Negotiated Rate	$75.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$56.90
Rate for Payer: Aetna of CA Government/Medicare	$56.90
Rate for Payer: Cash Price	$52.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$75.86
Rate for Payer: Health Smart Auto/Commercial	$56.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$56.90
Rate for Payer: LLUH Dept of Risk Management WC	$52.16
Rate for Payer: Multiplan Commercial	$71.12

THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]

Facility

$94.83

Service Code	HCPCS A9505
Hospital Charge Code	901700057
Hospital Revenue Code	343
Min. Negotiated Rate	$52.16
Max. Negotiated Rate	$75.86
Rate for Payer: Cash Price	$52.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$75.86
Rate for Payer: Health Smart Auto/Commercial	$56.90
Rate for Payer: LLUH Dept of Risk Management WC	$52.16
Rate for Payer: Multiplan Commercial	$71.12

THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]

Facility

$0.10

Service Code	NDC 0121-0820-16
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

THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]

Facility

$0.10

Service Code	NDC 0121-0820-16
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

THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]

Facility

$0.19

Service Code	NDC 27808-033-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]

Facility

$0.19

Service Code	NDC 27808-033-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14

THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]

Facility

$6.90

Service Code	NDC 52244-200-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.79
Max. Negotiated Rate	$5.52
Rate for Payer: Cash Price	$3.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.52
Rate for Payer: Health Smart Auto/Commercial	$4.14
Rate for Payer: LLUH Dept of Risk Management WC	$3.79
Rate for Payer: Multiplan Commercial	$5.17

THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]

Facility

$6.90

Service Code	NDC 52244-200-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.79
Max. Negotiated Rate	$5.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.14
Rate for Payer: Aetna of CA Government/Medicare	$4.14
Rate for Payer: Cash Price	$3.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.52
Rate for Payer: Health Smart Auto/Commercial	$4.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.14
Rate for Payer: LLUH Dept of Risk Management WC	$3.79
Rate for Payer: Multiplan Commercial	$5.17

THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]

Facility

$8.48

Service Code	NDC 52244-300-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.66
Max. Negotiated Rate	$6.78
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	$4.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.78
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	$4.66
Rate for Payer: Multiplan Commercial	$6.36

Know your out-of-pocket cost for care.

All Charges