Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: 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: LLUH Dept of Risk Management WC	$4.66
Rate for Payer: Multiplan Commercial	$6.36

THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]

Facility

$1.56

Service Code	NDC 68462-721-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.25
Rate for Payer: Cash Price	$0.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.25
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Commercial	$1.17

THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]

Facility

$1.56

Service Code	NDC 62332-025-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.94
Rate for Payer: Aetna of CA Government/Medicare	$0.94
Rate for Payer: Cash Price	$0.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.25
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Commercial	$1.17

THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]

Facility

$0.72

Service Code	NDC 72578-173-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.54

THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]

Facility

$1.56

Service Code	NDC 68462-721-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.94
Rate for Payer: Aetna of CA Government/Medicare	$0.94
Rate for Payer: Cash Price	$0.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.25
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Commercial	$1.17

THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]

Facility

$1.56

Service Code	NDC 62332-025-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.25
Rate for Payer: Cash Price	$0.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.25
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Commercial	$1.17

THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]

Facility

$0.72

Service Code	NDC 72578-173-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
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	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
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	$0.40
Rate for Payer: Multiplan Commercial	$0.54

THEOPHYLLINE ER 400 MG CAPSULE,EXTENDED RELEASE 24 HR [31783]

Facility

$4.64

Service Code	NDC 50474-400-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$3.71
Rate for Payer: Cash Price	$2.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.71
Rate for Payer: Health Smart Auto/Commercial	$2.78
Rate for Payer: LLUH Dept of Risk Management WC	$2.55
Rate for Payer: Multiplan Commercial	$3.48

THEOPHYLLINE ER 400 MG CAPSULE,EXTENDED RELEASE 24 HR [31783]

Facility

$4.64

Service Code	NDC 50474-400-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$3.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.78
Rate for Payer: Aetna of CA Government/Medicare	$2.78
Rate for Payer: Cash Price	$2.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.71
Rate for Payer: Health Smart Auto/Commercial	$2.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.78
Rate for Payer: LLUH Dept of Risk Management WC	$2.55
Rate for Payer: Multiplan Commercial	$3.48

THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR [110533]

Facility

$1.60

Service Code	NDC 68462-380-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.28
Rate for Payer: Cash Price	$0.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.28
Rate for Payer: Health Smart Auto/Commercial	$0.96
Rate for Payer: LLUH Dept of Risk Management WC	$0.88
Rate for Payer: Multiplan Commercial	$1.20

THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR [110533]

Facility

$1.60

Service Code	NDC 68462-380-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.96
Rate for Payer: Aetna of CA Government/Medicare	$0.96
Rate for Payer: Cash Price	$0.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.28
Rate for Payer: Health Smart Auto/Commercial	$0.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.96
Rate for Payer: LLUH Dept of Risk Management WC	$0.88
Rate for Payer: Multiplan Commercial	$1.20

THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]

Facility

$3.72

Service Code	HCPCS J3411
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.98
Rate for Payer: Cash Price	$2.05
Rate for Payer: Cash Price	$3.28
Rate for Payer: Cash Price	$2.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.10
Rate for Payer: Health Smart Auto/Commercial	$3.58
Rate for Payer: Health Smart Auto/Commercial	$3.07
Rate for Payer: Health Smart Auto/Commercial	$2.23
Rate for Payer: LLUH Dept of Risk Management WC	$3.28
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: LLUH Dept of Risk Management WC	$2.82
Rate for Payer: Multiplan Commercial	$4.48
Rate for Payer: Multiplan Commercial	$3.84
Rate for Payer: Multiplan Commercial	$2.79

THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]

Facility

$5.97

Service Code	HCPCS J3411
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$4.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.07
Rate for Payer: Aetna of CA Government/Medicare	$2.23
Rate for Payer: Aetna of CA Government/Medicare	$3.07
Rate for Payer: Aetna of CA Government/Medicare	$3.58
Rate for Payer: Cash Price	$2.82
Rate for Payer: Cash Price	$2.05
Rate for Payer: Cash Price	$3.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.10
Rate for Payer: Health Smart Auto/Commercial	$3.58
Rate for Payer: Health Smart Auto/Commercial	$3.07
Rate for Payer: Health Smart Auto/Commercial	$2.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.23
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: LLUH Dept of Risk Management WC	$2.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.28
Rate for Payer: Multiplan Commercial	$3.84
Rate for Payer: Multiplan Commercial	$2.79
Rate for Payer: Multiplan Commercial	$4.48

THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]

Facility

$0.03

Service Code	NDC 4098521151
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]

Facility

$0.18

Service Code	NDC 0904719106
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
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	$0.14
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

THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]

Facility

$0.04

Service Code	NDC 8068109800
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]

Facility

$0.18

Service Code	NDC 0904719106
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
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

THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]

Facility

$0.04

Service Code	NDC 8068109800
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]

Facility

$0.03

Service Code	NDC 8770140729
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]

Facility

$0.03

Service Code	NDC 4098521151
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]

Facility

$0.03

Service Code	NDC 8770140729
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

THIAMINE HCL (VITAMIN B1) 500 MG TABLET [8650]

Facility

$0.18

Service Code	NDC 1184573105
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
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	$0.14
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

THIAMINE HCL (VITAMIN B1) 500 MG TABLET [8650]

Facility

$0.18

Service Code	NDC 1184573105
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
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

THIAMINE HCL (VITAMIN B1) CRUSHED PARTIAL TABLET [4081453]

Facility

$0.03

Service Code	NDC 8068109700
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

THIAMINE HCL (VITAMIN B1) CRUSHED PARTIAL TABLET [4081453]

Facility

$0.03

Service Code	NDC 8068109700
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

Know your out-of-pocket cost for care.

All Charges