Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TIMOLOL MALEATE 0.5 % EYE DROPS [11562]

Facility

$2.33

Service Code	NDC 64980-514-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.40
Rate for Payer: Aetna of CA Government/Medicare	$1.40
Rate for Payer: Cash Price	$1.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.86
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.28
Rate for Payer: Multiplan Commercial	$1.75

TIMOLOL MALEATE 0.5 % ONCE DAILY EYE DROPS [70283]

Facility

$70.19

Service Code	NDC 82260-045-05
Hospital Charge Code	901700030
Hospital Revenue Code	259
Min. Negotiated Rate	$38.60
Max. Negotiated Rate	$56.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.11
Rate for Payer: Aetna of CA Government/Medicare	$42.11
Rate for Payer: Cash Price	$38.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$56.15
Rate for Payer: Health Smart Auto/Commercial	$42.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.11
Rate for Payer: LLUH Dept of Risk Management WC	$38.60
Rate for Payer: Multiplan Commercial	$52.64

TIMOLOL MALEATE 0.5 % ONCE DAILY EYE DROPS [70283]

Facility

$70.19

Service Code	NDC 82260-045-05
Hospital Charge Code	901700030
Hospital Revenue Code	259
Min. Negotiated Rate	$38.60
Max. Negotiated Rate	$56.15
Rate for Payer: Cash Price	$38.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$56.15
Rate for Payer: Health Smart Auto/Commercial	$42.11
Rate for Payer: LLUH Dept of Risk Management WC	$38.60
Rate for Payer: Multiplan Commercial	$52.64

TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE [38315]

Facility

$14.60

Service Code	NDC 0597-0075-75
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.03
Max. Negotiated Rate	$11.68
Rate for Payer: Cash Price	$8.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.68
Rate for Payer: Health Smart Auto/Commercial	$8.76
Rate for Payer: LLUH Dept of Risk Management WC	$8.03
Rate for Payer: Multiplan Commercial	$10.95

TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE [38315]

Facility

$14.60

Service Code	NDC 0597-0075-75
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.03
Max. Negotiated Rate	$11.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.76
Rate for Payer: Aetna of CA Government/Medicare	$8.76
Rate for Payer: Cash Price	$8.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.68
Rate for Payer: Health Smart Auto/Commercial	$8.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.76
Rate for Payer: LLUH Dept of Risk Management WC	$8.03
Rate for Payer: Multiplan Commercial	$10.95

TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION [207738]

Facility

$22.50

Service Code	NDC 0597-0100-51
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$18.00
Rate for Payer: Cash Price	$12.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.00
Rate for Payer: Health Smart Auto/Commercial	$13.50
Rate for Payer: LLUH Dept of Risk Management WC	$12.38
Rate for Payer: Multiplan Commercial	$16.88

TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION [207738]

Facility

$22.50

Service Code	NDC 0597-0100-51
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.50
Rate for Payer: Aetna of CA Government/Medicare	$13.50
Rate for Payer: Cash Price	$12.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.00
Rate for Payer: Health Smart Auto/Commercial	$13.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.50
Rate for Payer: LLUH Dept of Risk Management WC	$12.38
Rate for Payer: Multiplan Commercial	$16.88

TIROFIBAN 12.5 MG/250 ML (50 MCG/ML)-0.9 % SODIUM CHLORIDE INTRAVENOUS [120194]

Facility

$1.15

Service Code	HCPCS J3246
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.92
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cash Price	$0.42
Rate for Payer: Cash Price	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.69
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: LLUH Dept of Risk Management WC	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Commercial	$0.58
Rate for Payer: Multiplan Commercial	$0.82
Rate for Payer: Multiplan Commercial	$0.86

TIROFIBAN 12.5 MG/250 ML (50 MCG/ML)-0.9 % SODIUM CHLORIDE INTRAVENOUS [120194]

Facility

$1.15

Service Code	HCPCS J3246
Hospital Charge Code	901700025
Hospital Revenue Code	636
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 EPO/HMO/POS/PPO	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.46
Rate for Payer: Aetna of CA Government/Medicare	$0.69
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.42
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cash Price	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.87
Rate for Payer: Health Smart Auto/Commercial	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.69
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: Multiplan Commercial	$0.58
Rate for Payer: Multiplan Commercial	$0.82
Rate for Payer: Multiplan Commercial	$0.86

TIROFIBAN 12.5 MG/250 ML (50 MCG/ML) IN NS CONT IV INFUSION [4085694]

Facility

$1.15

Service Code	HCPCS J3246
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.92
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cash Price	$0.42
Rate for Payer: Cash Price	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.69
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: LLUH Dept of Risk Management WC	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Commercial	$0.58
Rate for Payer: Multiplan Commercial	$0.82
Rate for Payer: Multiplan Commercial	$0.86

TIROFIBAN 12.5 MG/250 ML (50 MCG/ML) IN NS CONT IV INFUSION [4085694]

Facility

$1.15

Service Code	HCPCS J3246
Hospital Charge Code	901700025
Hospital Revenue Code	636
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 EPO/HMO/POS/PPO	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.46
Rate for Payer: Aetna of CA Government/Medicare	$0.69
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.42
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cash Price	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.87
Rate for Payer: Health Smart Auto/Commercial	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.69
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: Multiplan Commercial	$0.58
Rate for Payer: Multiplan Commercial	$0.82
Rate for Payer: Multiplan Commercial	$0.86

TIZANIDINE 2 MG TABLET [14792]

Facility

$1.29

Service Code	NDC 68084-775-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$1.03
Rate for Payer: Cash Price	$0.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.03
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.71
Rate for Payer: Multiplan Commercial	$0.97

TIZANIDINE 2 MG TABLET [14792]

Facility

$0.20

Service Code	NDC 60505-0251-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

TIZANIDINE 2 MG TABLET [14792]

Facility

$0.20

Service Code	NDC 60505-0251-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

TIZANIDINE 2 MG TABLET [14792]

Facility

$1.29

Service Code	NDC 68084-775-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$1.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.77
Rate for Payer: Aetna of CA Government/Medicare	$0.77
Rate for Payer: Cash Price	$0.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.03
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.71
Rate for Payer: Multiplan Commercial	$0.97

TIZANIDINE 2 MG TABLET [14792]

Facility

$1.29

Service Code	NDC 68084-775-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$1.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.77
Rate for Payer: Aetna of CA Government/Medicare	$0.77
Rate for Payer: Cash Price	$0.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.03
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.71
Rate for Payer: Multiplan Commercial	$0.97

TIZANIDINE 2 MG TABLET [14792]

Facility

$1.29

Service Code	NDC 68084-775-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$1.03
Rate for Payer: Cash Price	$0.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.03
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.71
Rate for Payer: Multiplan Commercial	$0.97

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.79

Service Code	NDC 50268-760-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.63
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.63

Service Code	NDC 0904-6418-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.47

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.24

Service Code	NDC 60505-0252-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.18

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.79

Service Code	NDC 50268-760-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.24

Service Code	NDC 60505-0252-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.18

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.79

Service Code	NDC 50268-760-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.12

Service Code	NDC 29300-169-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
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	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
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	$0.07
Rate for Payer: Multiplan Commercial	$0.09

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.12

Service Code	NDC 55111-180-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
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	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
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	$0.07
Rate for Payer: Multiplan Commercial	$0.09

Know your out-of-pocket cost for care.

All Charges