Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]

Facility

$1.71

Service Code	NDC 42571-408-19
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.03
Rate for Payer: Aetna of CA Government/Medicare	$1.03
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Commercial	$1.28

TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]

Facility

$1.71

Service Code	NDC 70756-604-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.37
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Commercial	$1.28

TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]

Facility

$2.82

Service Code	NDC 43598-605-04
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

TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]

Facility

$1.71

Service Code	NDC 42571-408-92
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.37
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Commercial	$1.28

TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]

Facility

$1.71

Service Code	NDC 42571-408-09
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.03
Rate for Payer: Aetna of CA Government/Medicare	$1.03
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Commercial	$1.28

TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]

Facility

$1.71

Service Code	NDC 42571-408-09
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.37
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Commercial	$1.28

TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]

Facility

$2.82

Service Code	NDC 43598-605-04
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

TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]

Facility

$1.71

Service Code	NDC 70756-604-44
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.03
Rate for Payer: Aetna of CA Government/Medicare	$1.03
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Commercial	$1.28

TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]

Facility

$1.71

Service Code	NDC 70756-604-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.03
Rate for Payer: Aetna of CA Government/Medicare	$1.03
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Commercial	$1.28

TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]

Facility

$1.71

Service Code	NDC 42571-408-92
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.03
Rate for Payer: Aetna of CA Government/Medicare	$1.03
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Commercial	$1.28

TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]

Facility

$1.71

Service Code	NDC 42571-408-19
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.37
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Commercial	$1.28

TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]

Facility

$1.71

Service Code	NDC 70756-604-44
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.37
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Commercial	$1.28

TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]

Facility

$2.82

Service Code	NDC 43598-605-56
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

TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]

Facility

$0.86

Service Code	HCPCS J3260
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.69
Rate for Payer: Cash Price	$0.47
Rate for Payer: Cash Price	$0.65
Rate for Payer: Cash Price	$0.69
Rate for Payer: Cash Price	$0.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.01
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Commercial	$0.95
Rate for Payer: Multiplan Commercial	$0.89
Rate for Payer: Multiplan Commercial	$0.66
Rate for Payer: Multiplan Commercial	$0.65

TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]

Facility

$0.88

Service Code	HCPCS J3260
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.76
Rate for Payer: Aetna of CA Government/Medicare	$0.53
Rate for Payer: Aetna of CA Government/Medicare	$0.76
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.71
Rate for Payer: Cash Price	$0.47
Rate for Payer: Cash Price	$0.65
Rate for Payer: Cash Price	$0.48
Rate for Payer: Cash Price	$0.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.01
Rate for Payer: Health Smart Auto/Commercial	$0.76
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.76
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Commercial	$0.89
Rate for Payer: Multiplan Commercial	$0.65
Rate for Payer: Multiplan Commercial	$0.66
Rate for Payer: Multiplan Commercial	$0.95

TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]

Facility

$102.20

Service Code	NDC 0078-0876-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$56.21
Max. Negotiated Rate	$81.76
Rate for Payer: Cash Price	$56.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$81.76
Rate for Payer: Health Smart Auto/Commercial	$61.32
Rate for Payer: LLUH Dept of Risk Management WC	$56.21
Rate for Payer: Multiplan Commercial	$76.65

TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]

Facility

$102.20

Service Code	NDC 0078-0876-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$56.21
Max. Negotiated Rate	$81.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$61.32
Rate for Payer: Aetna of CA Government/Medicare	$61.32
Rate for Payer: Cash Price	$56.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$81.76
Rate for Payer: Health Smart Auto/Commercial	$61.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$61.32
Rate for Payer: LLUH Dept of Risk Management WC	$56.21
Rate for Payer: Multiplan Commercial	$76.65

TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION [108062]

Facility

$159.35

Service Code	HCPCS J3262
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$87.64
Max. Negotiated Rate	$127.48
Rate for Payer: Cash Price	$87.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$127.48
Rate for Payer: Health Smart Auto/Commercial	$95.61
Rate for Payer: LLUH Dept of Risk Management WC	$87.64
Rate for Payer: Multiplan Commercial	$119.51

TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION [108062]

Facility

$159.35

Service Code	HCPCS J3262
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$87.64
Max. Negotiated Rate	$127.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$95.61
Rate for Payer: Aetna of CA Government/Medicare	$95.61
Rate for Payer: Cash Price	$87.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$127.48
Rate for Payer: Health Smart Auto/Commercial	$95.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$95.61
Rate for Payer: LLUH Dept of Risk Management WC	$87.64
Rate for Payer: Multiplan Commercial	$119.51

TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [108061]

Facility

$159.35

Service Code	HCPCS J3262
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$87.64
Max. Negotiated Rate	$127.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$95.61
Rate for Payer: Aetna of CA Government/Medicare	$95.61
Rate for Payer: Cash Price	$87.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$127.48
Rate for Payer: Health Smart Auto/Commercial	$95.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$95.61
Rate for Payer: LLUH Dept of Risk Management WC	$87.64
Rate for Payer: Multiplan Commercial	$119.51

TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [108061]

Facility

$159.35

Service Code	HCPCS J3262
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$87.64
Max. Negotiated Rate	$127.48
Rate for Payer: Cash Price	$87.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$127.48
Rate for Payer: Health Smart Auto/Commercial	$95.61
Rate for Payer: LLUH Dept of Risk Management WC	$87.64
Rate for Payer: Multiplan Commercial	$119.51

TOCILIZUMAB-AAZG 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION [241038]

Facility

$117.50

Service Code	HCPCS Q5135
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$64.62
Max. Negotiated Rate	$94.00
Rate for Payer: Cash Price	$64.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$94.00
Rate for Payer: Health Smart Auto/Commercial	$70.50
Rate for Payer: LLUH Dept of Risk Management WC	$64.62
Rate for Payer: Multiplan Commercial	$88.12

TOCILIZUMAB-AAZG 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION [241038]

Facility

$117.50

Service Code	HCPCS Q5135
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$64.62
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$70.50
Rate for Payer: Aetna of CA Government/Medicare	$70.50
Rate for Payer: Cash Price	$64.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$94.00
Rate for Payer: Health Smart Auto/Commercial	$70.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$70.50
Rate for Payer: LLUH Dept of Risk Management WC	$64.62
Rate for Payer: Multiplan Commercial	$88.12

TOCILIZUMAB-AAZG 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION [241039]

Facility

$117.50

Service Code	HCPCS Q5135
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$64.62
Max. Negotiated Rate	$94.00
Rate for Payer: Cash Price	$64.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$94.00
Rate for Payer: Health Smart Auto/Commercial	$70.50
Rate for Payer: LLUH Dept of Risk Management WC	$64.62
Rate for Payer: Multiplan Commercial	$88.12

TOCILIZUMAB-AAZG 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION [241039]

Facility

$117.50

Service Code	HCPCS Q5135
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$64.62
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$70.50
Rate for Payer: Aetna of CA Government/Medicare	$70.50
Rate for Payer: Cash Price	$64.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$94.00
Rate for Payer: Health Smart Auto/Commercial	$70.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$70.50
Rate for Payer: LLUH Dept of Risk Management WC	$64.62
Rate for Payer: Multiplan Commercial	$88.12

Know your out-of-pocket cost for care.

All Charges