Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TOCILIZUMAB-AAZG 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [241037]

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 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [241037]

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

TOLNAFTATE 1 % TOPICAL CREAM [8020]

Facility

$0.18

Service Code	NDC 24385-032-03
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

TOLNAFTATE 1 % TOPICAL CREAM [8020]

Facility

$0.21

Service Code	NDC 51672-2020-2
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	$0.11
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

TOLNAFTATE 1 % TOPICAL CREAM [8020]

Facility

$0.21

Service Code	NDC 51672-2020-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.11
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

TOLNAFTATE 1 % TOPICAL CREAM [8020]

Facility

$0.18

Service Code	NDC 24385-032-03
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

TOLTERODINE 1 MG TABLET [22782]

Facility

$0.49

Service Code	NDC 33342-097-09
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37

TOLTERODINE 1 MG TABLET [22782]

Facility

$3.18

Service Code	NDC 0093-0010-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$2.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.91
Rate for Payer: Aetna of CA Government/Medicare	$1.91
Rate for Payer: Cash Price	$1.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.54
Rate for Payer: Health Smart Auto/Commercial	$1.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.91
Rate for Payer: LLUH Dept of Risk Management WC	$1.75
Rate for Payer: Multiplan Commercial	$2.38

TOLTERODINE 1 MG TABLET [22782]

Facility

$0.49

Service Code	NDC 33342-097-09
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37

TOLTERODINE 1 MG TABLET [22782]

Facility

$3.18

Service Code	NDC 0093-0010-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$2.54
Rate for Payer: Cash Price	$1.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.54
Rate for Payer: Health Smart Auto/Commercial	$1.91
Rate for Payer: LLUH Dept of Risk Management WC	$1.75
Rate for Payer: Multiplan Commercial	$2.38

TOLTERODINE 2 MG TABLET [22783]

Facility

$0.50

Service Code	NDC 33342-098-09
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

TOLTERODINE 2 MG TABLET [22783]

Facility

$0.40

Service Code	NDC 31722-806-60
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

TOLTERODINE 2 MG TABLET [22783]

Facility

$0.40

Service Code	NDC 31722-806-60
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

TOLTERODINE 2 MG TABLET [22783]

Facility

$0.50

Service Code	NDC 33342-098-09
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

TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]

Facility

$1.20

Service Code	NDC 27241-191-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Cash Price	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Commercial	$0.90

TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]

Facility

$1.20

Service Code	NDC 27241-191-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Cash Price	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Commercial	$0.90

TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]

Facility

$7.71

Service Code	NDC 0093-7163-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.24
Max. Negotiated Rate	$6.17
Rate for Payer: Cash Price	$4.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.17
Rate for Payer: Health Smart Auto/Commercial	$4.63
Rate for Payer: LLUH Dept of Risk Management WC	$4.24
Rate for Payer: Multiplan Commercial	$5.78

TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]

Facility

$3.03

Service Code	NDC 59762-0047-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$2.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.82
Rate for Payer: Aetna of CA Government/Medicare	$1.82
Rate for Payer: Cash Price	$1.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.42
Rate for Payer: Health Smart Auto/Commercial	$1.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$1.67
Rate for Payer: Multiplan Commercial	$2.27

TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]

Facility

$7.71

Service Code	NDC 0093-7163-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.24
Max. Negotiated Rate	$6.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.63
Rate for Payer: Aetna of CA Government/Medicare	$4.63
Rate for Payer: Cash Price	$4.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.17
Rate for Payer: Health Smart Auto/Commercial	$4.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.63
Rate for Payer: LLUH Dept of Risk Management WC	$4.24
Rate for Payer: Multiplan Commercial	$5.78

TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]

Facility

$3.03

Service Code	NDC 59762-0047-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$2.42
Rate for Payer: Cash Price	$1.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.42
Rate for Payer: Health Smart Auto/Commercial	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$1.67
Rate for Payer: Multiplan Commercial	$2.27

TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]

Facility

$1.20

Service Code	NDC 27241-192-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Cash Price	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Commercial	$0.90

TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]

Facility

$7.71

Service Code	NDC 0093-7164-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.24
Max. Negotiated Rate	$6.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.63
Rate for Payer: Aetna of CA Government/Medicare	$4.63
Rate for Payer: Cash Price	$4.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.17
Rate for Payer: Health Smart Auto/Commercial	$4.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.63
Rate for Payer: LLUH Dept of Risk Management WC	$4.24
Rate for Payer: Multiplan Commercial	$5.78

TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]

Facility

$7.71

Service Code	NDC 0093-7164-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.24
Max. Negotiated Rate	$6.17
Rate for Payer: Cash Price	$4.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.17
Rate for Payer: Health Smart Auto/Commercial	$4.63
Rate for Payer: LLUH Dept of Risk Management WC	$4.24
Rate for Payer: Multiplan Commercial	$5.78

TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]

Facility

$1.20

Service Code	NDC 27241-192-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Cash Price	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Commercial	$0.90

TOLVAPTAN 15 MG TABLET [97893]

Facility

$72.00

Service Code	NDC 31722-868-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$43.20
Rate for Payer: Aetna of CA Government/Medicare	$43.20
Rate for Payer: Cash Price	$39.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$57.60
Rate for Payer: Health Smart Auto/Commercial	$43.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$43.20
Rate for Payer: LLUH Dept of Risk Management WC	$39.60
Rate for Payer: Multiplan Commercial	$54.00

Know your out-of-pocket cost for care.

All Charges