Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TOLVAPTAN 15 MG TABLET [97893]

Facility

$72.00

Service Code	NDC 49884-768-54
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

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: 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: LLUH Dept of Risk Management WC	$39.60
Rate for Payer: Multiplan Commercial	$54.00

TOLVAPTAN 15 MG TABLET [97893]

Facility

$72.00

Service Code	NDC 31722-868-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$57.60
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: LLUH Dept of Risk Management WC	$39.60
Rate for Payer: Multiplan Commercial	$54.00

TOLVAPTAN 15 MG TABLET [97893]

Facility

$72.00

Service Code	NDC 49884-768-52
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$57.60
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: LLUH Dept of Risk Management WC	$39.60
Rate for Payer: Multiplan Commercial	$54.00

TOLVAPTAN 15 MG TABLET [97893]

Facility

$72.00

Service Code	NDC 49884-768-52
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

TOLVAPTAN 15 MG TABLET [97893]

Facility

$72.00

Service Code	NDC 49884-768-54
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$57.60
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: LLUH Dept of Risk Management WC	$39.60
Rate for Payer: Multiplan Commercial	$54.00

TOLVAPTAN 15 MG TABLET [97893]

Facility

$72.00

Service Code	NDC 31722-868-03
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

TOLVAPTAN 30 MG TABLET [97894]

Facility

$576.63

Service Code	NDC 67877-636-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$317.15
Max. Negotiated Rate	$461.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$345.98
Rate for Payer: Aetna of CA Government/Medicare	$345.98
Rate for Payer: Cash Price	$317.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$461.30
Rate for Payer: Health Smart Auto/Commercial	$345.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$345.98
Rate for Payer: LLUH Dept of Risk Management WC	$317.15
Rate for Payer: Multiplan Commercial	$432.47

TOLVAPTAN 30 MG TABLET [97894]

Facility

$647.57

Service Code	NDC 59148-021-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$356.16
Max. Negotiated Rate	$518.06
Rate for Payer: Cash Price	$356.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$518.06
Rate for Payer: Health Smart Auto/Commercial	$388.54
Rate for Payer: LLUH Dept of Risk Management WC	$356.16
Rate for Payer: Multiplan Commercial	$485.68

TOLVAPTAN 30 MG TABLET [97894]

Facility

$562.46

Service Code	NDC 60505-4318-0
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$309.35
Max. Negotiated Rate	$449.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$337.48
Rate for Payer: Aetna of CA Government/Medicare	$337.48
Rate for Payer: Cash Price	$309.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$449.97
Rate for Payer: Health Smart Auto/Commercial	$337.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$337.48
Rate for Payer: LLUH Dept of Risk Management WC	$309.35
Rate for Payer: Multiplan Commercial	$421.85

TOLVAPTAN 30 MG TABLET [97894]

Facility

$576.63

Service Code	NDC 67877-636-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$317.15
Max. Negotiated Rate	$461.30
Rate for Payer: Cash Price	$317.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$461.30
Rate for Payer: Health Smart Auto/Commercial	$345.98
Rate for Payer: LLUH Dept of Risk Management WC	$317.15
Rate for Payer: Multiplan Commercial	$432.47

TOLVAPTAN 30 MG TABLET [97894]

Facility

$562.46

Service Code	NDC 60505-4318-0
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$309.35
Max. Negotiated Rate	$449.97
Rate for Payer: Cash Price	$309.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$449.97
Rate for Payer: Health Smart Auto/Commercial	$337.48
Rate for Payer: LLUH Dept of Risk Management WC	$309.35
Rate for Payer: Multiplan Commercial	$421.85

TOLVAPTAN 30 MG TABLET [97894]

Facility

$647.57

Service Code	NDC 59148-021-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$356.16
Max. Negotiated Rate	$518.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$388.54
Rate for Payer: Aetna of CA Government/Medicare	$388.54
Rate for Payer: Cash Price	$356.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$518.06
Rate for Payer: Health Smart Auto/Commercial	$388.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$388.54
Rate for Payer: LLUH Dept of Risk Management WC	$356.16
Rate for Payer: Multiplan Commercial	$485.68

TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 1 MG/ML [40801044]

Facility

$31.25

Service Code	NDC 9940-8010-44
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$17.19
Max. Negotiated Rate	$25.00
Rate for Payer: Cash Price	$17.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.00
Rate for Payer: Health Smart Auto/Commercial	$18.75
Rate for Payer: LLUH Dept of Risk Management WC	$17.19
Rate for Payer: Multiplan Commercial	$23.44

TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 1 MG/ML [40801044]

Facility

$31.25

Service Code	NDC 9940-8010-44
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$17.19
Max. Negotiated Rate	$25.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.75
Rate for Payer: Aetna of CA Government/Medicare	$18.75
Rate for Payer: Cash Price	$17.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.00
Rate for Payer: Health Smart Auto/Commercial	$18.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.75
Rate for Payer: LLUH Dept of Risk Management WC	$17.19
Rate for Payer: Multiplan Commercial	$23.44

TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 3 MG/ML [4081044]

Facility

$31.25

Service Code	NDC 9994-0810-44
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$17.19
Max. Negotiated Rate	$25.00
Rate for Payer: Cash Price	$17.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.00
Rate for Payer: Health Smart Auto/Commercial	$18.75
Rate for Payer: LLUH Dept of Risk Management WC	$17.19
Rate for Payer: Multiplan Commercial	$23.44

TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 3 MG/ML [4081044]

Facility

$31.25

Service Code	NDC 9994-0810-44
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$17.19
Max. Negotiated Rate	$25.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.75
Rate for Payer: Aetna of CA Government/Medicare	$18.75
Rate for Payer: Cash Price	$17.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.00
Rate for Payer: Health Smart Auto/Commercial	$18.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.75
Rate for Payer: LLUH Dept of Risk Management WC	$17.19
Rate for Payer: Multiplan Commercial	$23.44

TOPIRAMATE 100 MG TABLET [18922]

Facility

$0.14

Service Code	NDC 68382-140-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

TOPIRAMATE 100 MG TABLET [18922]

Facility

$0.14

Service Code	NDC 68462-109-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

TOPIRAMATE 100 MG TABLET [18922]

Facility

$0.57

Service Code	NDC 68084-344-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.34
Rate for Payer: Aetna of CA Government/Medicare	$0.34
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.43

TOPIRAMATE 100 MG TABLET [18922]

Facility

$0.14

Service Code	NDC 68462-109-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

TOPIRAMATE 100 MG TABLET [18922]

Facility

$0.57

Service Code	NDC 68084-344-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.34
Rate for Payer: Aetna of CA Government/Medicare	$0.34
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.43

TOPIRAMATE 100 MG TABLET [18922]

Facility

$0.14

Service Code	NDC 69097-124-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

TOPIRAMATE 100 MG TABLET [18922]

Facility

$0.57

Service Code	NDC 68084-344-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.43

TOPIRAMATE 100 MG TABLET [18922]

Facility

$0.14

Service Code	NDC 68382-140-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

Know your out-of-pocket cost for care.

All Charges