Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TOPIRAMATE 50 MG TABLET [37616]

Facility

$0.50

Service Code	NDC 68084-343-11
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	$0.27
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

TOPIRAMATE 50 MG TABLET [37616]

Facility

$0.50

Service Code	NDC 68084-343-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.27
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

TOPIRAMATE 50 MG TABLET [37616]

Facility

$0.11

Service Code	NDC 68382-139-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]

Facility

$0.08

Service Code	NDC 68382-138-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]

Facility

$0.08

Service Code	NDC 68462-108-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]

Facility

$0.36

Service Code	NDC 68084-342-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]

Facility

$0.36

Service Code	NDC 68084-342-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]

Facility

$0.08

Service Code	NDC 68382-138-14
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]

Facility

$0.36

Service Code	NDC 68084-342-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]

Facility

$0.18

Service Code	NDC 62756-707-86
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

TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]

Facility

$0.08

Service Code	NDC 68462-108-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]

Facility

$0.18

Service Code	NDC 62756-707-86
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

TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]

Facility

$0.36

Service Code	NDC 68084-342-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

TOPIRAMATE ORAL SOLUTION COMPOUND 6 MG/ML [4080352]

Facility

$6.04

Service Code	NDC 9994-0803-52
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$4.83
Rate for Payer: Cash Price	$3.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.83
Rate for Payer: Health Smart Auto/Commercial	$3.62
Rate for Payer: LLUH Dept of Risk Management WC	$3.32
Rate for Payer: Multiplan Commercial	$4.53

TOPIRAMATE ORAL SOLUTION COMPOUND 6 MG/ML [4080352]

Facility

$6.04

Service Code	NDC 9994-0803-52
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$4.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.62
Rate for Payer: Aetna of CA Government/Medicare	$3.62
Rate for Payer: Cash Price	$3.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.83
Rate for Payer: Health Smart Auto/Commercial	$3.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.62
Rate for Payer: LLUH Dept of Risk Management WC	$3.32
Rate for Payer: Multiplan Commercial	$4.53

TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION [108590]

Facility

$41.57

Service Code	HCPCS J9351
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$22.86
Max. Negotiated Rate	$33.26
Rate for Payer: Cash Price	$22.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.26
Rate for Payer: Health Smart Auto/Commercial	$24.94
Rate for Payer: LLUH Dept of Risk Management WC	$22.86
Rate for Payer: Multiplan Commercial	$31.18

TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION [108590]

Facility

$41.57

Service Code	HCPCS J9351
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$22.86
Max. Negotiated Rate	$33.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.94
Rate for Payer: Aetna of CA Government/Medicare	$24.94
Rate for Payer: Cash Price	$22.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.26
Rate for Payer: Health Smart Auto/Commercial	$24.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.94
Rate for Payer: LLUH Dept of Risk Management WC	$22.86
Rate for Payer: Multiplan Commercial	$31.18

TOPOTECAN 4 MG INTRAVENOUS SOLUTION [17285]

Facility

$163.24

Service Code	HCPCS J9351
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$89.78
Max. Negotiated Rate	$130.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$97.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$169.20
Rate for Payer: Aetna of CA Government/Medicare	$169.20
Rate for Payer: Aetna of CA Government/Medicare	$97.94
Rate for Payer: Cash Price	$155.10
Rate for Payer: Cash Price	$89.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$130.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$225.60
Rate for Payer: Health Smart Auto/Commercial	$97.94
Rate for Payer: Health Smart Auto/Commercial	$169.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$97.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$169.20
Rate for Payer: LLUH Dept of Risk Management WC	$89.78
Rate for Payer: LLUH Dept of Risk Management WC	$155.10
Rate for Payer: Multiplan Commercial	$211.50
Rate for Payer: Multiplan Commercial	$122.43

TOPOTECAN 4 MG INTRAVENOUS SOLUTION [17285]

Facility

$282.00

Service Code	HCPCS J9351
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$155.10
Max. Negotiated Rate	$225.60
Rate for Payer: Cash Price	$155.10
Rate for Payer: Cash Price	$89.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$130.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$225.60
Rate for Payer: Health Smart Auto/Commercial	$169.20
Rate for Payer: Health Smart Auto/Commercial	$97.94
Rate for Payer: LLUH Dept of Risk Management WC	$89.78
Rate for Payer: LLUH Dept of Risk Management WC	$155.10
Rate for Payer: Multiplan Commercial	$122.43
Rate for Payer: Multiplan Commercial	$211.50

TORSEMIDE 100 MG TABLET [18294]

Facility

$0.49

Service Code	NDC 50268-757-15
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

TORSEMIDE 100 MG TABLET [18294]

Facility

$0.49

Service Code	NDC 50268-757-15
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

TORSEMIDE 100 MG TABLET [18294]

Facility

$0.49

Service Code	NDC 50268-757-11
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

TORSEMIDE 100 MG TABLET [18294]

Facility

$0.49

Service Code	NDC 50268-757-11
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

TORSEMIDE 10 MG TABLET [18292]

Facility

$0.37

Service Code	NDC 50268-755-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.28

TORSEMIDE 10 MG TABLET [18292]

Facility

$0.37

Service Code	NDC 50268-755-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.28

Know your out-of-pocket cost for care.

All Charges