Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TORSEMIDE 20 MG TABLET [18293]

Facility

$0.26

Service Code	NDC 65862-127-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

TORSEMIDE 20 MG TABLET [18293]

Facility

$0.26

Service Code	NDC 31722-531-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

TORSEMIDE 20 MG TABLET [18293]

Facility

$0.26

Service Code	NDC 65862-127-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

TORSEMIDE 20 MG TABLET [18293]

Facility

$0.43

Service Code	NDC 68084-539-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.32

TORSEMIDE 20 MG TABLET [18293]

Facility

$0.26

Service Code	NDC 31722-531-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

TORSEMIDE 20 MG TABLET [18293]

Facility

$0.43

Service Code	NDC 68084-539-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.32

TPN NICU NO DOSE REVISED [4082636]

Facility

$499.00

Service Code	NDC 9994-0816-36
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$274.45
Max. Negotiated Rate	$399.20
Rate for Payer: Cash Price	$274.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$399.20
Rate for Payer: Health Smart Auto/Commercial	$299.40
Rate for Payer: LLUH Dept of Risk Management WC	$274.45
Rate for Payer: Multiplan Commercial	$374.25

TPN NICU NO DOSE REVISED [4082636]

Facility

$499.00

Service Code	NDC 9994-0816-36
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$274.45
Max. Negotiated Rate	$399.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$299.40
Rate for Payer: Aetna of CA Government/Medicare	$299.40
Rate for Payer: Cash Price	$274.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$399.20
Rate for Payer: Health Smart Auto/Commercial	$299.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$299.40
Rate for Payer: LLUH Dept of Risk Management WC	$274.45
Rate for Payer: Multiplan Commercial	$374.25

TPN: NICU STARTER [196140]

Facility

$499.00

Service Code	NDC 9999-1961-40
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$274.45
Max. Negotiated Rate	$399.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$299.40
Rate for Payer: Aetna of CA Government/Medicare	$299.40
Rate for Payer: Cash Price	$274.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$399.20
Rate for Payer: Health Smart Auto/Commercial	$299.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$299.40
Rate for Payer: LLUH Dept of Risk Management WC	$274.45
Rate for Payer: Multiplan Commercial	$374.25

TPN: NICU STARTER [196140]

Facility

$499.00

Service Code	NDC 9999-1961-40
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$274.45
Max. Negotiated Rate	$399.20
Rate for Payer: Cash Price	$274.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$399.20
Rate for Payer: Health Smart Auto/Commercial	$299.40
Rate for Payer: LLUH Dept of Risk Management WC	$274.45
Rate for Payer: Multiplan Commercial	$374.25

TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS [18266]

Facility

$4.86

Service Code	NDC 0517-9203-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$3.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.92
Rate for Payer: Aetna of CA Government/Medicare	$2.92
Rate for Payer: Cash Price	$2.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.89
Rate for Payer: Health Smart Auto/Commercial	$2.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.92
Rate for Payer: LLUH Dept of Risk Management WC	$2.67
Rate for Payer: Multiplan Commercial	$3.65

TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS [18266]

Facility

$4.86

Service Code	NDC 0517-9203-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$3.89
Rate for Payer: Cash Price	$2.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.89
Rate for Payer: Health Smart Auto/Commercial	$2.92
Rate for Payer: LLUH Dept of Risk Management WC	$2.67
Rate for Payer: Multiplan Commercial	$3.65

TRACE ELEMENTS CHOLESTASIS [4080051]

Facility

$6.30

Service Code	NDC 9994-0800-51
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$5.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.78
Rate for Payer: Aetna of CA Government/Medicare	$3.78
Rate for Payer: Cash Price	$3.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.04
Rate for Payer: Health Smart Auto/Commercial	$3.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.78
Rate for Payer: LLUH Dept of Risk Management WC	$3.46
Rate for Payer: Multiplan Commercial	$4.72

TRACE ELEMENTS CHOLESTASIS [4080051]

Facility

$6.30

Service Code	NDC 9994-0800-51
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$5.04
Rate for Payer: Cash Price	$3.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.04
Rate for Payer: Health Smart Auto/Commercial	$3.78
Rate for Payer: LLUH Dept of Risk Management WC	$3.46
Rate for Payer: Multiplan Commercial	$4.72

TRACE ELEMENTS CHOLESTASIS [4080051]

Facility

$1.30

Service Code	NDC 9940-8830-17
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.78
Rate for Payer: Aetna of CA Government/Medicare	$0.78
Rate for Payer: Cash Price	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.04
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

TRACE ELEMENTS CHOLESTASIS [4080051]

Facility

$1.30

Service Code	NDC 9940-8830-17
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.04
Rate for Payer: Cash Price	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.04
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

TRACE ELEMENTS CR-CU-MN-SE-ZN 10 MCG-1 MG-0.5 MG-60 MCG-5MG/ML IV SOLN [18259]

Facility

$7.58

Service Code	NDC 99940-8830-16
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$4.17
Max. Negotiated Rate	$6.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.55
Rate for Payer: Aetna of CA Government/Medicare	$4.55
Rate for Payer: Cash Price	$4.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.06
Rate for Payer: Health Smart Auto/Commercial	$4.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.55
Rate for Payer: LLUH Dept of Risk Management WC	$4.17
Rate for Payer: Multiplan Commercial	$5.68

TRACE ELEMENTS CR-CU-MN-SE-ZN 10 MCG-1 MG-0.5 MG-60 MCG-5MG/ML IV SOLN [18259]

Facility

$7.58

Service Code	NDC 99940-8830-16
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$4.17
Max. Negotiated Rate	$6.06
Rate for Payer: Cash Price	$4.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.06
Rate for Payer: Health Smart Auto/Commercial	$4.55
Rate for Payer: LLUH Dept of Risk Management WC	$4.17
Rate for Payer: Multiplan Commercial	$5.68

TRACE ELEMENTS FULL TERM [4080053]

Facility

$6.30

Service Code	NDC 9994-0800-53
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$5.04
Rate for Payer: Cash Price	$3.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.04
Rate for Payer: Health Smart Auto/Commercial	$3.78
Rate for Payer: LLUH Dept of Risk Management WC	$3.46
Rate for Payer: Multiplan Commercial	$4.72

TRACE ELEMENTS FULL TERM [4080053]

Facility

$6.30

Service Code	NDC 9994-0800-53
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$5.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.78
Rate for Payer: Aetna of CA Government/Medicare	$3.78
Rate for Payer: Cash Price	$3.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.04
Rate for Payer: Health Smart Auto/Commercial	$3.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.78
Rate for Payer: LLUH Dept of Risk Management WC	$3.46
Rate for Payer: Multiplan Commercial	$4.72

TRACE ELEMENTS PRETERM [4080052]

Facility

$6.30

Service Code	NDC 9994-0800-52
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$5.04
Rate for Payer: Cash Price	$3.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.04
Rate for Payer: Health Smart Auto/Commercial	$3.78
Rate for Payer: LLUH Dept of Risk Management WC	$3.46
Rate for Payer: Multiplan Commercial	$4.72

TRACE ELEMENTS PRETERM [4080052]

Facility

$6.30

Service Code	NDC 9994-0800-52
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$5.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.78
Rate for Payer: Aetna of CA Government/Medicare	$3.78
Rate for Payer: Cash Price	$3.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.04
Rate for Payer: Health Smart Auto/Commercial	$3.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.78
Rate for Payer: LLUH Dept of Risk Management WC	$3.46
Rate for Payer: Multiplan Commercial	$4.72

TRAMADOL 50 MG TABLET [14632]

Facility

$0.16

Service Code	NDC 68084-808-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

TRAMADOL 50 MG TABLET [14632]

Facility

$0.16

Service Code	NDC 68084-808-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

TRAMADOL 50 MG TABLET [14632]

Facility

$0.09

Service Code	NDC 51079-991-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

Know your out-of-pocket cost for care.

All Charges