Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [191168]

Facility

$0.42

Service Code	NDC 72485-510-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
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	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.32

TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [191168]

Facility

$0.42

Service Code	NDC 72485-510-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
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	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.32

TRANEXAMIC ACID 650 MG TABLET [104576]

Facility

$5.15

Service Code	NDC 60687-750-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.83
Max. Negotiated Rate	$4.12
Rate for Payer: Cash Price	$2.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.12
Rate for Payer: Health Smart Auto/Commercial	$3.09
Rate for Payer: LLUH Dept of Risk Management WC	$2.83
Rate for Payer: Multiplan Commercial	$3.86

TRANEXAMIC ACID 650 MG TABLET [104576]

Facility

$5.15

Service Code	NDC 60687-750-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.83
Max. Negotiated Rate	$4.12
Rate for Payer: Cash Price	$2.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.12
Rate for Payer: Health Smart Auto/Commercial	$3.09
Rate for Payer: LLUH Dept of Risk Management WC	$2.83
Rate for Payer: Multiplan Commercial	$3.86

TRANEXAMIC ACID 650 MG TABLET [104576]

Facility

$5.15

Service Code	NDC 60687-750-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.83
Max. Negotiated Rate	$4.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.09
Rate for Payer: Aetna of CA Government/Medicare	$3.09
Rate for Payer: Cash Price	$2.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.12
Rate for Payer: Health Smart Auto/Commercial	$3.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.09
Rate for Payer: LLUH Dept of Risk Management WC	$2.83
Rate for Payer: Multiplan Commercial	$3.86

TRANEXAMIC ACID 650 MG TABLET [104576]

Facility

$5.15

Service Code	NDC 60687-750-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.83
Max. Negotiated Rate	$4.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.09
Rate for Payer: Aetna of CA Government/Medicare	$3.09
Rate for Payer: Cash Price	$2.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.12
Rate for Payer: Health Smart Auto/Commercial	$3.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.09
Rate for Payer: LLUH Dept of Risk Management WC	$2.83
Rate for Payer: Multiplan Commercial	$3.86

TRANEXAMIC ACID ORAL SOLUTION (IV FORM) 5% (50 MG/ML) [40820838]

Facility

$0.96

Service Code	NDC 9940-8208-38
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.77
Rate for Payer: Cash Price	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.77
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.72

TRANEXAMIC ACID ORAL SOLUTION (IV FORM) 5% (50 MG/ML) [40820838]

Facility

$0.96

Service Code	NDC 9940-8208-38
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.58
Rate for Payer: Aetna of CA Government/Medicare	$0.58
Rate for Payer: Cash Price	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.77
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.72

TRAVOPROST 0.004 % EYE DROPS [110762]

Facility

$60.37

Service Code	NDC 60505-0593-4
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$33.20
Max. Negotiated Rate	$48.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.22
Rate for Payer: Aetna of CA Government/Medicare	$36.22
Rate for Payer: Cash Price	$33.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.30
Rate for Payer: Health Smart Auto/Commercial	$36.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.22
Rate for Payer: LLUH Dept of Risk Management WC	$33.20
Rate for Payer: Multiplan Commercial	$45.28

TRAVOPROST 0.004 % EYE DROPS [110762]

Facility

$76.17

Service Code	NDC 0378-9651-32
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$41.89
Max. Negotiated Rate	$60.94
Rate for Payer: Cash Price	$41.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.94
Rate for Payer: Health Smart Auto/Commercial	$45.70
Rate for Payer: LLUH Dept of Risk Management WC	$41.89
Rate for Payer: Multiplan Commercial	$57.13

TRAVOPROST 0.004 % EYE DROPS [110762]

Facility

$60.37

Service Code	NDC 60505-0593-4
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$33.20
Max. Negotiated Rate	$48.30
Rate for Payer: Cash Price	$33.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.30
Rate for Payer: Health Smart Auto/Commercial	$36.22
Rate for Payer: LLUH Dept of Risk Management WC	$33.20
Rate for Payer: Multiplan Commercial	$45.28

TRAVOPROST 0.004 % EYE DROPS [110762]

Facility

$76.17

Service Code	NDC 0378-9651-32
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$41.89
Max. Negotiated Rate	$60.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.70
Rate for Payer: Aetna of CA Government/Medicare	$45.70
Rate for Payer: Cash Price	$41.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.94
Rate for Payer: Health Smart Auto/Commercial	$45.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.70
Rate for Payer: LLUH Dept of Risk Management WC	$41.89
Rate for Payer: Multiplan Commercial	$57.13

TRAZODONE 100 MG TABLET [8083]

Facility

$0.11

Service Code	NDC 70010-232-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

TRAZODONE 100 MG TABLET [8083]

Facility

$0.22

Service Code	NDC 60687-454-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
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	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
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	$0.17

TRAZODONE 100 MG TABLET [8083]

Facility

$0.22

Service Code	NDC 60687-454-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
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	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
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	$0.17

TRAZODONE 100 MG TABLET [8083]

Facility

$0.15

Service Code	NDC 50111-561-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.09
Rate for Payer: Aetna of CA Government/Medicare	$0.09
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

TRAZODONE 100 MG TABLET [8083]

Facility

$0.22

Service Code	NDC 60687-454-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
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	$0.17

TRAZODONE 100 MG TABLET [8083]

Facility

$0.11

Service Code	NDC 70010-232-01
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

TRAZODONE 100 MG TABLET [8083]

Facility

$0.15

Service Code	NDC 50111-561-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

TRAZODONE 100 MG TABLET [8083]

Facility

$0.22

Service Code	NDC 60687-454-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
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	$0.17

TRAZODONE 150 MG TABLET [8084]

Facility

$0.30

Service Code	NDC 68382-807-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

TRAZODONE 150 MG TABLET [8084]

Facility

$0.69

Service Code	NDC 68084-608-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Commercial	$0.52

TRAZODONE 150 MG TABLET [8084]

Facility

$0.30

Service Code	NDC 68382-807-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

TRAZODONE 150 MG TABLET [8084]

Facility

$0.69

Service Code	NDC 68084-608-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Commercial	$0.52

TRAZODONE 150 MG TABLET [8084]

Facility

$0.69

Service Code	NDC 60687-432-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Commercial	$0.52

Know your out-of-pocket cost for care.

All Charges