Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [8132]

Facility

$0.99

Service Code	NDC 68084-750-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.59
Rate for Payer: Aetna of CA Government/Medicare	$0.59
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.79
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [8132]

Facility

$0.99

Service Code	NDC 68084-750-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.79
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.79
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [8132]

Facility

$0.33

Service Code	NDC 68001-327-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.25

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [8132]

Facility

$0.99

Service Code	NDC 68084-750-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.79
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.79
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET [8134]

Facility

$0.34

Service Code	NDC 60505-2657-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET [8134]

Facility

$0.34

Service Code	NDC 68001-328-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET [8134]

Facility

$0.34

Service Code	NDC 60505-2657-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET [8134]

Facility

$0.34

Service Code	NDC 68001-328-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

TRIFLUOPERAZINE 10 MG TABLET [8162]

Facility

$3.08

Service Code	NDC 51079-575-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$2.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.85
Rate for Payer: Aetna of CA Government/Medicare	$1.85
Rate for Payer: Cash Price	$1.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.46
Rate for Payer: Health Smart Auto/Commercial	$1.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.85
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: Multiplan Commercial	$2.31

TRIFLUOPERAZINE 10 MG TABLET [8162]

Facility

$3.08

Service Code	NDC 51079-575-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$2.46
Rate for Payer: Cash Price	$1.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.46
Rate for Payer: Health Smart Auto/Commercial	$1.85
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: Multiplan Commercial	$2.31

TRIFLUOPERAZINE 10 MG TABLET [8162]

Facility

$3.08

Service Code	NDC 51079-575-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$2.46
Rate for Payer: Cash Price	$1.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.46
Rate for Payer: Health Smart Auto/Commercial	$1.85
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: Multiplan Commercial	$2.31

TRIFLUOPERAZINE 10 MG TABLET [8162]

Facility

$3.08

Service Code	NDC 51079-575-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$2.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.85
Rate for Payer: Aetna of CA Government/Medicare	$1.85
Rate for Payer: Cash Price	$1.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.46
Rate for Payer: Health Smart Auto/Commercial	$1.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.85
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: Multiplan Commercial	$2.31

TRIFLUOPERAZINE 1 MG TABLET [8161]

Facility

$1.34

Service Code	NDC 51079-572-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.07
Rate for Payer: Cash Price	$0.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.07
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.74
Rate for Payer: Multiplan Commercial	$1.00

TRIFLUOPERAZINE 1 MG TABLET [8161]

Facility

$1.34

Service Code	NDC 51079-572-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.80
Rate for Payer: Aetna of CA Government/Medicare	$0.80
Rate for Payer: Cash Price	$0.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.07
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.74
Rate for Payer: Multiplan Commercial	$1.00

TRIFLUOPERAZINE 2 MG TABLET [8163]

Facility

$2.00

Service Code	NDC 51079-573-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.20
Rate for Payer: Aetna of CA Government/Medicare	$1.20
Rate for Payer: Cash Price	$1.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Commercial	$1.50

TRIFLUOPERAZINE 2 MG TABLET [8163]

Facility

$2.00

Service Code	NDC 51079-573-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.60
Rate for Payer: Cash Price	$1.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.60
Rate for Payer: Health Smart Auto/Commercial	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Commercial	$1.50

TRIFLUOPERAZINE 5 MG TABLET [8164]

Facility

$2.55

Service Code	NDC 51079-574-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$2.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.53
Rate for Payer: Aetna of CA Government/Medicare	$1.53
Rate for Payer: Cash Price	$1.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.04
Rate for Payer: Health Smart Auto/Commercial	$1.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.53
Rate for Payer: LLUH Dept of Risk Management WC	$1.40
Rate for Payer: Multiplan Commercial	$1.91

TRIFLUOPERAZINE 5 MG TABLET [8164]

Facility

$2.55

Service Code	NDC 51079-574-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$2.04
Rate for Payer: Cash Price	$1.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.04
Rate for Payer: Health Smart Auto/Commercial	$1.53
Rate for Payer: LLUH Dept of Risk Management WC	$1.40
Rate for Payer: Multiplan Commercial	$1.91

TRIFLURIDINE 1 % EYE DROPS [11595]

Facility

$31.36

Service Code	NDC 61314-044-75
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$17.25
Max. Negotiated Rate	$25.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.82
Rate for Payer: Aetna of CA Government/Medicare	$18.82
Rate for Payer: Cash Price	$17.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.09
Rate for Payer: Health Smart Auto/Commercial	$18.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.82
Rate for Payer: LLUH Dept of Risk Management WC	$17.25
Rate for Payer: Multiplan Commercial	$23.52

TRIFLURIDINE 1 % EYE DROPS [11595]

Facility

$31.36

Service Code	NDC 61314-044-75
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$17.25
Max. Negotiated Rate	$25.09
Rate for Payer: Cash Price	$17.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.09
Rate for Payer: Health Smart Auto/Commercial	$18.82
Rate for Payer: LLUH Dept of Risk Management WC	$17.25
Rate for Payer: Multiplan Commercial	$23.52

TRIHEXYPHENIDYL 2 MG TABLET [8166]

Facility

$0.18

Service Code	NDC 0591-5335-01
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

TRIHEXYPHENIDYL 2 MG TABLET [8166]

Facility

$0.18

Service Code	NDC 70954-212-10
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

TRIHEXYPHENIDYL 2 MG TABLET [8166]

Facility

$0.18

Service Code	NDC 0591-5335-01
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

TRIHEXYPHENIDYL 2 MG TABLET [8166]

Facility

$0.18

Service Code	NDC 70954-212-10
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

TRIHEXYPHENIDYL 5 MG TABLET [8167]

Facility

$0.36

Service Code	NDC 0591-5337-01
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

Know your out-of-pocket cost for care.

All Charges