Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: 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

TRIHEXYPHENIDYL 5 MG TABLET [8167]

Facility

$0.27

Service Code	NDC 70954-211-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
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	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
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	$0.15
Rate for Payer: Multiplan Commercial	$0.20

TRIHEXYPHENIDYL 5 MG TABLET [8167]

Facility

$0.27

Service Code	NDC 70954-211-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

TRIMETHOBENZAMIDE 100 MG/ML INTRAMUSCULAR SOLUTION [110953]

Facility

$36.38

Service Code	HCPCS J3250
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$20.01
Max. Negotiated Rate	$29.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.83
Rate for Payer: Aetna of CA Government/Medicare	$21.83
Rate for Payer: Cash Price	$20.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.10
Rate for Payer: Health Smart Auto/Commercial	$21.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.83
Rate for Payer: LLUH Dept of Risk Management WC	$20.01
Rate for Payer: Multiplan Commercial	$27.29

TRIMETHOBENZAMIDE 100 MG/ML INTRAMUSCULAR SOLUTION [110953]

Facility

$36.38

Service Code	HCPCS J3250
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$20.01
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$20.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.10
Rate for Payer: Health Smart Auto/Commercial	$21.83
Rate for Payer: LLUH Dept of Risk Management WC	$20.01
Rate for Payer: Multiplan Commercial	$27.29

TROMETHAMINE 36 MG/ML (0.3 M) INTRAVENOUS SOLUTION [11608]

Facility

$0.94

Service Code	NDC 0409-1593-14
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
Rate for Payer: Cash Price	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Commercial	$0.71

TROMETHAMINE 36 MG/ML (0.3 M) INTRAVENOUS SOLUTION [11608]

Facility

$0.94

Service Code	NDC 0409-1593-14
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.56
Rate for Payer: Aetna of CA Government/Medicare	$0.56
Rate for Payer: Cash Price	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Commercial	$0.71

TROMETHAMINE 36 MG/ML (0.3 M) INTRAVENOUS SOLUTION [11608]

Facility

$0.94

Service Code	NDC 0409-1593-04
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
Rate for Payer: Cash Price	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Commercial	$0.71

TROMETHAMINE 36 MG/ML (0.3 M) INTRAVENOUS SOLUTION [11608]

Facility

$0.94

Service Code	NDC 0409-1593-04
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.56
Rate for Payer: Aetna of CA Government/Medicare	$0.56
Rate for Payer: Cash Price	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Commercial	$0.71

TROPICAMIDE 0.5 % EYE DROPS [8249]

Facility

$1.71

Service Code	NDC 61314-354-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.37
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Commercial	$1.28

TROPICAMIDE 0.5 % EYE DROPS [8249]

Facility

$1.71

Service Code	NDC 61314-354-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.03
Rate for Payer: Aetna of CA Government/Medicare	$1.03
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Commercial	$1.28

TROPICAMIDE 1 % EYE DROPS [8250]

Facility

$2.45

Service Code	NDC 61314-355-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.47
Rate for Payer: Aetna of CA Government/Medicare	$1.47
Rate for Payer: Cash Price	$1.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.96
Rate for Payer: Health Smart Auto/Commercial	$1.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.47
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Commercial	$1.84

TROPICAMIDE 1 % EYE DROPS [8250]

Facility

$2.45

Service Code	NDC 61314-355-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.96
Rate for Payer: Cash Price	$1.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.96
Rate for Payer: Health Smart Auto/Commercial	$1.47
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Commercial	$1.84

TROPICAMIDE 1 % EYE DROPS [8250]

Facility

$0.68

Service Code	NDC 70069-121-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
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	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
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	$0.37
Rate for Payer: Multiplan Commercial	$0.51

TROPICAMIDE 1 % EYE DROPS [8250]

Facility

$0.68

Service Code	NDC 70069-121-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.51

TROPICAMIDE 1 %-PROPARACAINE 0.5 %-PE 2.5 %-KETOROLAC 0.5 % EYE DROPS [223020]

Facility

$16.80

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.24
Max. Negotiated Rate	$13.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.08
Rate for Payer: Aetna of CA Government/Medicare	$10.08
Rate for Payer: Cash Price	$9.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.44
Rate for Payer: Health Smart Auto/Commercial	$10.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.08
Rate for Payer: LLUH Dept of Risk Management WC	$9.24
Rate for Payer: Multiplan Commercial	$12.60

TROPICAMIDE 1 %-PROPARACAINE 0.5 %-PE 2.5 %-KETOROLAC 0.5 % EYE DROPS [223020]

Facility

$16.80

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$9.24
Max. Negotiated Rate	$13.44
Rate for Payer: Cash Price	$9.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.44
Rate for Payer: Health Smart Auto/Commercial	$10.08
Rate for Payer: LLUH Dept of Risk Management WC	$9.24
Rate for Payer: Multiplan Commercial	$12.60

TRYPAN BLUE 0.06 % INTRAOCULAR SYRINGE [88317]

Facility

$198.96

Service Code	HCPCS Q9968
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$109.43
Max. Negotiated Rate	$159.17
Rate for Payer: Cash Price	$109.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$159.17
Rate for Payer: Health Smart Auto/Commercial	$119.38
Rate for Payer: LLUH Dept of Risk Management WC	$109.43
Rate for Payer: Multiplan Commercial	$149.22

TRYPAN BLUE 0.06 % INTRAOCULAR SYRINGE [88317]

Facility

$198.96

Service Code	HCPCS Q9968
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$109.43
Max. Negotiated Rate	$159.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$119.38
Rate for Payer: Aetna of CA Government/Medicare	$119.38
Rate for Payer: Cash Price	$109.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$159.17
Rate for Payer: Health Smart Auto/Commercial	$119.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$119.38
Rate for Payer: LLUH Dept of Risk Management WC	$109.43
Rate for Payer: Multiplan Commercial	$149.22

TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]

Facility

$138.89

Service Code	HCPCS 86580
Hospital Charge Code	901700020
Hospital Revenue Code	302
Min. Negotiated Rate	$76.39
Max. Negotiated Rate	$111.11
Rate for Payer: Cash Price	$76.39
Rate for Payer: Cash Price	$59.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$86.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$111.11
Rate for Payer: Health Smart Auto/Commercial	$83.33
Rate for Payer: Health Smart Auto/Commercial	$64.94
Rate for Payer: LLUH Dept of Risk Management WC	$59.53
Rate for Payer: LLUH Dept of Risk Management WC	$76.39
Rate for Payer: Multiplan Commercial	$81.18
Rate for Payer: Multiplan Commercial	$104.17

TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]

Facility

$108.24

Service Code	HCPCS 86580
Hospital Charge Code	901700020
Hospital Revenue Code	302
Min. Negotiated Rate	$59.53
Max. Negotiated Rate	$86.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$64.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$83.33
Rate for Payer: Aetna of CA Government/Medicare	$83.33
Rate for Payer: Aetna of CA Government/Medicare	$64.94
Rate for Payer: Cash Price	$76.39
Rate for Payer: Cash Price	$59.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$86.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$111.11
Rate for Payer: Health Smart Auto/Commercial	$64.94
Rate for Payer: Health Smart Auto/Commercial	$83.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$64.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$83.33
Rate for Payer: LLUH Dept of Risk Management WC	$59.53
Rate for Payer: LLUH Dept of Risk Management WC	$76.39
Rate for Payer: Multiplan Commercial	$104.17
Rate for Payer: Multiplan Commercial	$81.18

TUCATINIB 150 MG TABLET [227737]

Facility

$263.98

Service Code	NDC 51144-002-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$145.19
Max. Negotiated Rate	$211.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$158.39
Rate for Payer: Aetna of CA Government/Medicare	$158.39
Rate for Payer: Cash Price	$145.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$211.18
Rate for Payer: Health Smart Auto/Commercial	$158.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$158.39
Rate for Payer: LLUH Dept of Risk Management WC	$145.19
Rate for Payer: Multiplan Commercial	$197.99

TUCATINIB 150 MG TABLET [227737]

Facility

$263.98

Service Code	NDC 51144-002-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$145.19
Max. Negotiated Rate	$211.18
Rate for Payer: Cash Price	$145.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$211.18
Rate for Payer: Health Smart Auto/Commercial	$158.39
Rate for Payer: LLUH Dept of Risk Management WC	$145.19
Rate for Payer: Multiplan Commercial	$197.99

TUCATINIB 50 MG TABLET [227736]

Facility

$131.28

Service Code	NDC 51144-001-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$72.20
Max. Negotiated Rate	$105.02
Rate for Payer: Cash Price	$72.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$105.02
Rate for Payer: Health Smart Auto/Commercial	$78.77
Rate for Payer: LLUH Dept of Risk Management WC	$72.20
Rate for Payer: Multiplan Commercial	$98.46

TUCATINIB 50 MG TABLET [227736]

Facility

$131.28

Service Code	NDC 51144-001-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$72.20
Max. Negotiated Rate	$105.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$78.77
Rate for Payer: Aetna of CA Government/Medicare	$78.77
Rate for Payer: Cash Price	$72.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$105.02
Rate for Payer: Health Smart Auto/Commercial	$78.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$78.77
Rate for Payer: LLUH Dept of Risk Management WC	$72.20
Rate for Payer: Multiplan Commercial	$98.46

Know your out-of-pocket cost for care.

All Charges