Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TERLIPRESSIN 0.85 MG INTRAVENOUS POWDER FOR SOLUTION [235956]

Facility

$1,140.00

Service Code	CPT C9399
Hospital Charge Code	ERX235956
Hospital Revenue Code	636
Min. Negotiated Rate	$627.00
Max. Negotiated Rate	$855.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$684.00
Rate for Payer: Aetna of CA Government/Medicare	$684.00
Rate for Payer: Cash Price	$513.00
Rate for Payer: Health Smart Auto/Commercial	$684.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$684.00
Rate for Payer: LLUH Dept of Risk Management WC	$627.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$855.00

TERLIPRESSIN 0.85 MG INTRAVENOUS POWDER FOR SOLUTION [235956]

Facility

$1,140.00

Service Code	CPT C9399
Hospital Charge Code	ERX235956
Hospital Revenue Code	636
Min. Negotiated Rate	$627.00
Max. Negotiated Rate	$912.00
Rate for Payer: Cash Price	$513.00
Rate for Payer: Cigna of CA HMO/PPO	$912.00
Rate for Payer: Health Smart Auto/Commercial	$684.00
Rate for Payer: LLUH Dept of Risk Management WC	$627.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$855.00

TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL [7783]

Facility

$9.26

Service Code	CPT J1071
Hospital Charge Code	1720036
Hospital Revenue Code	636
Min. Negotiated Rate	$5.09
Max. Negotiated Rate	$7.41
Rate for Payer: Cash Price	$4.17
Rate for Payer: Cigna of CA HMO/PPO	$7.41
Rate for Payer: Health Smart Auto/Commercial	$5.56
Rate for Payer: LLUH Dept of Risk Management WC	$5.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.94

TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL [7783]

Facility

$9.26

Service Code	CPT J1071
Hospital Charge Code	1720036
Hospital Revenue Code	636
Min. Negotiated Rate	$5.09
Max. Negotiated Rate	$6.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.56
Rate for Payer: Aetna of CA Government/Medicare	$5.56
Rate for Payer: Cash Price	$4.17
Rate for Payer: Health Smart Auto/Commercial	$5.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.56
Rate for Payer: LLUH Dept of Risk Management WC	$5.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.94

TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [7784]

Facility

$22.25

Service Code	CPT J1071
Hospital Charge Code	1790026
Hospital Revenue Code	636
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$17.80
Rate for Payer: Cash Price	$10.01
Rate for Payer: Cigna of CA HMO/PPO	$17.80
Rate for Payer: Health Smart Auto/Commercial	$13.35
Rate for Payer: LLUH Dept of Risk Management WC	$12.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.69

TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [7784]

Facility

$22.25

Service Code	CPT J1071
Hospital Charge Code	1790026
Hospital Revenue Code	636
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$16.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.35
Rate for Payer: Aetna of CA Government/Medicare	$13.35
Rate for Payer: Cash Price	$10.01
Rate for Payer: Health Smart Auto/Commercial	$13.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.35
Rate for Payer: LLUH Dept of Risk Management WC	$12.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.69

TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [119618]

Facility

$91.77

Service Code	CPT 90714
Hospital Charge Code	1721039
Hospital Revenue Code	636
Min. Negotiated Rate	$50.47
Max. Negotiated Rate	$68.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$55.06
Rate for Payer: Aetna of CA Government/Medicare	$55.06
Rate for Payer: Cash Price	$41.30
Rate for Payer: Health Smart Auto/Commercial	$55.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$55.06
Rate for Payer: LLUH Dept of Risk Management WC	$50.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$68.83

TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [119618]

Facility

$91.77

Service Code	CPT 90714
Hospital Charge Code	1721039
Hospital Revenue Code	636
Min. Negotiated Rate	$50.47
Max. Negotiated Rate	$73.42
Rate for Payer: Cash Price	$41.30
Rate for Payer: Cigna of CA HMO/PPO	$73.42
Rate for Payer: Health Smart Auto/Commercial	$55.06
Rate for Payer: LLUH Dept of Risk Management WC	$50.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$68.83

TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION [37504]

Facility

$67.16

Service Code	CPT 90718
Hospital Charge Code	NDG37504
Hospital Revenue Code	250
Min. Negotiated Rate	$36.94
Max. Negotiated Rate	$53.73
Rate for Payer: Cash Price	$30.22
Rate for Payer: Cigna of CA HMO/PPO	$53.73
Rate for Payer: Health Smart Auto/Commercial	$40.30
Rate for Payer: LLUH Dept of Risk Management WC	$36.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$50.37

TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION [37504]

Facility

$67.16

Service Code	CPT 90718
Hospital Charge Code	NDG37504
Hospital Revenue Code	250
Min. Negotiated Rate	$36.94
Max. Negotiated Rate	$50.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.30
Rate for Payer: Aetna of CA Government/Medicare	$40.30
Rate for Payer: Cash Price	$30.22
Rate for Payer: Health Smart Auto/Commercial	$40.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.30
Rate for Payer: LLUH Dept of Risk Management WC	$36.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$50.37

TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]

Facility

$756.31

Service Code	CPT J1670
Hospital Charge Code	1720797
Hospital Revenue Code	636
Min. Negotiated Rate	$415.97
Max. Negotiated Rate	$605.05
Rate for Payer: Cash Price	$340.34
Rate for Payer: Cigna of CA HMO/PPO	$605.05
Rate for Payer: Health Smart Auto/Commercial	$453.79
Rate for Payer: LLUH Dept of Risk Management WC	$415.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$567.23

TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]

Facility

$756.31

Service Code	CPT J1670
Hospital Charge Code	1720797
Hospital Revenue Code	636
Min. Negotiated Rate	$415.97
Max. Negotiated Rate	$567.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$453.79
Rate for Payer: Aetna of CA Government/Medicare	$453.79
Rate for Payer: Cash Price	$340.34
Rate for Payer: Health Smart Auto/Commercial	$453.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$453.79
Rate for Payer: LLUH Dept of Risk Management WC	$415.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$567.23

TETRABENAZINE 12.5 MG TABLET [94563]

Facility

$15.70

Service Code	NDC 47335-277-23
Hospital Charge Code	1712628
Hospital Revenue Code	259
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$11.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.42
Rate for Payer: Aetna of CA Government/Medicare	$9.42
Rate for Payer: Cash Price	$7.07
Rate for Payer: Health Smart Auto/Commercial	$9.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.42
Rate for Payer: LLUH Dept of Risk Management WC	$8.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.78

TETRABENAZINE 12.5 MG TABLET [94563]

Facility

$9.42

Service Code	NDC 43598-394-67
Hospital Charge Code	1712628
Hospital Revenue Code	259
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$7.54
Rate for Payer: Cash Price	$4.24
Rate for Payer: Cigna of CA HMO/PPO	$7.54
Rate for Payer: Health Smart Auto/Commercial	$5.65
Rate for Payer: LLUH Dept of Risk Management WC	$5.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.06

TETRABENAZINE 12.5 MG TABLET [94563]

Facility

$9.42

Service Code	NDC 43598-394-67
Hospital Charge Code	1712628
Hospital Revenue Code	259
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$7.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.65
Rate for Payer: Aetna of CA Government/Medicare	$5.65
Rate for Payer: Cash Price	$4.24
Rate for Payer: Health Smart Auto/Commercial	$5.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.65
Rate for Payer: LLUH Dept of Risk Management WC	$5.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.06

TETRABENAZINE 12.5 MG TABLET [94563]

Facility

$15.70

Service Code	NDC 47335-277-23
Hospital Charge Code	1712628
Hospital Revenue Code	259
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$12.56
Rate for Payer: Cash Price	$7.07
Rate for Payer: Cigna of CA HMO/PPO	$12.56
Rate for Payer: Health Smart Auto/Commercial	$9.42
Rate for Payer: LLUH Dept of Risk Management WC	$8.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.78

TETRABENAZINE 25 MG TABLET [92777]

Facility

$397.49

Service Code	NDC 67386-422-01
Hospital Charge Code	1712629
Hospital Revenue Code	259
Min. Negotiated Rate	$218.62
Max. Negotiated Rate	$317.99
Rate for Payer: Cash Price	$178.87
Rate for Payer: Cigna of CA HMO/PPO	$317.99
Rate for Payer: Health Smart Auto/Commercial	$238.49
Rate for Payer: LLUH Dept of Risk Management WC	$218.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$298.12

TETRABENAZINE 25 MG TABLET [92777]

Facility

$397.49

Service Code	NDC 67386-422-01
Hospital Charge Code	1712629
Hospital Revenue Code	259
Min. Negotiated Rate	$218.62
Max. Negotiated Rate	$298.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$238.49
Rate for Payer: Aetna of CA Government/Medicare	$238.49
Rate for Payer: Cash Price	$178.87
Rate for Payer: Health Smart Auto/Commercial	$238.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$238.49
Rate for Payer: LLUH Dept of Risk Management WC	$218.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$298.12

TETRACAINE 0.5 % EYE DROPS [7795]

Facility

$7.20

Service Code	NDC 68682-920-05
Hospital Charge Code	NDG7795
Hospital Revenue Code	259
Min. Negotiated Rate	$3.96
Max. Negotiated Rate	$5.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.32
Rate for Payer: Aetna of CA Government/Medicare	$4.32
Rate for Payer: Cash Price	$3.24
Rate for Payer: Health Smart Auto/Commercial	$4.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.32
Rate for Payer: LLUH Dept of Risk Management WC	$3.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.40

TETRACAINE 0.5 % EYE DROPS [7795]

Facility

$7.20

Service Code	NDC 68682-920-05
Hospital Charge Code	NDG7795
Hospital Revenue Code	259
Min. Negotiated Rate	$3.96
Max. Negotiated Rate	$5.76
Rate for Payer: Cash Price	$3.24
Rate for Payer: Cigna of CA HMO/PPO	$5.76
Rate for Payer: Health Smart Auto/Commercial	$4.32
Rate for Payer: LLUH Dept of Risk Management WC	$3.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.40

TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]

Facility

$3.74

Service Code	NDC 0065-0741-14
Hospital Charge Code	NDG121651B
Hospital Revenue Code	259
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$2.99
Rate for Payer: Cash Price	$1.68
Rate for Payer: Cigna of CA HMO/PPO	$2.99
Rate for Payer: Health Smart Auto/Commercial	$2.24
Rate for Payer: LLUH Dept of Risk Management WC	$2.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.80

TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]

Facility

$3.74

Service Code	NDC 0065-0741-14
Hospital Charge Code	NDG121651B
Hospital Revenue Code	259
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$2.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.24
Rate for Payer: Aetna of CA Government/Medicare	$2.24
Rate for Payer: Cash Price	$1.68
Rate for Payer: Health Smart Auto/Commercial	$2.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.24
Rate for Payer: LLUH Dept of Risk Management WC	$2.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.80

TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION [11517]

Facility

$45.57

Service Code	NDC 17478-045-32
Hospital Charge Code	1720080
Hospital Revenue Code	250
Min. Negotiated Rate	$25.06
Max. Negotiated Rate	$36.46
Rate for Payer: Cash Price	$20.51
Rate for Payer: Cigna of CA HMO/PPO	$36.46
Rate for Payer: Health Smart Auto/Commercial	$27.34
Rate for Payer: LLUH Dept of Risk Management WC	$25.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$34.18

TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION [11517]

Facility

$45.57

Service Code	NDC 17478-045-32
Hospital Charge Code	1720080
Hospital Revenue Code	250
Min. Negotiated Rate	$25.06
Max. Negotiated Rate	$34.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.34
Rate for Payer: Aetna of CA Government/Medicare	$27.34
Rate for Payer: Cash Price	$20.51
Rate for Payer: Health Smart Auto/Commercial	$27.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.34
Rate for Payer: LLUH Dept of Risk Management WC	$25.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$34.18

TETRACYCLINE 500 MG CAPSULE [7797]

Facility

$3.94

Service Code	NDC 23155-767-01
Hospital Charge Code	1710677
Hospital Revenue Code	259
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$2.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.36
Rate for Payer: Aetna of CA Government/Medicare	$2.36
Rate for Payer: Cash Price	$1.77
Rate for Payer: Health Smart Auto/Commercial	$2.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.36
Rate for Payer: LLUH Dept of Risk Management WC	$2.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.96

Know your out-of-pocket cost for care.

All Charges