Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TETRACYCLINE 500 MG CAPSULE [7797]

Facility

$3.94

Service Code	NDC 62135-266-60
Hospital Charge Code	1710677
Hospital Revenue Code	259
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$3.15
Rate for Payer: Cash Price	$1.77
Rate for Payer: Cigna of CA HMO/PPO	$3.15
Rate for Payer: Health Smart Auto/Commercial	$2.36
Rate for Payer: LLUH Dept of Risk Management WC	$2.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.96

TETRACYCLINE 500 MG CAPSULE [7797]

Facility

$3.94

Service Code	NDC 62135-266-60
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

TETRACYCLINE 500 MG CAPSULE [7797]

Facility

$3.94

Service Code	NDC 51991-907-01
Hospital Charge Code	1710677
Hospital Revenue Code	259
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$3.15
Rate for Payer: Cash Price	$1.77
Rate for Payer: Cigna of CA HMO/PPO	$3.15
Rate for Payer: Health Smart Auto/Commercial	$2.36
Rate for Payer: LLUH Dept of Risk Management WC	$2.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.96

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

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	$3.15
Rate for Payer: Cash Price	$1.77
Rate for Payer: Cigna of CA HMO/PPO	$3.15
Rate for Payer: Health Smart Auto/Commercial	$2.36
Rate for Payer: LLUH Dept of Risk Management WC	$2.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.96

TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]

Facility

$0.21

Service Code	NDC 9994-0803-48
Hospital Charge Code	1715971
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]

Facility

$0.21

Service Code	NDC 9994-0803-48
Hospital Charge Code	1715971
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.16
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	$0.09
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 Beech St/Commercial/PHCS	$0.16

THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]

Facility

$94.83

Service Code	CPT A9505
Hospital Charge Code	ERX98468
Hospital Revenue Code	343
Min. Negotiated Rate	$52.16
Max. Negotiated Rate	$71.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$56.90
Rate for Payer: Aetna of CA Government/Medicare	$56.90
Rate for Payer: Cash Price	$42.67
Rate for Payer: Health Smart Auto/Commercial	$56.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$56.90
Rate for Payer: LLUH Dept of Risk Management WC	$52.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$71.12

THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]

Facility

$94.83

Service Code	CPT A9505
Hospital Charge Code	ERX98468
Hospital Revenue Code	343
Min. Negotiated Rate	$52.16
Max. Negotiated Rate	$75.86
Rate for Payer: Cash Price	$42.67
Rate for Payer: Cigna of CA HMO/PPO	$75.86
Rate for Payer: Health Smart Auto/Commercial	$56.90
Rate for Payer: LLUH Dept of Risk Management WC	$52.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$71.12

THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]

Facility

$0.10

Service Code	NDC 0121-0820-16
Hospital Charge Code	1715472
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]

Facility

$0.10

Service Code	NDC 0121-0820-16
Hospital Charge Code	1715472
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]

Facility

$0.19

Service Code	NDC 54838-556-80
Hospital Charge Code	NDG7821
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	$0.09
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 Beech St/Commercial/PHCS	$0.14

THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]

Facility

$0.19

Service Code	NDC 27808-033-01
Hospital Charge Code	NDG7821
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]

Facility

$0.19

Service Code	NDC 27808-033-01
Hospital Charge Code	NDG7821
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	$0.09
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 Beech St/Commercial/PHCS	$0.14

THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]

Facility

$0.19

Service Code	NDC 54838-556-80
Hospital Charge Code	NDG7821
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]

Facility

$5.71

Service Code	NDC 52244-200-10
Hospital Charge Code	ERX27419
Hospital Revenue Code	259
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$4.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.43
Rate for Payer: Aetna of CA Government/Medicare	$3.43
Rate for Payer: Cash Price	$2.57
Rate for Payer: Health Smart Auto/Commercial	$3.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.43
Rate for Payer: LLUH Dept of Risk Management WC	$3.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.28

THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]

Facility

$5.71

Service Code	NDC 52244-200-10
Hospital Charge Code	ERX27419
Hospital Revenue Code	259
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$4.57
Rate for Payer: Cash Price	$2.57
Rate for Payer: Cigna of CA HMO/PPO	$4.57
Rate for Payer: Health Smart Auto/Commercial	$3.43
Rate for Payer: LLUH Dept of Risk Management WC	$3.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.28

THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]

Facility

$7.02

Service Code	NDC 52244-300-10
Hospital Charge Code	ERX27421
Hospital Revenue Code	259
Min. Negotiated Rate	$3.86
Max. Negotiated Rate	$5.62
Rate for Payer: Cash Price	$3.16
Rate for Payer: Cigna of CA HMO/PPO	$5.62
Rate for Payer: Health Smart Auto/Commercial	$4.21
Rate for Payer: LLUH Dept of Risk Management WC	$3.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.26

THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]

Facility

$7.02

Service Code	NDC 52244-300-10
Hospital Charge Code	ERX27421
Hospital Revenue Code	259
Min. Negotiated Rate	$3.86
Max. Negotiated Rate	$5.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.21
Rate for Payer: Aetna of CA Government/Medicare	$4.21
Rate for Payer: Cash Price	$3.16
Rate for Payer: Health Smart Auto/Commercial	$4.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.21
Rate for Payer: LLUH Dept of Risk Management WC	$3.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.26

THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]

Facility

$4.12

Service Code	NDC 68462-721-01
Hospital Charge Code	1710671
Hospital Revenue Code	259
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$3.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.47
Rate for Payer: Aetna of CA Government/Medicare	$2.47
Rate for Payer: Cash Price	$1.85
Rate for Payer: Health Smart Auto/Commercial	$2.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.47
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.09

THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]

Facility

$4.12

Service Code	NDC 62332-025-31
Hospital Charge Code	1710671
Hospital Revenue Code	259
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$3.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.47
Rate for Payer: Aetna of CA Government/Medicare	$2.47
Rate for Payer: Cash Price	$1.85
Rate for Payer: Health Smart Auto/Commercial	$2.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.47
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.09

THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]

Facility

$4.12

Service Code	NDC 68462-721-01
Hospital Charge Code	1710671
Hospital Revenue Code	259
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$3.30
Rate for Payer: Cash Price	$1.85
Rate for Payer: Cigna of CA HMO/PPO	$3.30
Rate for Payer: Health Smart Auto/Commercial	$2.47
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.09

THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]

Facility

$4.12

Service Code	NDC 62332-025-31
Hospital Charge Code	1710671
Hospital Revenue Code	259
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$3.30
Rate for Payer: Cash Price	$1.85
Rate for Payer: Cigna of CA HMO/PPO	$3.30
Rate for Payer: Health Smart Auto/Commercial	$2.47
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.09

THEOPHYLLINE ER 400 MG CAPSULE,EXTENDED RELEASE 24 HR [31783]

Facility

$4.64

Service Code	NDC 50474-400-01
Hospital Charge Code	1712630
Hospital Revenue Code	259
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$3.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.78
Rate for Payer: Aetna of CA Government/Medicare	$2.78
Rate for Payer: Cash Price	$2.09
Rate for Payer: Health Smart Auto/Commercial	$2.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.78
Rate for Payer: LLUH Dept of Risk Management WC	$2.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.48

THEOPHYLLINE ER 400 MG CAPSULE,EXTENDED RELEASE 24 HR [31783]

Facility

$4.64

Service Code	NDC 50474-400-01
Hospital Charge Code	1712630
Hospital Revenue Code	259
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$3.71
Rate for Payer: Cash Price	$2.09
Rate for Payer: Cigna of CA HMO/PPO	$3.71
Rate for Payer: Health Smart Auto/Commercial	$2.78
Rate for Payer: LLUH Dept of Risk Management WC	$2.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.48

Know your out-of-pocket cost for care.

All Charges