Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

THIOGUANINE 40 MG TABLET [7886]

Facility

$30.33

Service Code	NDC 76388-880-25
Hospital Charge Code	1711149
Hospital Revenue Code	259
Min. Negotiated Rate	$16.68
Max. Negotiated Rate	$24.26
Rate for Payer: Cash Price	$13.65
Rate for Payer: Cigna of CA HMO/PPO	$24.26
Rate for Payer: Health Smart Auto/Commercial	$18.20
Rate for Payer: LLUH Dept of Risk Management WC	$16.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.75

THIOGUANINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080349]

Facility

$6.03

Service Code	NDC 9994-0803-49
Hospital Charge Code	1715020
Hospital Revenue Code	259
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$4.82
Rate for Payer: Cash Price	$2.71
Rate for Payer: Cigna of CA HMO/PPO	$4.82
Rate for Payer: Health Smart Auto/Commercial	$3.62
Rate for Payer: LLUH Dept of Risk Management WC	$3.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.52

THIOGUANINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080349]

Facility

$6.03

Service Code	NDC 9994-0803-49
Hospital Charge Code	1715020
Hospital Revenue Code	259
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$4.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.62
Rate for Payer: Aetna of CA Government/Medicare	$3.62
Rate for Payer: Cash Price	$2.71
Rate for Payer: Health Smart Auto/Commercial	$3.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.62
Rate for Payer: LLUH Dept of Risk Management WC	$3.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.52

THIORIDAZINE 25 MG TABLET [7899]

Facility

$0.64

Service Code	NDC 51079-566-01
Hospital Charge Code	1710344
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.48

THIORIDAZINE 25 MG TABLET [7899]

Facility

$0.64

Service Code	NDC 51079-566-01
Hospital Charge Code	1710344
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.48

THIOTEPA 100 MG SOLUTION FOR INJECTION [216126]

Facility

$5,640.00

Service Code	CPT J9340
Hospital Charge Code	ERX216126
Hospital Revenue Code	636
Min. Negotiated Rate	$3,102.00
Max. Negotiated Rate	$4,512.00
Rate for Payer: Cash Price	$2,538.00
Rate for Payer: Cigna of CA HMO/PPO	$4,512.00
Rate for Payer: Health Smart Auto/Commercial	$3,384.00
Rate for Payer: LLUH Dept of Risk Management WC	$3,102.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,230.00

THIOTEPA 100 MG SOLUTION FOR INJECTION [216126]

Facility

$5,640.00

Service Code	CPT J9340
Hospital Charge Code	ERX216126
Hospital Revenue Code	636
Min. Negotiated Rate	$3,102.00
Max. Negotiated Rate	$4,230.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3,384.00
Rate for Payer: Aetna of CA Government/Medicare	$3,384.00
Rate for Payer: Cash Price	$2,538.00
Rate for Payer: Health Smart Auto/Commercial	$3,384.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3,384.00
Rate for Payer: LLUH Dept of Risk Management WC	$3,102.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,230.00

THIOTEPA 15 MG SOLUTION FOR INJECTION [7901]

Facility

$900.00

Service Code	CPT J9340
Hospital Charge Code	1755061
Hospital Revenue Code	636
Min. Negotiated Rate	$495.00
Max. Negotiated Rate	$675.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$540.00
Rate for Payer: Aetna of CA Government/Medicare	$540.00
Rate for Payer: Cash Price	$405.00
Rate for Payer: Health Smart Auto/Commercial	$540.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$540.00
Rate for Payer: LLUH Dept of Risk Management WC	$495.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$675.00

THIOTEPA 15 MG SOLUTION FOR INJECTION [7901]

Facility

$900.00

Service Code	CPT J9340
Hospital Charge Code	1755061
Hospital Revenue Code	636
Min. Negotiated Rate	$495.00
Max. Negotiated Rate	$720.00
Rate for Payer: Cash Price	$405.00
Rate for Payer: Cigna of CA HMO/PPO	$720.00
Rate for Payer: Health Smart Auto/Commercial	$540.00
Rate for Payer: LLUH Dept of Risk Management WC	$495.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$675.00

THIOTHIXENE 2 MG CAPSULE [7904]

Facility

$2.39

Service Code	NDC 51079-587-01
Hospital Charge Code	1711269
Hospital Revenue Code	259
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.91
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cigna of CA HMO/PPO	$1.91
Rate for Payer: Health Smart Auto/Commercial	$1.43
Rate for Payer: LLUH Dept of Risk Management WC	$1.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.79

THIOTHIXENE 2 MG CAPSULE [7904]

Facility

$2.39

Service Code	NDC 51079-587-01
Hospital Charge Code	1711269
Hospital Revenue Code	259
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.43
Rate for Payer: Aetna of CA Government/Medicare	$1.43
Rate for Payer: Cash Price	$1.08
Rate for Payer: Health Smart Auto/Commercial	$1.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.43
Rate for Payer: LLUH Dept of Risk Management WC	$1.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.79

THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 10 ML TOPICAL SYRINGE [221104]

Facility

$80.93

Service Code	NDC 0338-9568-01
Hospital Charge Code	NDG221104
Hospital Revenue Code	250
Min. Negotiated Rate	$44.51
Max. Negotiated Rate	$64.74
Rate for Payer: Cash Price	$36.42
Rate for Payer: Cigna of CA HMO/PPO	$64.74
Rate for Payer: Health Smart Auto/Commercial	$48.56
Rate for Payer: LLUH Dept of Risk Management WC	$44.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.70

THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 10 ML TOPICAL SYRINGE [221104]

Facility

$80.93

Service Code	NDC 0338-9568-01
Hospital Charge Code	NDG221104
Hospital Revenue Code	250
Min. Negotiated Rate	$44.51
Max. Negotiated Rate	$60.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$48.56
Rate for Payer: Aetna of CA Government/Medicare	$48.56
Rate for Payer: Cash Price	$36.42
Rate for Payer: Health Smart Auto/Commercial	$48.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$48.56
Rate for Payer: LLUH Dept of Risk Management WC	$44.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.70

THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 4 ML TOPICAL SYRINGE [221103]

Facility

$82.46

Service Code	NDC 0338-9564-01
Hospital Charge Code	NDG221103
Hospital Revenue Code	250
Min. Negotiated Rate	$45.35
Max. Negotiated Rate	$65.97
Rate for Payer: Cash Price	$37.11
Rate for Payer: Cigna of CA HMO/PPO	$65.97
Rate for Payer: Health Smart Auto/Commercial	$49.48
Rate for Payer: LLUH Dept of Risk Management WC	$45.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$61.84

THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 4 ML TOPICAL SYRINGE [221103]

Facility

$82.46

Service Code	NDC 0338-9564-01
Hospital Charge Code	NDG221103
Hospital Revenue Code	250
Min. Negotiated Rate	$45.35
Max. Negotiated Rate	$61.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$49.48
Rate for Payer: Aetna of CA Government/Medicare	$49.48
Rate for Payer: Cash Price	$37.11
Rate for Payer: Health Smart Auto/Commercial	$49.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$49.48
Rate for Payer: LLUH Dept of Risk Management WC	$45.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$61.84

THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]

Facility

$103.20

Service Code	NDC 0338-0322-01
Hospital Charge Code	ERX89570
Hospital Revenue Code	250
Min. Negotiated Rate	$56.76
Max. Negotiated Rate	$82.56
Rate for Payer: Cash Price	$46.44
Rate for Payer: Cigna of CA HMO/PPO	$82.56
Rate for Payer: Health Smart Auto/Commercial	$61.92
Rate for Payer: LLUH Dept of Risk Management WC	$56.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$77.40

THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]

Facility

$103.20

Service Code	NDC 0338-0324-01
Hospital Charge Code	ERX89570
Hospital Revenue Code	250
Min. Negotiated Rate	$56.76
Max. Negotiated Rate	$82.56
Rate for Payer: Cash Price	$46.44
Rate for Payer: Cigna of CA HMO/PPO	$82.56
Rate for Payer: Health Smart Auto/Commercial	$61.92
Rate for Payer: LLUH Dept of Risk Management WC	$56.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$77.40

THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]

Facility

$103.20

Service Code	NDC 0338-0324-01
Hospital Charge Code	ERX89570
Hospital Revenue Code	250
Min. Negotiated Rate	$56.76
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$61.92
Rate for Payer: Aetna of CA Government/Medicare	$61.92
Rate for Payer: Cash Price	$46.44
Rate for Payer: Health Smart Auto/Commercial	$61.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$61.92
Rate for Payer: LLUH Dept of Risk Management WC	$56.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$77.40

THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]

Facility

$103.20

Service Code	NDC 0338-0322-01
Hospital Charge Code	ERX89570
Hospital Revenue Code	250
Min. Negotiated Rate	$56.76
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$61.92
Rate for Payer: Aetna of CA Government/Medicare	$61.92
Rate for Payer: Cash Price	$46.44
Rate for Payer: Health Smart Auto/Commercial	$61.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$61.92
Rate for Payer: LLUH Dept of Risk Management WC	$56.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$77.40

THYROID (PORK) 15 MG TABLET [120628]

Facility

$0.70

Service Code	NDC 42192-327-01
Hospital Charge Code	1711089
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.56
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

THYROID (PORK) 15 MG TABLET [120628]

Facility

$0.70

Service Code	NDC 42192-327-01
Hospital Charge Code	1711089
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.42
Rate for Payer: Aetna of CA Government/Medicare	$0.42
Rate for Payer: Cash Price	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.53

THYROID (PORK) 15 MG TABLET [120628]

Facility

$0.94

Service Code	NDC 0456-0457-01
Hospital Charge Code	1711089
Hospital Revenue Code	259
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
Rate for Payer: Cash Price	$0.42
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.71

THYROID (PORK) 15 MG TABLET [120628]

Facility

$0.94

Service Code	NDC 0456-0457-01
Hospital Charge Code	1711089
Hospital Revenue Code	259
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.71
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	$0.42
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 Beech St/Commercial/PHCS	$0.71

THYROID (PORK) 180 MG TABLET [120633]

Facility

$1.68

Service Code	NDC 0456-0462-01
Hospital Charge Code	1711143
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Cash Price	$0.76
Rate for Payer: Cigna of CA HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.26

THYROID (PORK) 180 MG TABLET [120633]

Facility

$1.68

Service Code	NDC 0456-0462-01
Hospital Charge Code	1711143
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.01
Rate for Payer: Aetna of CA Government/Medicare	$1.01
Rate for Payer: Cash Price	$0.76
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.26

Know your out-of-pocket cost for care.

All Charges