Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

THYROID (PORK) 300 MG TABLET [120635]

Facility

$2.40

Service Code	NDC 0456-0464-01
Hospital Charge Code	1711155
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cigna of CA HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80

THYROID (PORK) 300 MG TABLET [120635]

Facility

$2.40

Service Code	NDC 0456-0464-01
Hospital Charge Code	1711155
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Cash Price	$1.08
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80

THYROID (PORK) 30 MG TABLET [120629]

Facility

$0.83

Service Code	NDC 42192-329-01
Hospital Charge Code	1711096
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.62

THYROID (PORK) 30 MG TABLET [120629]

Facility

$1.10

Service Code	NDC 0456-0458-01
Hospital Charge Code	1711096
Hospital Revenue Code	259
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.66
Rate for Payer: Aetna of CA Government/Medicare	$0.66
Rate for Payer: Cash Price	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$0.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.83

THYROID (PORK) 30 MG TABLET [120629]

Facility

$1.10

Service Code	NDC 0456-0458-01
Hospital Charge Code	1711096
Hospital Revenue Code	259
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.88
Rate for Payer: Cash Price	$0.50
Rate for Payer: Cigna of CA HMO/PPO	$0.88
Rate for Payer: Health Smart Auto/Commercial	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$0.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.83

THYROID (PORK) 30 MG TABLET [120629]

Facility

$0.83

Service Code	NDC 42192-329-01
Hospital Charge Code	1711096
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.66
Rate for Payer: Cash Price	$0.37
Rate for Payer: Cigna of CA HMO/PPO	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.62

THYROID (PORK) 60 MG TABLET [120630]

Facility

$0.92

Service Code	NDC 42192-330-01
Hospital Charge Code	1711108
Hospital Revenue Code	259
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.74
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of CA HMO/PPO	$0.74
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.69

THYROID (PORK) 60 MG TABLET [120630]

Facility

$1.22

Service Code	NDC 0456-0459-01
Hospital Charge Code	1711108
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.98
Rate for Payer: Cash Price	$0.55
Rate for Payer: Cigna of CA HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.92

THYROID (PORK) 60 MG TABLET [120630]

Facility

$0.92

Service Code	NDC 42192-330-01
Hospital Charge Code	1711108
Hospital Revenue Code	259
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.55
Rate for Payer: Aetna of CA Government/Medicare	$0.55
Rate for Payer: Cash Price	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.69

THYROID (PORK) 60 MG TABLET [120630]

Facility

$1.22

Service Code	NDC 0456-0459-01
Hospital Charge Code	1711108
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.73
Rate for Payer: Aetna of CA Government/Medicare	$0.73
Rate for Payer: Cash Price	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.92

THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION [230836]

Facility

$2,314.82

Service Code	CPT J3240
Hospital Charge Code	ERX24409
Hospital Revenue Code	636
Min. Negotiated Rate	$1,273.15
Max. Negotiated Rate	$1,736.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,388.89
Rate for Payer: Aetna of CA Government/Medicare	$1,388.89
Rate for Payer: Cash Price	$1,041.67
Rate for Payer: Health Smart Auto/Commercial	$1,388.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,388.89
Rate for Payer: LLUH Dept of Risk Management WC	$1,273.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,736.12

THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION [230836]

Facility

$2,314.82

Service Code	CPT J3240
Hospital Charge Code	ERX24409
Hospital Revenue Code	636
Min. Negotiated Rate	$1,273.15
Max. Negotiated Rate	$1,851.86
Rate for Payer: Cash Price	$1,041.67
Rate for Payer: Cigna of CA HMO/PPO	$1,851.86
Rate for Payer: Health Smart Auto/Commercial	$1,388.89
Rate for Payer: LLUH Dept of Risk Management WC	$1,273.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,736.12

TICAGRELOR 60 MG TABLET [211180]

Facility

$8.76

Service Code	NDC 0186-0776-60
Hospital Charge Code	ERX211180
Hospital Revenue Code	259
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$6.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.26
Rate for Payer: Aetna of CA Government/Medicare	$5.26
Rate for Payer: Cash Price	$3.94
Rate for Payer: Health Smart Auto/Commercial	$5.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.26
Rate for Payer: LLUH Dept of Risk Management WC	$4.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.57

TICAGRELOR 60 MG TABLET [211180]

Facility

$8.76

Service Code	NDC 0186-0776-60
Hospital Charge Code	ERX211180
Hospital Revenue Code	259
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$7.01
Rate for Payer: Cash Price	$3.94
Rate for Payer: Cigna of CA HMO/PPO	$7.01
Rate for Payer: Health Smart Auto/Commercial	$5.26
Rate for Payer: LLUH Dept of Risk Management WC	$4.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.57

TICAGRELOR 90 MG TABLET [153988]

Facility

$8.76

Service Code	NDC 0186-0777-60
Hospital Charge Code	1712531
Hospital Revenue Code	259
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$7.01
Rate for Payer: Cash Price	$3.94
Rate for Payer: Cigna of CA HMO/PPO	$7.01
Rate for Payer: Health Smart Auto/Commercial	$5.26
Rate for Payer: LLUH Dept of Risk Management WC	$4.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.57

TICAGRELOR 90 MG TABLET [153988]

Facility

$8.76

Service Code	NDC 0186-0777-60
Hospital Charge Code	1712531
Hospital Revenue Code	259
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$6.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.26
Rate for Payer: Aetna of CA Government/Medicare	$5.26
Rate for Payer: Cash Price	$3.94
Rate for Payer: Health Smart Auto/Commercial	$5.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.26
Rate for Payer: LLUH Dept of Risk Management WC	$4.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.57

TICAGRELOR 90 MG TABLET [153988]

Facility

$8.76

Service Code	NDC 0186-0777-39
Hospital Charge Code	1712531
Hospital Revenue Code	259
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$7.01
Rate for Payer: Cash Price	$3.94
Rate for Payer: Cigna of CA HMO/PPO	$7.01
Rate for Payer: Health Smart Auto/Commercial	$5.26
Rate for Payer: LLUH Dept of Risk Management WC	$4.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.57

TICAGRELOR 90 MG TABLET [153988]

Facility

$8.76

Service Code	NDC 0186-0777-39
Hospital Charge Code	1712531
Hospital Revenue Code	259
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$6.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.26
Rate for Payer: Aetna of CA Government/Medicare	$5.26
Rate for Payer: Cash Price	$3.94
Rate for Payer: Health Smart Auto/Commercial	$5.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.26
Rate for Payer: LLUH Dept of Risk Management WC	$4.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.57

TIGECYCLINE 50 MG INTRAVENOUS SOLUTION [41652]

Facility

$124.80

Service Code	CPT J3243
Hospital Charge Code	1753538
Hospital Revenue Code	636
Min. Negotiated Rate	$68.64
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$43.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$75.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$90.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$114.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$74.88
Rate for Payer: Aetna of CA Government/Medicare	$90.14
Rate for Payer: Aetna of CA Government/Medicare	$75.60
Rate for Payer: Aetna of CA Government/Medicare	$74.88
Rate for Payer: Aetna of CA Government/Medicare	$114.38
Rate for Payer: Aetna of CA Government/Medicare	$43.20
Rate for Payer: Cash Price	$56.16
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cash Price	$85.78
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cash Price	$67.61
Rate for Payer: Health Smart Auto/Commercial	$75.60
Rate for Payer: Health Smart Auto/Commercial	$114.38
Rate for Payer: Health Smart Auto/Commercial	$74.88
Rate for Payer: Health Smart Auto/Commercial	$43.20
Rate for Payer: Health Smart Auto/Commercial	$90.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$114.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$43.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$74.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$90.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$75.60
Rate for Payer: LLUH Dept of Risk Management WC	$82.63
Rate for Payer: LLUH Dept of Risk Management WC	$104.85
Rate for Payer: LLUH Dept of Risk Management WC	$68.64
Rate for Payer: LLUH Dept of Risk Management WC	$69.30
Rate for Payer: LLUH Dept of Risk Management WC	$39.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$94.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$54.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$112.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$142.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$93.60

TIGECYCLINE 50 MG INTRAVENOUS SOLUTION [41652]

Facility

$150.24

Service Code	CPT J3243
Hospital Charge Code	1753538
Hospital Revenue Code	636
Min. Negotiated Rate	$82.63
Max. Negotiated Rate	$120.19
Rate for Payer: Cash Price	$67.61
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cash Price	$85.78
Rate for Payer: Cash Price	$56.16
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cigna of CA HMO/PPO	$57.60
Rate for Payer: Cigna of CA HMO/PPO	$99.84
Rate for Payer: Cigna of CA HMO/PPO	$100.80
Rate for Payer: Cigna of CA HMO/PPO	$120.19
Rate for Payer: Cigna of CA HMO/PPO	$152.50
Rate for Payer: Health Smart Auto/Commercial	$114.38
Rate for Payer: Health Smart Auto/Commercial	$74.88
Rate for Payer: Health Smart Auto/Commercial	$75.60
Rate for Payer: Health Smart Auto/Commercial	$90.14
Rate for Payer: Health Smart Auto/Commercial	$43.20
Rate for Payer: LLUH Dept of Risk Management WC	$39.60
Rate for Payer: LLUH Dept of Risk Management WC	$104.85
Rate for Payer: LLUH Dept of Risk Management WC	$69.30
Rate for Payer: LLUH Dept of Risk Management WC	$82.63
Rate for Payer: LLUH Dept of Risk Management WC	$68.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$93.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$94.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$54.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$142.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$112.68

TIMOLOL MALEATE 0.25 % EYE DROPS [11561]

Facility

$1.31

Service Code	NDC 61314-226-10
Hospital Charge Code	NDG11561
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Cash Price	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

TIMOLOL MALEATE 0.25 % EYE DROPS [11561]

Facility

$0.72

Service Code	NDC 60758-802-05
Hospital Charge Code	1740182
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.54

TIMOLOL MALEATE 0.25 % EYE DROPS [11561]

Facility

$1.24

Service Code	NDC 61314-226-05
Hospital Charge Code	1740182
Hospital Revenue Code	259
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.99
Rate for Payer: Cash Price	$0.56
Rate for Payer: Cigna of CA HMO/PPO	$0.99
Rate for Payer: Health Smart Auto/Commercial	$0.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.93

TIMOLOL MALEATE 0.25 % EYE DROPS [11561]

Facility

$1.24

Service Code	NDC 61314-226-05
Hospital Charge Code	1740182
Hospital Revenue Code	259
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.74
Rate for Payer: Aetna of CA Government/Medicare	$0.74
Rate for Payer: Cash Price	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.93

TIMOLOL MALEATE 0.25 % EYE DROPS [11561]

Facility

$1.31

Service Code	NDC 61314-226-10
Hospital Charge Code	NDG11561
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.05
Rate for Payer: Cash Price	$0.59
Rate for Payer: Cigna of CA HMO/PPO	$1.05
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

Know your out-of-pocket cost for care.

All Charges