Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.63

Service Code	NDC 0904-6418-61
Hospital Charge Code	1710900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.47
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	$0.28
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	$0.47

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.79

Service Code	NDC 50268-760-15
Hospital Charge Code	1710900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.24

Service Code	NDC 60505-0252-3
Hospital Charge Code	1710900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.12

Service Code	NDC 29300-169-15
Hospital Charge Code	1710900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.09

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.63

Service Code	NDC 0904-6418-61
Hospital Charge Code	1710900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.28
Rate for Payer: Cigna of CA HMO/PPO	$0.50
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	$0.47

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.12

Service Code	NDC 29300-169-15
Hospital Charge Code	1710900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.09

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.12

Service Code	NDC 55111-180-15
Hospital Charge Code	1710900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.09

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.24

Service Code	NDC 60505-0252-3
Hospital Charge Code	1710900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.79

Service Code	NDC 50268-760-11
Hospital Charge Code	1710900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.63
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

TIZANIDINE 4 MG TABLET [14793]

Facility

$0.79

Service Code	NDC 50268-760-15
Hospital Charge Code	1710900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.63
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]

Facility

$24.34

Service Code	NDC 24208-295-05
Hospital Charge Code	NDG11567
Hospital Revenue Code	259
Min. Negotiated Rate	$13.39
Max. Negotiated Rate	$19.47
Rate for Payer: Cash Price	$10.95
Rate for Payer: Cigna of CA HMO/PPO	$19.47
Rate for Payer: Health Smart Auto/Commercial	$14.60
Rate for Payer: LLUH Dept of Risk Management WC	$13.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.26

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]

Facility

$39.97

Service Code	NDC 0065-0647-05
Hospital Charge Code	NDG11567
Hospital Revenue Code	259
Min. Negotiated Rate	$21.98
Max. Negotiated Rate	$29.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.98
Rate for Payer: Aetna of CA Government/Medicare	$23.98
Rate for Payer: Cash Price	$17.99
Rate for Payer: Health Smart Auto/Commercial	$23.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.98
Rate for Payer: LLUH Dept of Risk Management WC	$21.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.98

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]

Facility

$39.97

Service Code	NDC 0065-0647-05
Hospital Charge Code	NDG11567
Hospital Revenue Code	259
Min. Negotiated Rate	$21.98
Max. Negotiated Rate	$31.98
Rate for Payer: Cash Price	$17.99
Rate for Payer: Cigna of CA HMO/PPO	$31.98
Rate for Payer: Health Smart Auto/Commercial	$23.98
Rate for Payer: LLUH Dept of Risk Management WC	$21.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.98

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]

Facility

$18.21

Service Code	NDC 0574-4031-25
Hospital Charge Code	1740306
Hospital Revenue Code	259
Min. Negotiated Rate	$10.02
Max. Negotiated Rate	$13.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.93
Rate for Payer: Aetna of CA Government/Medicare	$10.93
Rate for Payer: Cash Price	$8.19
Rate for Payer: Health Smart Auto/Commercial	$10.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.93
Rate for Payer: LLUH Dept of Risk Management WC	$10.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.66

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]

Facility

$24.34

Service Code	NDC 24208-295-05
Hospital Charge Code	NDG11567
Hospital Revenue Code	259
Min. Negotiated Rate	$13.39
Max. Negotiated Rate	$18.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.60
Rate for Payer: Aetna of CA Government/Medicare	$14.60
Rate for Payer: Cash Price	$10.95
Rate for Payer: Health Smart Auto/Commercial	$14.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.60
Rate for Payer: LLUH Dept of Risk Management WC	$13.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.26

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]

Facility

$18.21

Service Code	NDC 0574-4031-25
Hospital Charge Code	1740306
Hospital Revenue Code	259
Min. Negotiated Rate	$10.02
Max. Negotiated Rate	$14.57
Rate for Payer: Cash Price	$8.19
Rate for Payer: Cigna of CA HMO/PPO	$14.57
Rate for Payer: Health Smart Auto/Commercial	$10.93
Rate for Payer: LLUH Dept of Risk Management WC	$10.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.66

TOBRAMYCIN 0.3 % EYE DROPS [7995]

Facility

$1.20

Service Code	NDC 70069-131-01
Hospital Charge Code	1740185
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cigna of CA HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90

TOBRAMYCIN 0.3 % EYE DROPS [7995]

Facility

$3.72

Service Code	NDC 62332-518-05
Hospital Charge Code	1740185
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.23
Rate for Payer: Aetna of CA Government/Medicare	$2.23
Rate for Payer: Cash Price	$1.67
Rate for Payer: Health Smart Auto/Commercial	$2.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.23
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.79

TOBRAMYCIN 0.3 % EYE DROPS [7995]

Facility

$1.20

Service Code	NDC 70069-131-01
Hospital Charge Code	1740185
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Cash Price	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.90

TOBRAMYCIN 0.3 % EYE DROPS [7995]

Facility

$3.72

Service Code	NDC 62332-518-05
Hospital Charge Code	1740185
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.98
Rate for Payer: Cash Price	$1.67
Rate for Payer: Cigna of CA HMO/PPO	$2.98
Rate for Payer: Health Smart Auto/Commercial	$2.23
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.79

TOBRAMYCIN 0.3 % EYE DROPS FOR COMPOUNDS [4087995]

Facility

$2.80

Service Code	NDC 17478-290-10
Hospital Charge Code	1740185
Hospital Revenue Code	259
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$2.24
Rate for Payer: Cash Price	$1.26
Rate for Payer: Cigna of CA HMO/PPO	$2.24
Rate for Payer: Health Smart Auto/Commercial	$1.68
Rate for Payer: LLUH Dept of Risk Management WC	$1.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.10

TOBRAMYCIN 0.3 % EYE DROPS FOR COMPOUNDS [4087995]

Facility

$3.72

Service Code	NDC 61314-643-05
Hospital Charge Code	1740185
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.98
Rate for Payer: Cash Price	$1.67
Rate for Payer: Cigna of CA HMO/PPO	$2.98
Rate for Payer: Health Smart Auto/Commercial	$2.23
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.79

TOBRAMYCIN 0.3 % EYE DROPS FOR COMPOUNDS [4087995]

Facility

$2.82

Service Code	NDC 24208-290-05
Hospital Charge Code	1740185
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.26
Rate for Payer: Cash Price	$1.27
Rate for Payer: Cigna of CA HMO/PPO	$2.26
Rate for Payer: Health Smart Auto/Commercial	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.12

TOBRAMYCIN 0.3 % EYE DROPS FOR COMPOUNDS [4087995]

Facility

$2.82

Service Code	NDC 24208-290-05
Hospital Charge Code	1740185
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.69
Rate for Payer: Aetna of CA Government/Medicare	$1.69
Rate for Payer: Cash Price	$1.27
Rate for Payer: Health Smart Auto/Commercial	$1.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.12

TOBRAMYCIN 0.3 % EYE DROPS FOR COMPOUNDS [4087995]

Facility

$2.80

Service Code	NDC 17478-290-10
Hospital Charge Code	1740185
Hospital Revenue Code	259
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$2.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.68
Rate for Payer: Aetna of CA Government/Medicare	$1.68
Rate for Payer: Cash Price	$1.26
Rate for Payer: Health Smart Auto/Commercial	$1.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.68
Rate for Payer: LLUH Dept of Risk Management WC	$1.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.10

Know your out-of-pocket cost for care.

All Charges