Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TOLNAFTATE 1 % TOPICAL CREAM [8020]

Facility

$0.18

Service Code	NDC 24385-032-03
Hospital Charge Code	NDG8020
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
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

TOLNAFTATE 1 % TOPICAL CREAM [8020]

Facility

$0.18

Service Code	NDC 24385-032-03
Hospital Charge Code	NDG8020
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	$0.08
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

TOLNAFTATE 1 % TOPICAL CREAM [8020]

Facility

$0.21

Service Code	NDC 51672-2020-2
Hospital Charge Code	NDG8020
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

TOLNAFTATE 1 % TOPICAL CREAM [8020]

Facility

$0.21

Service Code	NDC 51672-2020-2
Hospital Charge Code	NDG8020
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

TOLNAFTATE 1 % TOPICAL POWDER [8021]

Facility

$0.06

Service Code	NDC 0536-5150-26
Hospital Charge Code	1743283
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

TOLNAFTATE 1 % TOPICAL POWDER [8021]

Facility

$0.06

Service Code	NDC 0536-5150-26
Hospital Charge Code	1743283
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

TOLTERODINE 1 MG TABLET [22782]

Facility

$0.49

Service Code	NDC 33342-097-09
Hospital Charge Code	1711744
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.37

TOLTERODINE 1 MG TABLET [22782]

Facility

$3.18

Service Code	NDC 0093-0010-06
Hospital Charge Code	1711744
Hospital Revenue Code	259
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.91
Rate for Payer: Aetna of CA Government/Medicare	$1.91
Rate for Payer: Cash Price	$1.43
Rate for Payer: Health Smart Auto/Commercial	$1.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.91
Rate for Payer: LLUH Dept of Risk Management WC	$1.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.38

TOLTERODINE 1 MG TABLET [22782]

Facility

$0.49

Service Code	NDC 33342-097-09
Hospital Charge Code	1711744
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cigna of CA HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.37

TOLTERODINE 1 MG TABLET [22782]

Facility

$3.18

Service Code	NDC 0093-0010-06
Hospital Charge Code	1711744
Hospital Revenue Code	259
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$2.54
Rate for Payer: Cash Price	$1.43
Rate for Payer: Cigna of CA HMO/PPO	$2.54
Rate for Payer: Health Smart Auto/Commercial	$1.91
Rate for Payer: LLUH Dept of Risk Management WC	$1.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.38

TOLTERODINE 2 MG TABLET [22783]

Facility

$0.40

Service Code	NDC 31722-806-60
Hospital Charge Code	1711745
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.30

TOLTERODINE 2 MG TABLET [22783]

Facility

$0.40

Service Code	NDC 31722-806-60
Hospital Charge Code	1711745
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.30

TOLTERODINE 2 MG TABLET [22783]

Facility

$0.50

Service Code	NDC 33342-098-09
Hospital Charge Code	1711745
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

TOLTERODINE 2 MG TABLET [22783]

Facility

$0.50

Service Code	NDC 33342-098-09
Hospital Charge Code	1711745
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]

Facility

$7.71

Service Code	NDC 0093-7163-56
Hospital Charge Code	1711848
Hospital Revenue Code	259
Min. Negotiated Rate	$4.24
Max. Negotiated Rate	$5.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.63
Rate for Payer: Aetna of CA Government/Medicare	$4.63
Rate for Payer: Cash Price	$3.47
Rate for Payer: Health Smart Auto/Commercial	$4.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.63
Rate for Payer: LLUH Dept of Risk Management WC	$4.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.78

TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]

Facility

$1.20

Service Code	NDC 27241-191-30
Hospital Charge Code	1711848
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

TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]

Facility

$1.20

Service Code	NDC 27241-191-30
Hospital Charge Code	1711848
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

TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]

Facility

$3.03

Service Code	NDC 59762-0047-1
Hospital Charge Code	1711848
Hospital Revenue Code	259
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$2.42
Rate for Payer: Cash Price	$1.36
Rate for Payer: Cigna of CA HMO/PPO	$2.42
Rate for Payer: Health Smart Auto/Commercial	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$1.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.27

TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]

Facility

$3.03

Service Code	NDC 59762-0047-1
Hospital Charge Code	1711848
Hospital Revenue Code	259
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$2.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.82
Rate for Payer: Aetna of CA Government/Medicare	$1.82
Rate for Payer: Cash Price	$1.36
Rate for Payer: Health Smart Auto/Commercial	$1.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$1.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.27

TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]

Facility

$7.71

Service Code	NDC 0093-7163-56
Hospital Charge Code	1711848
Hospital Revenue Code	259
Min. Negotiated Rate	$4.24
Max. Negotiated Rate	$6.17
Rate for Payer: Cash Price	$3.47
Rate for Payer: Cigna of CA HMO/PPO	$6.17
Rate for Payer: Health Smart Auto/Commercial	$4.63
Rate for Payer: LLUH Dept of Risk Management WC	$4.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.78

TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]

Facility

$7.71

Service Code	NDC 0093-7164-56
Hospital Charge Code	1711849
Hospital Revenue Code	259
Min. Negotiated Rate	$4.24
Max. Negotiated Rate	$6.17
Rate for Payer: Cash Price	$3.47
Rate for Payer: Cigna of CA HMO/PPO	$6.17
Rate for Payer: Health Smart Auto/Commercial	$4.63
Rate for Payer: LLUH Dept of Risk Management WC	$4.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.78

TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]

Facility

$7.71

Service Code	NDC 0093-7164-56
Hospital Charge Code	1711849
Hospital Revenue Code	259
Min. Negotiated Rate	$4.24
Max. Negotiated Rate	$5.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.63
Rate for Payer: Aetna of CA Government/Medicare	$4.63
Rate for Payer: Cash Price	$3.47
Rate for Payer: Health Smart Auto/Commercial	$4.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.63
Rate for Payer: LLUH Dept of Risk Management WC	$4.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.78

TOLVAPTAN 15 MG TABLET [97893]

Facility

$542.19

Service Code	NDC 60505-4704-2
Hospital Charge Code	1712438
Hospital Revenue Code	259
Min. Negotiated Rate	$298.20
Max. Negotiated Rate	$433.75
Rate for Payer: Cash Price	$243.99
Rate for Payer: Cigna of CA HMO/PPO	$433.75
Rate for Payer: Health Smart Auto/Commercial	$325.31
Rate for Payer: LLUH Dept of Risk Management WC	$298.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$406.64

TOLVAPTAN 15 MG TABLET [97893]

Facility

$542.19

Service Code	NDC 60505-4704-0
Hospital Charge Code	1712438
Hospital Revenue Code	259
Min. Negotiated Rate	$298.20
Max. Negotiated Rate	$433.75
Rate for Payer: Cash Price	$243.99
Rate for Payer: Cigna of CA HMO/PPO	$433.75
Rate for Payer: Health Smart Auto/Commercial	$325.31
Rate for Payer: LLUH Dept of Risk Management WC	$298.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$406.64

TOLVAPTAN 15 MG TABLET [97893]

Facility

$72.00

Service Code	NDC 49884-768-52
Hospital Charge Code	1712438
Hospital Revenue Code	259
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$43.20
Rate for Payer: Aetna of CA Government/Medicare	$43.20
Rate for Payer: Cash Price	$32.40
Rate for Payer: Health Smart Auto/Commercial	$43.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$43.20
Rate for Payer: LLUH Dept of Risk Management WC	$39.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$54.00

Know your out-of-pocket cost for care.

All Charges