Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]

Facility

$0.08

Service Code	NDC 68382-138-14
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

TOPIRAMATE ORAL SOLUTION COMPOUND 6 MG/ML [4080352]

Facility

$6.04

Service Code	NDC 9994-0803-52
Hospital Charge Code	1715211
Hospital Revenue Code	259
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$4.53
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	$2.72
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	$4.53

TOPIRAMATE ORAL SOLUTION COMPOUND 6 MG/ML [4080352]

Facility

$6.04

Service Code	NDC 9994-0803-52
Hospital Charge Code	1715211
Hospital Revenue Code	259
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$4.83
Rate for Payer: Cash Price	$2.72
Rate for Payer: Cigna of CA HMO/PPO	$4.83
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	$4.53

TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION [108590]

Facility

$20.78

Service Code	CPT J9351
Hospital Charge Code	NDG108590
Hospital Revenue Code	636
Min. Negotiated Rate	$11.43
Max. Negotiated Rate	$16.62
Rate for Payer: Cash Price	$9.35
Rate for Payer: Cash Price	$20.25
Rate for Payer: Cigna of CA HMO/PPO	$16.62
Rate for Payer: Cigna of CA HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Health Smart Auto/Commercial	$12.47
Rate for Payer: LLUH Dept of Risk Management WC	$11.43
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.75

TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION [108590]

Facility

$20.78

Service Code	CPT J9351
Hospital Charge Code	NDG108590
Hospital Revenue Code	636
Min. Negotiated Rate	$11.43
Max. Negotiated Rate	$15.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.00
Rate for Payer: Aetna of CA Government/Medicare	$12.47
Rate for Payer: Aetna of CA Government/Medicare	$27.00
Rate for Payer: Cash Price	$20.25
Rate for Payer: Cash Price	$9.35
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Health Smart Auto/Commercial	$12.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.47
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: LLUH Dept of Risk Management WC	$11.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.58

TOPOTECAN 4 MG INTRAVENOUS SOLUTION [17285]

Facility

$282.00

Service Code	NDC 63323-762-10
Hospital Charge Code	1755756
Hospital Revenue Code	636
Min. Negotiated Rate	$155.10
Max. Negotiated Rate	$225.60
Rate for Payer: Cash Price	$126.90
Rate for Payer: Cigna of CA HMO/PPO	$225.60
Rate for Payer: Health Smart Auto/Commercial	$169.20
Rate for Payer: LLUH Dept of Risk Management WC	$155.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$211.50

TOPOTECAN 4 MG INTRAVENOUS SOLUTION [17285]

Facility

$282.00

Service Code	NDC 63323-762-17
Hospital Charge Code	1755756
Hospital Revenue Code	636
Min. Negotiated Rate	$155.10
Max. Negotiated Rate	$225.60
Rate for Payer: Cash Price	$126.90
Rate for Payer: Cigna of CA HMO/PPO	$225.60
Rate for Payer: Health Smart Auto/Commercial	$169.20
Rate for Payer: LLUH Dept of Risk Management WC	$155.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$211.50

TOPOTECAN 4 MG INTRAVENOUS SOLUTION [17285]

Facility

$282.00

Service Code	NDC 63323-762-17
Hospital Charge Code	1755756
Hospital Revenue Code	636
Min. Negotiated Rate	$155.10
Max. Negotiated Rate	$211.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$169.20
Rate for Payer: Aetna of CA Government/Medicare	$169.20
Rate for Payer: Cash Price	$126.90
Rate for Payer: Health Smart Auto/Commercial	$169.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$169.20
Rate for Payer: LLUH Dept of Risk Management WC	$155.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$211.50

TOPOTECAN 4 MG INTRAVENOUS SOLUTION [17285]

Facility

$282.00

Service Code	NDC 63323-762-10
Hospital Charge Code	1755756
Hospital Revenue Code	636
Min. Negotiated Rate	$155.10
Max. Negotiated Rate	$211.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$169.20
Rate for Payer: Aetna of CA Government/Medicare	$169.20
Rate for Payer: Cash Price	$126.90
Rate for Payer: Health Smart Auto/Commercial	$169.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$169.20
Rate for Payer: LLUH Dept of Risk Management WC	$155.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$211.50

TORSEMIDE 100 MG TABLET [18294]

Facility

$0.57

Service Code	NDC 50268-757-15
Hospital Charge Code	1712177
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cigna of CA HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.43

TORSEMIDE 100 MG TABLET [18294]

Facility

$0.57

Service Code	NDC 50268-757-15
Hospital Charge Code	1712177
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.34
Rate for Payer: Aetna of CA Government/Medicare	$0.34
Rate for Payer: Cash Price	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.43

TORSEMIDE 100 MG TABLET [18294]

Facility

$0.57

Service Code	NDC 50268-757-11
Hospital Charge Code	1712177
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cigna of CA HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.43

TORSEMIDE 100 MG TABLET [18294]

Facility

$0.57

Service Code	NDC 50268-757-11
Hospital Charge Code	1712177
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.34
Rate for Payer: Aetna of CA Government/Medicare	$0.34
Rate for Payer: Cash Price	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.43

TORSEMIDE 10 MG TABLET [18292]

Facility

$0.19

Service Code	NDC 57237-139-01
Hospital Charge Code	1712175
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

TORSEMIDE 10 MG TABLET [18292]

Facility

$0.19

Service Code	NDC 57237-139-01
Hospital Charge Code	1712175
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

TORSEMIDE 10 MG TABLET [18292]

Facility

$0.37

Service Code	NDC 50268-755-15
Hospital Charge Code	1712175
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.28

TORSEMIDE 10 MG TABLET [18292]

Facility

$0.37

Service Code	NDC 50268-755-15
Hospital Charge Code	1712175
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of CA HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.28

TORSEMIDE 20 MG TABLET [18293]

Facility

$0.43

Service Code	NDC 68084-539-11
Hospital Charge Code	1712176
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

TORSEMIDE 20 MG TABLET [18293]

Facility

$0.43

Service Code	NDC 68084-539-11
Hospital Charge Code	1712176
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

TORSEMIDE 20 MG TABLET [18293]

Facility

$0.26

Service Code	NDC 65862-127-01
Hospital Charge Code	1712176
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

TORSEMIDE 20 MG TABLET [18293]

Facility

$0.26

Service Code	NDC 31722-531-01
Hospital Charge Code	1712176
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

TORSEMIDE 20 MG TABLET [18293]

Facility

$0.26

Service Code	NDC 65862-127-01
Hospital Charge Code	1712176
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

TORSEMIDE 20 MG TABLET [18293]

Facility

$0.26

Service Code	NDC 31722-531-01
Hospital Charge Code	1712176
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

TPN NICU NO DOSE REVISED [4082636]

Facility

$499.00

Service Code	NDC 9994-0816-36
Hospital Charge Code	NDG4082636
Hospital Revenue Code	250
Min. Negotiated Rate	$274.45
Max. Negotiated Rate	$374.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$299.40
Rate for Payer: Aetna of CA Government/Medicare	$299.40
Rate for Payer: Cash Price	$224.55
Rate for Payer: Health Smart Auto/Commercial	$299.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$299.40
Rate for Payer: LLUH Dept of Risk Management WC	$274.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$374.25

TPN NICU NO DOSE REVISED [4082636]

Facility

$499.00

Service Code	NDC 9994-0816-36
Hospital Charge Code	NDG4082636
Hospital Revenue Code	250
Min. Negotiated Rate	$274.45
Max. Negotiated Rate	$399.20
Rate for Payer: Cash Price	$224.55
Rate for Payer: Cigna of CA HMO/PPO	$399.20
Rate for Payer: Health Smart Auto/Commercial	$299.40
Rate for Payer: LLUH Dept of Risk Management WC	$274.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$374.25

Know your out-of-pocket cost for care.

All Charges