Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TPN: NICU STARTER [196140]

Facility

$499.00

Service Code	NDC 9999-1961-40
Hospital Charge Code	NDC196140
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 STARTER [196140]

Facility

$499.00

Service Code	NDC 9999-1961-40
Hospital Charge Code	NDC196140
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

TRABECTEDIN 1 MG INTRAVENOUS SOLUTION [211543]

Facility

$3,866.89

Service Code	CPT J9352
Hospital Charge Code	ERX211543
Hospital Revenue Code	636
Min. Negotiated Rate	$2,126.79
Max. Negotiated Rate	$2,900.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,320.13
Rate for Payer: Aetna of CA Government/Medicare	$2,320.13
Rate for Payer: Cash Price	$1,740.10
Rate for Payer: Health Smart Auto/Commercial	$2,320.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,320.13
Rate for Payer: LLUH Dept of Risk Management WC	$2,126.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,900.17

TRABECTEDIN 1 MG INTRAVENOUS SOLUTION [211543]

Facility

$3,866.89

Service Code	CPT J9352
Hospital Charge Code	ERX211543
Hospital Revenue Code	636
Min. Negotiated Rate	$2,126.79
Max. Negotiated Rate	$3,093.51
Rate for Payer: Cash Price	$1,740.10
Rate for Payer: Cigna of CA HMO/PPO	$3,093.51
Rate for Payer: Health Smart Auto/Commercial	$2,320.13
Rate for Payer: LLUH Dept of Risk Management WC	$2,126.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,900.17

TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS [18266]

Facility

$4.86

Service Code	NDC 0517-9203-25
Hospital Charge Code	NDG18266
Hospital Revenue Code	250
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$3.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.92
Rate for Payer: Aetna of CA Government/Medicare	$2.92
Rate for Payer: Cash Price	$2.19
Rate for Payer: Health Smart Auto/Commercial	$2.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.92
Rate for Payer: LLUH Dept of Risk Management WC	$2.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.64

TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS [18266]

Facility

$4.86

Service Code	NDC 0517-9203-25
Hospital Charge Code	NDG18266
Hospital Revenue Code	250
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$3.89
Rate for Payer: Cash Price	$2.19
Rate for Payer: Cigna of CA HMO/PPO	$3.89
Rate for Payer: Health Smart Auto/Commercial	$2.92
Rate for Payer: LLUH Dept of Risk Management WC	$2.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.64

TRACE ELEMENTS CHOLESTASIS [4080051]

Facility

$6.30

Service Code	NDC 9994-0800-51
Hospital Charge Code	ERX4080051
Hospital Revenue Code	250
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$4.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.78
Rate for Payer: Aetna of CA Government/Medicare	$3.78
Rate for Payer: Cash Price	$2.84
Rate for Payer: Health Smart Auto/Commercial	$3.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.78
Rate for Payer: LLUH Dept of Risk Management WC	$3.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.72

TRACE ELEMENTS CHOLESTASIS [4080051]

Facility

$6.30

Service Code	NDC 9994-0800-51
Hospital Charge Code	ERX4080051
Hospital Revenue Code	250
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$5.04
Rate for Payer: Cash Price	$2.84
Rate for Payer: Cigna of CA HMO/PPO	$5.04
Rate for Payer: Health Smart Auto/Commercial	$3.78
Rate for Payer: LLUH Dept of Risk Management WC	$3.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.72

TRACE ELEMENTS FULL TERM [4080053]

Facility

$6.30

Service Code	NDC 9994-0800-53
Hospital Charge Code	ERX4080053
Hospital Revenue Code	250
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$4.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.78
Rate for Payer: Aetna of CA Government/Medicare	$3.78
Rate for Payer: Cash Price	$2.84
Rate for Payer: Health Smart Auto/Commercial	$3.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.78
Rate for Payer: LLUH Dept of Risk Management WC	$3.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.72

TRACE ELEMENTS FULL TERM [4080053]

Facility

$6.30

Service Code	NDC 9994-0800-53
Hospital Charge Code	ERX4080053
Hospital Revenue Code	250
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$5.04
Rate for Payer: Cash Price	$2.84
Rate for Payer: Cigna of CA HMO/PPO	$5.04
Rate for Payer: Health Smart Auto/Commercial	$3.78
Rate for Payer: LLUH Dept of Risk Management WC	$3.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.72

TRACE ELEMENTS PRETERM [4080052]

Facility

$6.30

Service Code	NDC 9994-0800-52
Hospital Charge Code	ERX4080052
Hospital Revenue Code	250
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$5.04
Rate for Payer: Cash Price	$2.84
Rate for Payer: Cigna of CA HMO/PPO	$5.04
Rate for Payer: Health Smart Auto/Commercial	$3.78
Rate for Payer: LLUH Dept of Risk Management WC	$3.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.72

TRACE ELEMENTS PRETERM [4080052]

Facility

$6.30

Service Code	NDC 9994-0800-52
Hospital Charge Code	ERX4080052
Hospital Revenue Code	250
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$4.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.78
Rate for Payer: Aetna of CA Government/Medicare	$3.78
Rate for Payer: Cash Price	$2.84
Rate for Payer: Health Smart Auto/Commercial	$3.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.78
Rate for Payer: LLUH Dept of Risk Management WC	$3.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.72

TRAMADOL 50 MG TABLET [14632]

Facility

$0.09

Service Code	NDC 51079-991-01
Hospital Charge Code	1711651
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

TRAMADOL 50 MG TABLET [14632]

Facility

$0.09

Service Code	NDC 51079-991-01
Hospital Charge Code	1711651
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

TRAMADOL 50 MG TABLET [14632]

Facility

$0.16

Service Code	NDC 68084-808-11
Hospital Charge Code	1711651
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

TRAMADOL 50 MG TABLET [14632]

Facility

$0.16

Service Code	NDC 68084-808-01
Hospital Charge Code	1711651
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

TRAMADOL 50 MG TABLET [14632]

Facility

$0.16

Service Code	NDC 68084-808-11
Hospital Charge Code	1711651
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

TRAMADOL 50 MG TABLET [14632]

Facility

$0.09

Service Code	NDC 51079-991-20
Hospital Charge Code	1711651
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

TRAMADOL 50 MG TABLET [14632]

Facility

$0.09

Service Code	NDC 51079-991-20
Hospital Charge Code	1711651
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

TRAMADOL 50 MG TABLET [14632]

Facility

$0.06

Service Code	NDC 57664-377-08
Hospital Charge Code	1711651
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

TRAMADOL 50 MG TABLET [14632]

Facility

$0.16

Service Code	NDC 68084-808-01
Hospital Charge Code	1711651
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

TRAMADOL 50 MG TABLET [14632]

Facility

$0.06

Service Code	NDC 57664-377-08
Hospital Charge Code	1711651
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

TRAMADOL ER 100 MG TABLET,EXTENDED RELEASE 24 HR [70352]

Facility

$3.23

Service Code	NDC 47335-859-83
Hospital Charge Code	1711964
Hospital Revenue Code	259
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.94
Rate for Payer: Aetna of CA Government/Medicare	$1.94
Rate for Payer: Cash Price	$1.45
Rate for Payer: Health Smart Auto/Commercial	$1.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.42

TRAMADOL ER 100 MG TABLET,EXTENDED RELEASE 24 HR [70352]

Facility

$3.23

Service Code	NDC 47335-859-83
Hospital Charge Code	1711964
Hospital Revenue Code	259
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.58
Rate for Payer: Cash Price	$1.45
Rate for Payer: Cigna of CA HMO/PPO	$2.58
Rate for Payer: Health Smart Auto/Commercial	$1.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.42

TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION [191168]

Facility

$0.87

Service Code	NDC 70860-407-10
Hospital Charge Code	1721084
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna of CA HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

Know your out-of-pocket cost for care.

All Charges