Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TRAZODONE 50 MG TABLET [8085]

Facility

$0.16

Service Code	NDC 60687-443-11
Hospital Charge Code	1710068
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

TRAZODONE 50 MG TABLET [8085]

Facility

$0.16

Service Code	NDC 60687-443-01
Hospital Charge Code	1710068
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

TRAZODONE 50 MG TABLET [8085]

Facility

$0.05

Service Code	NDC 42291-868-90
Hospital Charge Code	1710068
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

TRAZODONE 50 MG TABLET [8085]

Facility

$0.05

Service Code	NDC 42291-868-90
Hospital Charge Code	1710068
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

TRAZODONE 50 MG TABLET [8085]

Facility

$0.08

Service Code	NDC 50111-560-01
Hospital Charge Code	1710068
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

TRAZODONE 50 MG TABLET [8085]

Facility

$0.08

Service Code	NDC 50111-560-01
Hospital Charge Code	1710068
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
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	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

TRAZODONE 50 MG TABLET [8085]

Facility

$0.16

Service Code	NDC 60687-443-11
Hospital Charge Code	1710068
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

TRAZODONE 50 MG TABLET [8085]

Facility

$0.16

Service Code	NDC 60687-443-01
Hospital Charge Code	1710068
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

TRAZODONE 50 MG TABLET [8085]

Facility

$0.08

Service Code	NDC 60505-2653-1
Hospital Charge Code	1710068
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

TRAZODONE ORAL SUSPENSION COMPOUND 10 MG/ML [4080353]

Facility

$0.15

Service Code	NDC 9994-0803-53
Hospital Charge Code	1715307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.09
Rate for Payer: Aetna of CA Government/Medicare	$0.09
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

TRAZODONE ORAL SUSPENSION COMPOUND 10 MG/ML [4080353]

Facility

$0.15

Service Code	NDC 9994-0803-53
Hospital Charge Code	1715307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

TREMELIMUMAB-ACTL 20 MG/ML INTRAVENOUS SOLUTION [236035]

Facility

$3,120.00

Service Code	CPT J9347
Hospital Charge Code	ERX236035
Hospital Revenue Code	636
Min. Negotiated Rate	$1,716.00
Max. Negotiated Rate	$2,496.00
Rate for Payer: Cash Price	$1,404.00
Rate for Payer: Cigna of CA HMO/PPO	$2,496.00
Rate for Payer: Health Smart Auto/Commercial	$1,872.00
Rate for Payer: LLUH Dept of Risk Management WC	$1,716.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,340.00

TREMELIMUMAB-ACTL 20 MG/ML INTRAVENOUS SOLUTION [236035]

Facility

$3,120.00

Service Code	CPT J9347
Hospital Charge Code	ERX236035
Hospital Revenue Code	636
Min. Negotiated Rate	$1,716.00
Max. Negotiated Rate	$2,340.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,872.00
Rate for Payer: Aetna of CA Government/Medicare	$1,872.00
Rate for Payer: Cash Price	$1,404.00
Rate for Payer: Health Smart Auto/Commercial	$1,872.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,872.00
Rate for Payer: LLUH Dept of Risk Management WC	$1,716.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,340.00

TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION [120688]

Facility

$353.43

Service Code	CPT J7686
Hospital Charge Code	NDG120688
Hospital Revenue Code	636
Min. Negotiated Rate	$194.39
Max. Negotiated Rate	$265.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$212.06
Rate for Payer: Aetna of CA Government/Medicare	$212.06
Rate for Payer: Cash Price	$159.04
Rate for Payer: Health Smart Auto/Commercial	$212.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$212.06
Rate for Payer: LLUH Dept of Risk Management WC	$194.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$265.07

TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION [120688]

Facility

$353.43

Service Code	CPT J7686
Hospital Charge Code	NDG120688
Hospital Revenue Code	636
Min. Negotiated Rate	$194.39
Max. Negotiated Rate	$282.74
Rate for Payer: Cash Price	$159.04
Rate for Payer: Cigna of CA HMO/PPO	$282.74
Rate for Payer: Health Smart Auto/Commercial	$212.06
Rate for Payer: LLUH Dept of Risk Management WC	$194.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$265.07

TREPROSTINIL DIOLAMINE ER 0.125 MG TABLET,EXTENDED RELEASE [205150]

Facility

$7.43

Service Code	NDC 66302-300-10
Hospital Charge Code	ERX205150
Hospital Revenue Code	259
Min. Negotiated Rate	$4.09
Max. Negotiated Rate	$5.94
Rate for Payer: Cash Price	$3.34
Rate for Payer: Cigna of CA HMO/PPO	$5.94
Rate for Payer: Health Smart Auto/Commercial	$4.46
Rate for Payer: LLUH Dept of Risk Management WC	$4.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.57

TREPROSTINIL DIOLAMINE ER 0.125 MG TABLET,EXTENDED RELEASE [205150]

Facility

$7.43

Service Code	NDC 66302-300-10
Hospital Charge Code	ERX205150
Hospital Revenue Code	259
Min. Negotiated Rate	$4.09
Max. Negotiated Rate	$5.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.46
Rate for Payer: Aetna of CA Government/Medicare	$4.46
Rate for Payer: Cash Price	$3.34
Rate for Payer: Health Smart Auto/Commercial	$4.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.46
Rate for Payer: LLUH Dept of Risk Management WC	$4.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.57

TREPROSTINIL DIOLAMINE ER 0.125 MG TABLET,EXTENDED RELEASE [205150]

Facility

$7.43

Service Code	NDC 66302-300-01
Hospital Charge Code	ERX205150
Hospital Revenue Code	259
Min. Negotiated Rate	$4.09
Max. Negotiated Rate	$5.94
Rate for Payer: Cash Price	$3.34
Rate for Payer: Cigna of CA HMO/PPO	$5.94
Rate for Payer: Health Smart Auto/Commercial	$4.46
Rate for Payer: LLUH Dept of Risk Management WC	$4.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.57

TREPROSTINIL DIOLAMINE ER 0.125 MG TABLET,EXTENDED RELEASE [205150]

Facility

$7.43

Service Code	NDC 66302-300-01
Hospital Charge Code	ERX205150
Hospital Revenue Code	259
Min. Negotiated Rate	$4.09
Max. Negotiated Rate	$5.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.46
Rate for Payer: Aetna of CA Government/Medicare	$4.46
Rate for Payer: Cash Price	$3.34
Rate for Payer: Health Smart Auto/Commercial	$4.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.46
Rate for Payer: LLUH Dept of Risk Management WC	$4.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.57

TREPROSTINIL DIOLAMINE ER 0.25 MG TABLET,EXTENDED RELEASE [205149]

Facility

$14.86

Service Code	NDC 66302-302-10
Hospital Charge Code	ERX205149
Hospital Revenue Code	259
Min. Negotiated Rate	$8.17
Max. Negotiated Rate	$11.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.92
Rate for Payer: Aetna of CA Government/Medicare	$8.92
Rate for Payer: Cash Price	$6.69
Rate for Payer: Health Smart Auto/Commercial	$8.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.92
Rate for Payer: LLUH Dept of Risk Management WC	$8.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.14

TREPROSTINIL DIOLAMINE ER 0.25 MG TABLET,EXTENDED RELEASE [205149]

Facility

$14.86

Service Code	NDC 66302-302-10
Hospital Charge Code	ERX205149
Hospital Revenue Code	259
Min. Negotiated Rate	$8.17
Max. Negotiated Rate	$11.89
Rate for Payer: Cash Price	$6.69
Rate for Payer: Cigna of CA HMO/PPO	$11.89
Rate for Payer: Health Smart Auto/Commercial	$8.92
Rate for Payer: LLUH Dept of Risk Management WC	$8.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.14

TREPROSTINIL DIOLAMINE ER 1 MG TABLET,EXTENDED RELEASE [205151]

Facility

$59.45

Service Code	NDC 66302-310-01
Hospital Charge Code	ERX205151
Hospital Revenue Code	259
Min. Negotiated Rate	$32.70
Max. Negotiated Rate	$44.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.67
Rate for Payer: Aetna of CA Government/Medicare	$35.67
Rate for Payer: Cash Price	$26.75
Rate for Payer: Health Smart Auto/Commercial	$35.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.67
Rate for Payer: LLUH Dept of Risk Management WC	$32.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.59

TREPROSTINIL DIOLAMINE ER 1 MG TABLET,EXTENDED RELEASE [205151]

Facility

$59.45

Service Code	NDC 66302-310-10
Hospital Charge Code	ERX205151
Hospital Revenue Code	259
Min. Negotiated Rate	$32.70
Max. Negotiated Rate	$47.56
Rate for Payer: Cash Price	$26.75
Rate for Payer: Cigna of CA HMO/PPO	$47.56
Rate for Payer: Health Smart Auto/Commercial	$35.67
Rate for Payer: LLUH Dept of Risk Management WC	$32.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.59

TREPROSTINIL DIOLAMINE ER 1 MG TABLET,EXTENDED RELEASE [205151]

Facility

$59.45

Service Code	NDC 66302-310-10
Hospital Charge Code	ERX205151
Hospital Revenue Code	259
Min. Negotiated Rate	$32.70
Max. Negotiated Rate	$44.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.67
Rate for Payer: Aetna of CA Government/Medicare	$35.67
Rate for Payer: Cash Price	$26.75
Rate for Payer: Health Smart Auto/Commercial	$35.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.67
Rate for Payer: LLUH Dept of Risk Management WC	$32.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.59

TREPROSTINIL DIOLAMINE ER 1 MG TABLET,EXTENDED RELEASE [205151]

Facility

$59.45

Service Code	NDC 66302-310-01
Hospital Charge Code	ERX205151
Hospital Revenue Code	259
Min. Negotiated Rate	$32.70
Max. Negotiated Rate	$47.56
Rate for Payer: Cash Price	$26.75
Rate for Payer: Cigna of CA HMO/PPO	$47.56
Rate for Payer: Health Smart Auto/Commercial	$35.67
Rate for Payer: LLUH Dept of Risk Management WC	$32.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.59

Know your out-of-pocket cost for care.

All Charges