Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TROMETHAMINE 36 MG/ML (0.3 M) INTRAVENOUS SOLUTION [11608]

Facility

$0.78

Service Code	NDC 0409-1593-04
Hospital Charge Code	1758619
Hospital Revenue Code	250
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	$0.35
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

TROMETHAMINE 36 MG/ML (0.3 M) INTRAVENOUS SOLUTION [11608]

Facility

$0.78

Service Code	NDC 0409-1593-04
Hospital Charge Code	1758619
Hospital Revenue Code	250
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.35
Rate for Payer: Cigna of CA HMO/PPO	$0.62
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

TROPICAMIDE 0.5 % EYE DROPS [8249]

Facility

$1.71

Service Code	NDC 61314-354-01
Hospital Charge Code	1740094
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.37
Rate for Payer: Cash Price	$0.77
Rate for Payer: Cigna of CA HMO/PPO	$1.37
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.28

TROPICAMIDE 0.5 % EYE DROPS [8249]

Facility

$0.64

Service Code	NDC 17478-101-12
Hospital Charge Code	1740094
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.48
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	$0.29
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	$0.48

TROPICAMIDE 0.5 % EYE DROPS [8249]

Facility

$0.64

Service Code	NDC 17478-101-12
Hospital Charge Code	1740094
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.51
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	$0.48

TROPICAMIDE 0.5 % EYE DROPS [8249]

Facility

$1.71

Service Code	NDC 61314-354-01
Hospital Charge Code	1740094
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.28
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Cash Price	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.03
Rate for Payer: Aetna of CA Government/Medicare	$1.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.28

TROPICAMIDE 1 % EYE DROPS [8250]

Facility

$0.68

Service Code	NDC 70069-121-01
Hospital Charge Code	1740096
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cigna of CA HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.51

TROPICAMIDE 1 % EYE DROPS [8250]

Facility

$2.45

Service Code	NDC 61314-355-02
Hospital Charge Code	1740096
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.96
Rate for Payer: Cash Price	$1.10
Rate for Payer: Cigna of CA HMO/PPO	$1.96
Rate for Payer: Health Smart Auto/Commercial	$1.47
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.84

TROPICAMIDE 1 % EYE DROPS [8250]

Facility

$0.68

Service Code	NDC 70069-121-01
Hospital Charge Code	1740096
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.51

TROPICAMIDE 1 % EYE DROPS [8250]

Facility

$2.45

Service Code	NDC 61314-355-02
Hospital Charge Code	1740096
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.47
Rate for Payer: Aetna of CA Government/Medicare	$1.47
Rate for Payer: Cash Price	$1.10
Rate for Payer: Health Smart Auto/Commercial	$1.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.47
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.84

TROPICAMIDE 1 %-PROPARACAINE 0.5 %-PE 2.5 %-KETOROLAC 0.5 % EYE DROPS [223020]

Facility

$16.80

Service Code	CPT J3490
Hospital Charge Code	NDG223020
Hospital Revenue Code	636
Min. Negotiated Rate	$9.24
Max. Negotiated Rate	$13.44
Rate for Payer: Cash Price	$7.56
Rate for Payer: Cigna of CA HMO/PPO	$13.44
Rate for Payer: Health Smart Auto/Commercial	$10.08
Rate for Payer: LLUH Dept of Risk Management WC	$9.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.60

TROPICAMIDE 1 %-PROPARACAINE 0.5 %-PE 2.5 %-KETOROLAC 0.5 % EYE DROPS [223020]

Facility

$16.80

Service Code	CPT J3490
Hospital Charge Code	NDG223020
Hospital Revenue Code	636
Min. Negotiated Rate	$9.24
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.08
Rate for Payer: Aetna of CA Government/Medicare	$10.08
Rate for Payer: Cash Price	$7.56
Rate for Payer: Health Smart Auto/Commercial	$10.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.08
Rate for Payer: LLUH Dept of Risk Management WC	$9.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.60

TRYPAN BLUE 0.06 % INTRAOCULAR SYRINGE [88317]

Facility

$177.84

Service Code	CPT Q9968
Hospital Charge Code	1740332
Hospital Revenue Code	636
Min. Negotiated Rate	$97.81
Max. Negotiated Rate	$142.27
Rate for Payer: Cash Price	$80.03
Rate for Payer: Cigna of CA HMO/PPO	$142.27
Rate for Payer: Health Smart Auto/Commercial	$106.70
Rate for Payer: LLUH Dept of Risk Management WC	$97.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$133.38

TRYPAN BLUE 0.06 % INTRAOCULAR SYRINGE [88317]

Facility

$177.84

Service Code	CPT Q9968
Hospital Charge Code	1740332
Hospital Revenue Code	636
Min. Negotiated Rate	$97.81
Max. Negotiated Rate	$133.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$106.70
Rate for Payer: Aetna of CA Government/Medicare	$106.70
Rate for Payer: Cash Price	$80.03
Rate for Payer: Health Smart Auto/Commercial	$106.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$106.70
Rate for Payer: LLUH Dept of Risk Management WC	$97.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$133.38

TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]

Facility

$118.70

Service Code	CPT 86580
Hospital Charge Code	1720235
Hospital Revenue Code	302
Min. Negotiated Rate	$65.28
Max. Negotiated Rate	$94.96
Rate for Payer: Cash Price	$53.42
Rate for Payer: Cigna of CA HMO/PPO	$94.96
Rate for Payer: Health Smart Auto/Commercial	$71.22
Rate for Payer: LLUH Dept of Risk Management WC	$65.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$89.02

TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]

Facility

$113.05

Service Code	CPT 86580
Hospital Charge Code	NDG2224
Hospital Revenue Code	302
Min. Negotiated Rate	$62.18
Max. Negotiated Rate	$84.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$67.83
Rate for Payer: Aetna of CA Government/Medicare	$67.83
Rate for Payer: Cash Price	$50.87
Rate for Payer: Health Smart Auto/Commercial	$67.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$67.83
Rate for Payer: LLUH Dept of Risk Management WC	$62.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$84.79

TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]

Facility

$118.70

Service Code	CPT 86580
Hospital Charge Code	1720235
Hospital Revenue Code	302
Min. Negotiated Rate	$65.28
Max. Negotiated Rate	$89.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$71.22
Rate for Payer: Aetna of CA Government/Medicare	$71.22
Rate for Payer: Cash Price	$53.42
Rate for Payer: Health Smart Auto/Commercial	$71.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$71.22
Rate for Payer: LLUH Dept of Risk Management WC	$65.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$89.02

TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]

Facility

$92.05

Service Code	CPT 86580
Hospital Charge Code	NDG8259
Hospital Revenue Code	302
Min. Negotiated Rate	$50.63
Max. Negotiated Rate	$73.64
Rate for Payer: Cash Price	$41.42
Rate for Payer: Cigna of CA HMO/PPO	$73.64
Rate for Payer: Health Smart Auto/Commercial	$55.23
Rate for Payer: LLUH Dept of Risk Management WC	$50.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$69.04

TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]

Facility

$92.05

Service Code	CPT 86580
Hospital Charge Code	NDG8259
Hospital Revenue Code	302
Min. Negotiated Rate	$50.63
Max. Negotiated Rate	$69.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$55.23
Rate for Payer: Aetna of CA Government/Medicare	$55.23
Rate for Payer: Cash Price	$41.42
Rate for Payer: Health Smart Auto/Commercial	$55.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$55.23
Rate for Payer: LLUH Dept of Risk Management WC	$50.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$69.04

TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]

Facility

$113.05

Service Code	CPT 86580
Hospital Charge Code	NDG2224
Hospital Revenue Code	302
Min. Negotiated Rate	$62.18
Max. Negotiated Rate	$90.44
Rate for Payer: Cash Price	$50.87
Rate for Payer: Cigna of CA HMO/PPO	$90.44
Rate for Payer: Health Smart Auto/Commercial	$67.83
Rate for Payer: LLUH Dept of Risk Management WC	$62.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$84.79

TUCATINIB 150 MG TABLET [227737]

Facility

$235.14

Service Code	NDC 51144-002-12
Hospital Revenue Code	259
Min. Negotiated Rate	$129.33
Max. Negotiated Rate	$176.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$141.08
Rate for Payer: Aetna of CA Government/Medicare	$141.08
Rate for Payer: Cash Price	$105.81
Rate for Payer: Health Smart Auto/Commercial	$141.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$141.08
Rate for Payer: LLUH Dept of Risk Management WC	$129.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$176.36

TUCATINIB 150 MG TABLET [227737]

Facility

$235.14

Service Code	NDC 51144-002-12
Hospital Revenue Code	259
Min. Negotiated Rate	$129.33
Max. Negotiated Rate	$188.11
Rate for Payer: Cash Price	$105.81
Rate for Payer: Cigna of CA HMO/PPO	$188.11
Rate for Payer: Health Smart Auto/Commercial	$141.08
Rate for Payer: LLUH Dept of Risk Management WC	$129.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$176.36

TUCATINIB 50 MG TABLET [227736]

Facility

$116.94

Service Code	NDC 51144-001-60
Hospital Revenue Code	259
Min. Negotiated Rate	$64.32
Max. Negotiated Rate	$93.55
Rate for Payer: Cash Price	$52.62
Rate for Payer: Cigna of CA HMO/PPO	$93.55
Rate for Payer: Health Smart Auto/Commercial	$70.16
Rate for Payer: LLUH Dept of Risk Management WC	$64.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$87.70

TUCATINIB 50 MG TABLET [227736]

Facility

$116.94

Service Code	NDC 51144-001-60
Hospital Revenue Code	259
Min. Negotiated Rate	$64.32
Max. Negotiated Rate	$87.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$70.16
Rate for Payer: Aetna of CA Government/Medicare	$70.16
Rate for Payer: Cash Price	$52.62
Rate for Payer: Health Smart Auto/Commercial	$70.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$70.16
Rate for Payer: LLUH Dept of Risk Management WC	$64.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$87.70

TYPHOID VI POLYSACCH VACCINE 25 MCG/0.5 ML INTRAMUSCULAR SYRINGE [14678]

Facility

$293.26

Service Code	CPT 90691
Hospital Charge Code	NDG14678
Hospital Revenue Code	636
Min. Negotiated Rate	$161.29
Max. Negotiated Rate	$219.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$175.96
Rate for Payer: Aetna of CA Government/Medicare	$175.96
Rate for Payer: Cash Price	$131.97
Rate for Payer: Health Smart Auto/Commercial	$175.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$175.96
Rate for Payer: LLUH Dept of Risk Management WC	$161.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$219.94

Know your out-of-pocket cost for care.

All Charges