Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HALOPERIDOL 5 MG TABLET [3583]

Facility

$1.09

Service Code	NDC 60687-161-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.87
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Commercial	$0.82

HALOPERIDOL 5 MG TABLET [3583]

Facility

$1.09

Service Code	NDC 60687-161-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.87
Rate for Payer: Cash Price	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.87
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Commercial	$0.82

HALOPERIDOL 5 MG TABLET [3583]

Facility

$0.98

Service Code	NDC 0378-0327-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.78
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.78
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION [10162]

Facility

$52.80

Service Code	HCPCS J1631
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$29.04
Max. Negotiated Rate	$42.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.24
Rate for Payer: Aetna of CA Government/Medicare	$31.68
Rate for Payer: Aetna of CA Government/Medicare	$30.24
Rate for Payer: Cash Price	$29.04
Rate for Payer: Cash Price	$27.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.32
Rate for Payer: Health Smart Auto/Commercial	$30.24
Rate for Payer: Health Smart Auto/Commercial	$31.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$31.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.24
Rate for Payer: LLUH Dept of Risk Management WC	$27.72
Rate for Payer: LLUH Dept of Risk Management WC	$29.04
Rate for Payer: Multiplan Commercial	$39.60
Rate for Payer: Multiplan Commercial	$37.80

HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION [10162]

Facility

$50.40

Service Code	HCPCS J1631
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$27.72
Max. Negotiated Rate	$40.32
Rate for Payer: Cash Price	$27.72
Rate for Payer: Cash Price	$29.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.32
Rate for Payer: Health Smart Auto/Commercial	$31.68
Rate for Payer: Health Smart Auto/Commercial	$30.24
Rate for Payer: LLUH Dept of Risk Management WC	$27.72
Rate for Payer: LLUH Dept of Risk Management WC	$29.04
Rate for Payer: Multiplan Commercial	$37.80
Rate for Payer: Multiplan Commercial	$39.60

HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION [10163]

Facility

$33.70

Service Code	HCPCS J1631
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$18.54
Max. Negotiated Rate	$26.96
Rate for Payer: Cash Price	$18.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.96
Rate for Payer: Health Smart Auto/Commercial	$20.22
Rate for Payer: LLUH Dept of Risk Management WC	$18.54
Rate for Payer: Multiplan Commercial	$25.27

HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION [10163]

Facility

$33.70

Service Code	HCPCS J1631
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$18.54
Max. Negotiated Rate	$26.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.22
Rate for Payer: Aetna of CA Government/Medicare	$20.22
Rate for Payer: Cash Price	$18.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.96
Rate for Payer: Health Smart Auto/Commercial	$20.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.22
Rate for Payer: LLUH Dept of Risk Management WC	$18.54
Rate for Payer: Multiplan Commercial	$25.27

HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION [3584]

Facility

$1.06

Service Code	HCPCS J1630
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.85
Rate for Payer: Cash Price	$0.58
Rate for Payer: Cash Price	$3.95
Rate for Payer: Cash Price	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$4.31
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: Health Smart Auto/Commercial	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$3.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Commercial	$5.39
Rate for Payer: Multiplan Commercial	$1.44
Rate for Payer: Multiplan Commercial	$0.80

HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION [3584]

Facility

$7.19

Service Code	HCPCS J1630
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$5.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.15
Rate for Payer: Aetna of CA Government/Medicare	$0.64
Rate for Payer: Aetna of CA Government/Medicare	$1.15
Rate for Payer: Aetna of CA Government/Medicare	$4.31
Rate for Payer: Cash Price	$1.06
Rate for Payer: Cash Price	$0.58
Rate for Payer: Cash Price	$3.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$4.31
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: Health Smart Auto/Commercial	$0.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: LLUH Dept of Risk Management WC	$3.95
Rate for Payer: Multiplan Commercial	$1.44
Rate for Payer: Multiplan Commercial	$0.80
Rate for Payer: Multiplan Commercial	$5.39

HC 5-HIAA BY HPLC

Facility

$42.00

Service Code	CPT 83497
Hospital Charge Code	900910535
Hospital Revenue Code	301
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.60
Rate for Payer: Cash Price	$18.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.60
Rate for Payer: Health Smart Auto/Commercial	$25.20
Rate for Payer: LLUH Dept of Risk Management WC	$23.10
Rate for Payer: Multiplan Commercial	$31.50

HC 5-HIAA BY HPLC

Facility

$38.00

Service Code	CPT 83497
Hospital Charge Code	900910535
Hospital Revenue Code	301
Min. Negotiated Rate	$12.90
Max. Negotiated Rate	$30.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.80
Rate for Payer: Aetna of CA Government/Medicare	$22.80
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cash Price	$17.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.40
Rate for Payer: Health Smart Auto/Commercial	$22.80
Rate for Payer: Intervalley Health Plan Commercial	$12.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.80
Rate for Payer: LLUH Dept of Risk Management WC	$20.90
Rate for Payer: Multiplan Commercial	$28.50

HC ABDOMEN KUB SUPINE

Facility

$539.00

Service Code	CPT 74018
Hospital Charge Code	909001702
Hospital Revenue Code	320
Min. Negotiated Rate	$296.45
Max. Negotiated Rate	$431.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$323.40
Rate for Payer: Aetna of CA Government/Medicare	$323.40
Rate for Payer: Cash Price	$242.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$431.20
Rate for Payer: Health Smart Auto/Commercial	$323.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$323.40
Rate for Payer: LLUH Dept of Risk Management WC	$296.45
Rate for Payer: Multiplan Commercial	$404.25

HC ABDOMEN KUB SUPINE

Facility

$539.00

Service Code	CPT 74018
Hospital Charge Code	909001702
Hospital Revenue Code	320
Min. Negotiated Rate	$296.45
Max. Negotiated Rate	$431.20
Rate for Payer: Cash Price	$242.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$431.20
Rate for Payer: Health Smart Auto/Commercial	$323.40
Rate for Payer: LLUH Dept of Risk Management WC	$296.45
Rate for Payer: Multiplan Commercial	$404.25

HC ABDOMEN THREE OR MORE VIEWS

Facility

$842.00

Service Code	CPT 74021
Hospital Charge Code	909074021
Hospital Revenue Code	320
Min. Negotiated Rate	$463.10
Max. Negotiated Rate	$673.60
Rate for Payer: Cash Price	$378.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$673.60
Rate for Payer: Health Smart Auto/Commercial	$505.20
Rate for Payer: LLUH Dept of Risk Management WC	$463.10
Rate for Payer: Multiplan Commercial	$631.50

HC ABDOMEN THREE OR MORE VIEWS

Facility

$842.00

Service Code	CPT 74021
Hospital Charge Code	909074021
Hospital Revenue Code	320
Min. Negotiated Rate	$463.10
Max. Negotiated Rate	$673.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$505.20
Rate for Payer: Aetna of CA Government/Medicare	$505.20
Rate for Payer: Cash Price	$378.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$673.60
Rate for Payer: Health Smart Auto/Commercial	$505.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$505.20
Rate for Payer: LLUH Dept of Risk Management WC	$463.10
Rate for Payer: Multiplan Commercial	$631.50

HC ABDOMEN TWO VIEWS

Facility

$674.00

Service Code	CPT 74019
Hospital Charge Code	909074019
Hospital Revenue Code	320
Min. Negotiated Rate	$370.70
Max. Negotiated Rate	$539.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$404.40
Rate for Payer: Aetna of CA Government/Medicare	$404.40
Rate for Payer: Cash Price	$303.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$539.20
Rate for Payer: Health Smart Auto/Commercial	$404.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$404.40
Rate for Payer: LLUH Dept of Risk Management WC	$370.70
Rate for Payer: Multiplan Commercial	$505.50

HC ABDOMEN TWO VIEWS

Facility

$674.00

Service Code	CPT 74019
Hospital Charge Code	909074019
Hospital Revenue Code	320
Min. Negotiated Rate	$370.70
Max. Negotiated Rate	$539.20
Rate for Payer: Cash Price	$303.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$539.20
Rate for Payer: Health Smart Auto/Commercial	$404.40
Rate for Payer: LLUH Dept of Risk Management WC	$370.70
Rate for Payer: Multiplan Commercial	$505.50

HC ACETAMINOPHEN (TYLENOL)

Facility

$79.00

Service Code	CPT 80143
Hospital Charge Code	900911302
Hospital Revenue Code	301
Min. Negotiated Rate	$18.64
Max. Negotiated Rate	$63.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$47.40
Rate for Payer: Aetna of CA Government/Medicare	$47.40
Rate for Payer: Cash Price	$35.55
Rate for Payer: Cash Price	$35.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$63.20
Rate for Payer: Health Smart Auto/Commercial	$47.40
Rate for Payer: Intervalley Health Plan Commercial	$18.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$47.40
Rate for Payer: LLUH Dept of Risk Management WC	$43.45
Rate for Payer: Multiplan Commercial	$59.25

HC ACETAMINOPHEN (TYLENOL)

Facility

$549.00

Service Code	CPT 80143
Hospital Charge Code	900911302
Hospital Revenue Code	301
Min. Negotiated Rate	$301.95
Max. Negotiated Rate	$439.20
Rate for Payer: Cash Price	$247.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$439.20
Rate for Payer: Health Smart Auto/Commercial	$329.40
Rate for Payer: LLUH Dept of Risk Management WC	$301.95
Rate for Payer: Multiplan Commercial	$411.75

HC ACETOACETATE, SEMIQUANTITATIVE

Facility

$244.00

Service Code	CPT 82010
Hospital Charge Code	900910466
Hospital Revenue Code	301
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$195.20
Rate for Payer: Cash Price	$109.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$195.20
Rate for Payer: Health Smart Auto/Commercial	$146.40
Rate for Payer: LLUH Dept of Risk Management WC	$134.20
Rate for Payer: Multiplan Commercial	$183.00

HC ACETOACETATE, SEMIQUANTITATIVE

Facility

$41.00

Service Code	CPT 82010
Hospital Charge Code	900910466
Hospital Revenue Code	301
Min. Negotiated Rate	$8.17
Max. Negotiated Rate	$32.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.60
Rate for Payer: Aetna of CA Government/Medicare	$24.60
Rate for Payer: Cash Price	$18.45
Rate for Payer: Cash Price	$18.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$32.80
Rate for Payer: Health Smart Auto/Commercial	$24.60
Rate for Payer: Intervalley Health Plan Commercial	$8.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.60
Rate for Payer: LLUH Dept of Risk Management WC	$22.55
Rate for Payer: Multiplan Commercial	$30.75

HC ACID FAST CONCENTRATION

Facility

$26.00

Service Code	CPT 87015
Hospital Charge Code	900911551
Hospital Revenue Code	306
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$20.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.60
Rate for Payer: Aetna of CA Government/Medicare	$15.60
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cash Price	$11.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.80
Rate for Payer: Health Smart Auto/Commercial	$15.60
Rate for Payer: Intervalley Health Plan Commercial	$6.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.60
Rate for Payer: LLUH Dept of Risk Management WC	$14.30
Rate for Payer: Multiplan Commercial	$19.50

HC ACID FAST CONCENTRATION

Facility

$139.00

Service Code	CPT 87015
Hospital Charge Code	900911551
Hospital Revenue Code	306
Min. Negotiated Rate	$76.45
Max. Negotiated Rate	$111.20
Rate for Payer: Cash Price	$62.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$111.20
Rate for Payer: Health Smart Auto/Commercial	$83.40
Rate for Payer: LLUH Dept of Risk Management WC	$76.45
Rate for Payer: Multiplan Commercial	$104.25

HC ACID HEMOGLOBIN CONFIRMATION

Facility

$75.00

Service Code	CPT 83020
Hospital Charge Code	900913569
Hospital Revenue Code	302
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$60.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.00
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Commercial	$56.25

HC ACID HEMOGLOBIN CONFIRMATION

Facility

$59.00

Service Code	CPT 83020
Hospital Charge Code	900913569
Hospital Revenue Code	302
Min. Negotiated Rate	$12.87
Max. Negotiated Rate	$47.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.40
Rate for Payer: Aetna of CA Government/Medicare	$35.40
Rate for Payer: Cash Price	$26.55
Rate for Payer: Cash Price	$26.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.20
Rate for Payer: Health Smart Auto/Commercial	$35.40
Rate for Payer: Intervalley Health Plan Commercial	$12.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.40
Rate for Payer: LLUH Dept of Risk Management WC	$32.45
Rate for Payer: Multiplan Commercial	$44.25

Know your out-of-pocket cost for care.

All Charges