Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HEPATITIS B IMMUNE GLOBULIN > 1,560 UNIT/5 ML INTRAMUSCULAR SOLUTION [91047]

Facility

$189.69

Service Code	HCPCS 90371
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$104.33
Max. Negotiated Rate	$151.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$113.81
Rate for Payer: Aetna of CA Government/Medicare	$113.81
Rate for Payer: Cash Price	$104.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$151.75
Rate for Payer: Health Smart Auto/Commercial	$113.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$113.81
Rate for Payer: LLUH Dept of Risk Management WC	$104.33
Rate for Payer: Multiplan Commercial	$142.27

HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE [222472]

Facility

$373.80

Service Code	HCPCS 90739
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$205.59
Max. Negotiated Rate	$299.04
Rate for Payer: Cash Price	$205.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$299.04
Rate for Payer: Health Smart Auto/Commercial	$224.28
Rate for Payer: LLUH Dept of Risk Management WC	$205.59
Rate for Payer: Multiplan Commercial	$280.35

HEPATITIS B VACCINE 20 MCG/0.5 ML-ADJUVANT CPG 1018 (PF) IM SYRINGE [222472]

Facility

$373.80

Service Code	HCPCS 90739
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$205.59
Max. Negotiated Rate	$299.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$224.28
Rate for Payer: Aetna of CA Government/Medicare	$224.28
Rate for Payer: Cash Price	$205.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$299.04
Rate for Payer: Health Smart Auto/Commercial	$224.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$224.28
Rate for Payer: LLUH Dept of Risk Management WC	$205.59
Rate for Payer: Multiplan Commercial	$280.35

HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE [118672]

Facility

$68.40

Service Code	HCPCS 90744
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$37.62
Max. Negotiated Rate	$54.72
Rate for Payer: Cash Price	$37.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$54.72
Rate for Payer: Health Smart Auto/Commercial	$41.04
Rate for Payer: LLUH Dept of Risk Management WC	$37.62
Rate for Payer: Multiplan Commercial	$51.30

HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE [118672]

Facility

$68.40

Service Code	HCPCS 90744
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$37.62
Max. Negotiated Rate	$54.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$41.04
Rate for Payer: Aetna of CA Government/Medicare	$41.04
Rate for Payer: Cash Price	$37.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$54.72
Rate for Payer: Health Smart Auto/Commercial	$41.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$41.04
Rate for Payer: LLUH Dept of Risk Management WC	$37.62
Rate for Payer: Multiplan Commercial	$51.30

HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML INTRAMUSCULAR. [4081931]

Facility

$68.40

Service Code	HCPCS 90744
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$37.62
Max. Negotiated Rate	$54.72
Rate for Payer: Cash Price	$37.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$54.72
Rate for Payer: Health Smart Auto/Commercial	$41.04
Rate for Payer: LLUH Dept of Risk Management WC	$37.62
Rate for Payer: Multiplan Commercial	$51.30

HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML INTRAMUSCULAR. [4081931]

Facility

$68.40

Service Code	HCPCS 90744
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$37.62
Max. Negotiated Rate	$54.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$41.04
Rate for Payer: Aetna of CA Government/Medicare	$41.04
Rate for Payer: Cash Price	$37.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$54.72
Rate for Payer: Health Smart Auto/Commercial	$41.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$41.04
Rate for Payer: LLUH Dept of Risk Management WC	$37.62
Rate for Payer: Multiplan Commercial	$51.30

HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/ML INTRAMUSCULAR SUSP [119731]

Facility

$81.67

Service Code	HCPCS 90744
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$44.92
Max. Negotiated Rate	$65.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$49.00
Rate for Payer: Aetna of CA Government/Medicare	$49.00
Rate for Payer: Cash Price	$44.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$65.34
Rate for Payer: Health Smart Auto/Commercial	$49.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$49.00
Rate for Payer: LLUH Dept of Risk Management WC	$44.92
Rate for Payer: Multiplan Commercial	$61.25

HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/ML INTRAMUSCULAR SUSP [119731]

Facility

$81.67

Service Code	HCPCS 90744
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$44.92
Max. Negotiated Rate	$65.34
Rate for Payer: Cash Price	$44.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$65.34
Rate for Payer: Health Smart Auto/Commercial	$49.00
Rate for Payer: LLUH Dept of Risk Management WC	$44.92
Rate for Payer: Multiplan Commercial	$61.25

HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE [118608]

Facility

$85.79

Service Code	HCPCS 90746
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$47.18
Max. Negotiated Rate	$68.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.47
Rate for Payer: Aetna of CA Government/Medicare	$51.47
Rate for Payer: Cash Price	$47.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.63
Rate for Payer: Health Smart Auto/Commercial	$51.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.47
Rate for Payer: LLUH Dept of Risk Management WC	$47.18
Rate for Payer: Multiplan Commercial	$64.34

HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE [118608]

Facility

$85.79

Service Code	HCPCS 90746
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$47.18
Max. Negotiated Rate	$68.63
Rate for Payer: Cash Price	$47.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.63
Rate for Payer: Health Smart Auto/Commercial	$51.47
Rate for Payer: LLUH Dept of Risk Management WC	$47.18
Rate for Payer: Multiplan Commercial	$64.34

HEPATITIS B VIRUS VACCINE RECOMB (PF) 40 MCG/ML INTRAMUSCULAR SUSP [108150]

Facility

$223.25

Service Code	HCPCS 90740
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$122.79
Max. Negotiated Rate	$178.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$133.95
Rate for Payer: Aetna of CA Government/Medicare	$133.95
Rate for Payer: Cash Price	$122.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$178.60
Rate for Payer: Health Smart Auto/Commercial	$133.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$133.95
Rate for Payer: LLUH Dept of Risk Management WC	$122.79
Rate for Payer: Multiplan Commercial	$167.44

HEPATITIS B VIRUS VACCINE RECOMB (PF) 40 MCG/ML INTRAMUSCULAR SUSP [108150]

Facility

$223.25

Service Code	HCPCS 90740
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$122.79
Max. Negotiated Rate	$178.60
Rate for Payer: Cash Price	$122.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$178.60
Rate for Payer: Health Smart Auto/Commercial	$133.95
Rate for Payer: LLUH Dept of Risk Management WC	$122.79
Rate for Payer: Multiplan Commercial	$167.44

HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE [34550]

Facility

$239.69

Service Code	HCPCS 90723
Hospital Charge Code	901700022
Hospital Revenue Code	636
Min. Negotiated Rate	$131.83
Max. Negotiated Rate	$191.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$143.81
Rate for Payer: Aetna of CA Government/Medicare	$143.81
Rate for Payer: Cash Price	$131.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$191.75
Rate for Payer: Health Smart Auto/Commercial	$143.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$143.81
Rate for Payer: LLUH Dept of Risk Management WC	$131.83
Rate for Payer: Multiplan Commercial	$179.77

HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE [34550]

Facility

$239.69

Service Code	HCPCS 90723
Hospital Charge Code	901700022
Hospital Revenue Code	636
Min. Negotiated Rate	$131.83
Max. Negotiated Rate	$191.75
Rate for Payer: Cash Price	$131.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$191.75
Rate for Payer: Health Smart Auto/Commercial	$143.81
Rate for Payer: LLUH Dept of Risk Management WC	$131.83
Rate for Payer: Multiplan Commercial	$179.77

HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT(PF) 0.5 ML INTRAMUSCULAR SYRINGE [208396]

Facility

$736.46

Service Code	HCPCS 90651
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$405.05
Max. Negotiated Rate	$589.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$441.88
Rate for Payer: Aetna of CA Government/Medicare	$441.88
Rate for Payer: Cash Price	$405.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$589.17
Rate for Payer: Health Smart Auto/Commercial	$441.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$441.88
Rate for Payer: LLUH Dept of Risk Management WC	$405.05
Rate for Payer: Multiplan Commercial	$552.35

HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT(PF) 0.5 ML INTRAMUSCULAR SYRINGE [208396]

Facility

$736.46

Service Code	HCPCS 90651
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$405.05
Max. Negotiated Rate	$589.17
Rate for Payer: Cash Price	$405.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$589.17
Rate for Payer: Health Smart Auto/Commercial	$441.88
Rate for Payer: LLUH Dept of Risk Management WC	$405.05
Rate for Payer: Multiplan Commercial	$552.35

HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION [205938]

Facility

$3.58

Service Code	HCPCS J7168
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.86
Rate for Payer: Cash Price	$1.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.86
Rate for Payer: Health Smart Auto/Commercial	$2.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.97
Rate for Payer: Multiplan Commercial	$2.69

HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION [205938]

Facility

$3.58

Service Code	HCPCS J7168
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.15
Rate for Payer: Aetna of CA Government/Medicare	$2.15
Rate for Payer: Cash Price	$1.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.86
Rate for Payer: Health Smart Auto/Commercial	$2.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.97
Rate for Payer: Multiplan Commercial	$2.69

HUMAN PROTHROMBIN COMPLEX CONCENTRATE-LANS 500 UNIT IV SOLUTION [239091]

Facility

$3.78

Service Code	HCPCS J7165
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.08
Max. Negotiated Rate	$3.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.27
Rate for Payer: Aetna of CA Government/Medicare	$2.27
Rate for Payer: Cash Price	$2.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.02
Rate for Payer: Health Smart Auto/Commercial	$2.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.27
Rate for Payer: LLUH Dept of Risk Management WC	$2.08
Rate for Payer: Multiplan Commercial	$2.83

HUMAN PROTHROMBIN COMPLEX CONCENTRATE-LANS 500 UNIT IV SOLUTION [239091]

Facility

$3.78

Service Code	HCPCS J7165
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.08
Max. Negotiated Rate	$3.02
Rate for Payer: Cash Price	$2.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.02
Rate for Payer: Health Smart Auto/Commercial	$2.27
Rate for Payer: LLUH Dept of Risk Management WC	$2.08
Rate for Payer: Multiplan Commercial	$2.83

HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION [76338]

Facility

$66.96

Service Code	HCPCS J3473
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$36.83
Max. Negotiated Rate	$53.57
Rate for Payer: Cash Price	$36.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$53.57
Rate for Payer: Health Smart Auto/Commercial	$40.18
Rate for Payer: LLUH Dept of Risk Management WC	$36.83
Rate for Payer: Multiplan Commercial	$50.22

HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION [76338]

Facility

$66.96

Service Code	HCPCS J3473
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$36.83
Max. Negotiated Rate	$53.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.18
Rate for Payer: Aetna of CA Government/Medicare	$40.18
Rate for Payer: Cash Price	$36.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$53.57
Rate for Payer: Health Smart Auto/Commercial	$40.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.18
Rate for Payer: LLUH Dept of Risk Management WC	$36.83
Rate for Payer: Multiplan Commercial	$50.22

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.04

Service Code	NDC 50228-182-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.33

Service Code	NDC 60687-811-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.25

Know your out-of-pocket cost for care.

All Charges