Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HYDROCORTISONE ORAL SUSPENSION COMPOUND 2 MG/ML [4080281]

Facility

$0.62

Service Code	NDC 9994-0802-81
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.47

HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION [111163]

Facility

$22.98

Service Code	HCPCS J1720
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$12.64
Max. Negotiated Rate	$18.38
Rate for Payer: Cash Price	$12.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.38
Rate for Payer: Health Smart Auto/Commercial	$13.79
Rate for Payer: LLUH Dept of Risk Management WC	$12.64
Rate for Payer: Multiplan Commercial	$17.23

HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION [111163]

Facility

$22.98

Service Code	HCPCS J1720
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$12.64
Max. Negotiated Rate	$18.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.79
Rate for Payer: Aetna of CA Government/Medicare	$13.79
Rate for Payer: Cash Price	$12.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.38
Rate for Payer: Health Smart Auto/Commercial	$13.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.79
Rate for Payer: LLUH Dept of Risk Management WC	$12.64
Rate for Payer: Multiplan Commercial	$17.23

HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION [121171]

Facility

$28.35

Service Code	HCPCS J1720
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$15.59
Max. Negotiated Rate	$22.68
Rate for Payer: Cash Price	$15.59
Rate for Payer: Cash Price	$15.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.68
Rate for Payer: Health Smart Auto/Commercial	$17.01
Rate for Payer: Health Smart Auto/Commercial	$17.33
Rate for Payer: LLUH Dept of Risk Management WC	$15.59
Rate for Payer: LLUH Dept of Risk Management WC	$15.88
Rate for Payer: Multiplan Commercial	$21.26
Rate for Payer: Multiplan Commercial	$21.66

HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION [121171]

Facility

$28.88

Service Code	HCPCS J1720
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$15.88
Max. Negotiated Rate	$23.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.01
Rate for Payer: Aetna of CA Government/Medicare	$17.01
Rate for Payer: Aetna of CA Government/Medicare	$17.33
Rate for Payer: Cash Price	$15.59
Rate for Payer: Cash Price	$15.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.68
Rate for Payer: Health Smart Auto/Commercial	$17.33
Rate for Payer: Health Smart Auto/Commercial	$17.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.33
Rate for Payer: LLUH Dept of Risk Management WC	$15.59
Rate for Payer: LLUH Dept of Risk Management WC	$15.88
Rate for Payer: Multiplan Commercial	$21.66
Rate for Payer: Multiplan Commercial	$21.26

HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION [121170]

Facility

$52.44

Service Code	HCPCS J1720
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$28.84
Max. Negotiated Rate	$41.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$32.06
Rate for Payer: Aetna of CA Government/Medicare	$32.06
Rate for Payer: Aetna of CA Government/Medicare	$31.46
Rate for Payer: Cash Price	$29.39
Rate for Payer: Cash Price	$28.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$41.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.75
Rate for Payer: Health Smart Auto/Commercial	$31.46
Rate for Payer: Health Smart Auto/Commercial	$32.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$31.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$32.06
Rate for Payer: LLUH Dept of Risk Management WC	$28.84
Rate for Payer: LLUH Dept of Risk Management WC	$29.39
Rate for Payer: Multiplan Commercial	$40.08
Rate for Payer: Multiplan Commercial	$39.33

HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION [121170]

Facility

$53.44

Service Code	HCPCS J1720
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$29.39
Max. Negotiated Rate	$42.75
Rate for Payer: Cash Price	$29.39
Rate for Payer: Cash Price	$28.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$41.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.75
Rate for Payer: Health Smart Auto/Commercial	$32.06
Rate for Payer: Health Smart Auto/Commercial	$31.46
Rate for Payer: LLUH Dept of Risk Management WC	$28.84
Rate for Payer: LLUH Dept of Risk Management WC	$29.39
Rate for Payer: Multiplan Commercial	$39.33
Rate for Payer: Multiplan Commercial	$40.08

HYDROCORTISONE SOD SUCCINATE (PF) 500 MG/4 ML SOLUTION FOR INJECTION [121169]

Facility

$104.93

Service Code	HCPCS J1720
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$57.71
Max. Negotiated Rate	$83.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$62.96
Rate for Payer: Aetna of CA Government/Medicare	$62.96
Rate for Payer: Cash Price	$57.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$83.94
Rate for Payer: Health Smart Auto/Commercial	$62.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$62.96
Rate for Payer: LLUH Dept of Risk Management WC	$57.71
Rate for Payer: Multiplan Commercial	$78.70

HYDROCORTISONE SOD SUCCINATE (PF) 500 MG/4 ML SOLUTION FOR INJECTION [121169]

Facility

$104.93

Service Code	HCPCS J1720
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$57.71
Max. Negotiated Rate	$83.94
Rate for Payer: Cash Price	$57.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$83.94
Rate for Payer: Health Smart Auto/Commercial	$62.96
Rate for Payer: LLUH Dept of Risk Management WC	$57.71
Rate for Payer: Multiplan Commercial	$78.70

HYDROCORTISONE VALERATE 0.2 % TOPICAL OINTMENT [10219]

Facility

$6.30

Service Code	NDC 51672-1292-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$5.04
Rate for Payer: Cash Price	$3.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$4.72

HYDROCORTISONE VALERATE 0.2 % TOPICAL OINTMENT [10219]

Facility

$6.30

Service Code	NDC 51672-1292-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$5.04
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	$3.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.04
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 Commercial	$4.72

HYDROMORPHONE 0.5 MG/0.5 ML INJECTION. [4082191]

Facility

$7.63

Service Code	HCPCS J1171
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$6.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.98
Rate for Payer: Aetna of CA Government/Medicare	$5.98
Rate for Payer: Aetna of CA Government/Medicare	$4.58
Rate for Payer: Cash Price	$5.48
Rate for Payer: Cash Price	$4.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.97
Rate for Payer: Health Smart Auto/Commercial	$4.58
Rate for Payer: Health Smart Auto/Commercial	$5.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.98
Rate for Payer: LLUH Dept of Risk Management WC	$4.20
Rate for Payer: LLUH Dept of Risk Management WC	$5.48
Rate for Payer: Multiplan Commercial	$7.47
Rate for Payer: Multiplan Commercial	$5.72

HYDROMORPHONE 0.5 MG/0.5 ML INJECTION. [4082191]

Facility

$9.96

Service Code	HCPCS J1171
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.48
Max. Negotiated Rate	$7.97
Rate for Payer: Cash Price	$5.48
Rate for Payer: Cash Price	$4.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.97
Rate for Payer: Health Smart Auto/Commercial	$5.98
Rate for Payer: Health Smart Auto/Commercial	$4.58
Rate for Payer: LLUH Dept of Risk Management WC	$4.20
Rate for Payer: LLUH Dept of Risk Management WC	$5.48
Rate for Payer: Multiplan Commercial	$5.72
Rate for Payer: Multiplan Commercial	$7.47

HYDROMORPHONE 1 MG/ML INJECTION. [4081869]

Facility

$4.98

Service Code	HCPCS J1171
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$3.98
Rate for Payer: Cash Price	$2.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.98
Rate for Payer: Health Smart Auto/Commercial	$2.99
Rate for Payer: LLUH Dept of Risk Management WC	$2.74
Rate for Payer: Multiplan Commercial	$3.73

HYDROMORPHONE 1 MG/ML INJECTION. [4081869]

Facility

$4.98

Service Code	HCPCS J1171
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$3.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.99
Rate for Payer: Aetna of CA Government/Medicare	$2.99
Rate for Payer: Cash Price	$2.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.98
Rate for Payer: Health Smart Auto/Commercial	$2.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.99
Rate for Payer: LLUH Dept of Risk Management WC	$2.74
Rate for Payer: Multiplan Commercial	$3.73

HYDROMORPHONE 1 MG/ML ORAL LIQUID [10225]

Facility

$0.58

Service Code	NDC 0054-0386-63
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

HYDROMORPHONE 1 MG/ML ORAL LIQUID [10225]

Facility

$1.04

Service Code	NDC 9999-9102-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.83
Rate for Payer: Cash Price	$0.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.83
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Commercial	$0.78

HYDROMORPHONE 1 MG/ML ORAL LIQUID [10225]

Facility

$1.04

Service Code	NDC 9999-9102-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.62
Rate for Payer: Aetna of CA Government/Medicare	$0.62
Rate for Payer: Cash Price	$0.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.83
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Commercial	$0.78

HYDROMORPHONE 1 MG/ML ORAL LIQUID [10225]

Facility

$0.38

Service Code	NDC 42858-304-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Cash Price	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

HYDROMORPHONE 1 MG/ML ORAL LIQUID [10225]

Facility

$0.58

Service Code	NDC 0054-0386-63
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

HYDROMORPHONE 1 MG/ML ORAL LIQUID [10225]

Facility

$0.38

Service Code	NDC 42858-304-16
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

HYDROMORPHONE 2 MG/ML INJECTION. [4081801]

Facility

$3.60

Service Code	HCPCS J1171
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70

HYDROMORPHONE 2 MG/ML INJECTION. [4081801]

Facility

$3.60

Service Code	HCPCS J1171
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70

HYDROMORPHONE 2 MG TABLET [3760]

Facility

$0.20

Service Code	NDC 42858-301-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

HYDROMORPHONE 2 MG TABLET [3760]

Facility

$0.22

Service Code	NDC 0406-3243-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

Know your out-of-pocket cost for care.

All Charges