Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HYDROMORPHONE 2 MG TABLET [3760]

Facility

$0.28

Service Code	NDC 42858-301-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

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: 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: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

HYDROMORPHONE 2 MG TABLET [3760]

Facility

$0.30

Service Code	NDC 60687-579-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

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

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: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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

$0.43

Service Code	NDC 60687-579-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.32

HYDROMORPHONE 2 MG TABLET [3760]

Facility

$0.30

Service Code	NDC 60687-579-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

HYDROMORPHONE 2 MG TABLET [3760]

Facility

$0.28

Service Code	NDC 42858-301-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

HYDROMORPHONE 3 MG RECTAL SUPPOSITORY [10227]

Facility

$11.78

Service Code	NDC 0574-7224-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$9.42
Rate for Payer: Cash Price	$6.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.42
Rate for Payer: Health Smart Auto/Commercial	$7.07
Rate for Payer: LLUH Dept of Risk Management WC	$6.48
Rate for Payer: Multiplan Commercial	$8.84

HYDROMORPHONE 3 MG RECTAL SUPPOSITORY [10227]

Facility

$11.78

Service Code	NDC 0574-7224-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$9.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.07
Rate for Payer: Aetna of CA Government/Medicare	$7.07
Rate for Payer: Cash Price	$6.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.42
Rate for Payer: Health Smart Auto/Commercial	$7.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.07
Rate for Payer: LLUH Dept of Risk Management WC	$6.48
Rate for Payer: Multiplan Commercial	$8.84

HYDROMORPHONE 4 MG/ML INJECTION. [4081870]

Facility

$3.77

Service Code	HCPCS J1171
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.07
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	$2.26
Rate for Payer: LLUH Dept of Risk Management WC	$2.07
Rate for Payer: Multiplan Commercial	$2.83

HYDROMORPHONE 4 MG/ML INJECTION. [4081870]

Facility

$3.77

Service Code	HCPCS J1171
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.07
Max. Negotiated Rate	$3.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.26
Rate for Payer: Aetna of CA Government/Medicare	$2.26
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	$2.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.26
Rate for Payer: LLUH Dept of Risk Management WC	$2.07
Rate for Payer: Multiplan Commercial	$2.83

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.26

Service Code	NDC 0406-3244-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.50

Service Code	NDC 60687-590-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.41

Service Code	NDC 42858-302-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.31

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.26

Service Code	NDC 42858-302-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.41

Service Code	NDC 42858-302-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.31

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.26

Service Code	NDC 0406-3244-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.50

Service Code	NDC 60687-590-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.26

Service Code	NDC 42858-302-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.50

Service Code	NDC 60687-590-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.50

Service Code	NDC 60687-590-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

HYDROMORPHONE FOR SCD (PF) 50 MG/50 ML IN NS IV PCA SYRINGE [4081932]

Facility

$0.33

Service Code	HCPCS J1171
Hospital Charge Code	901700025
Hospital Revenue Code	636
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

HYDROMORPHONE FOR SCD (PF) 50 MG/50 ML IN NS IV PCA SYRINGE [4081932]

Facility

$0.33

Service Code	HCPCS J1171
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.25

HYDROMORPHONE PCA CLINICIAN BOLUS [4083524]

Facility

$2.45

Service Code	NDC 9994-0818-83
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.96
Rate for Payer: Cash Price	$1.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$1.84

Know your out-of-pocket cost for care.

All Charges