Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

Facility

$643.26

Service Code	CPT 90651
Hospital Charge Code	NDG208396
Hospital Revenue Code	636
Min. Negotiated Rate	$353.79
Max. Negotiated Rate	$482.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$385.96
Rate for Payer: Aetna of CA Government/Medicare	$385.96
Rate for Payer: Cash Price	$289.47
Rate for Payer: Health Smart Auto/Commercial	$385.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$385.96
Rate for Payer: LLUH Dept of Risk Management WC	$353.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$482.44

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

Facility

$643.26

Service Code	CPT 90651
Hospital Charge Code	NDG208396
Hospital Revenue Code	636
Min. Negotiated Rate	$353.79
Max. Negotiated Rate	$514.61
Rate for Payer: Cash Price	$289.47
Rate for Payer: Cigna of CA HMO/PPO	$514.61
Rate for Payer: Health Smart Auto/Commercial	$385.96
Rate for Payer: LLUH Dept of Risk Management WC	$353.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$482.44

HUM PROTHROMBIN CPLX(PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION [206243]

Facility

$3.58

Service Code	CPT J7168
Hospital Charge Code	ERX206243
Hospital Revenue Code	636
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.86
Rate for Payer: Cash Price	$1.61
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$2.68

HUM PROTHROMBIN CPLX(PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION [206243]

Facility

$3.58

Service Code	CPT J7168
Hospital Charge Code	ERX206243
Hospital Revenue Code	636
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.68
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	$1.61
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 Beech St/Commercial/PHCS	$2.68

HUM PROTHROMBIN CPLX (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION [205938]

Facility

$3.58

Service Code	CPT J7168
Hospital Charge Code	ERX205938
Hospital Revenue Code	636
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.86
Rate for Payer: Health Smart Auto/Commercial	$2.15
Rate for Payer: Cash Price	$1.61
Rate for Payer: Cigna of CA HMO/PPO	$2.86
Rate for Payer: LLUH Dept of Risk Management WC	$1.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.68

HUM PROTHROMBIN CPLX (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION [205938]

Facility

$3.58

Service Code	CPT J7168
Hospital Charge Code	ERX205938
Hospital Revenue Code	636
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.68
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	$1.61
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 Beech St/Commercial/PHCS	$2.68

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

Facility

$66.96

Service Code	CPT J3473
Hospital Charge Code	1721178
Hospital Revenue Code	636
Min. Negotiated Rate	$36.83
Max. Negotiated Rate	$50.22
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	$30.13
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 Beech St/Commercial/PHCS	$50.22

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

Facility

$66.96

Service Code	CPT J3473
Hospital Charge Code	1721178
Hospital Revenue Code	636
Min. Negotiated Rate	$36.83
Max. Negotiated Rate	$53.57
Rate for Payer: Cash Price	$30.13
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$50.22

HYALURONIDASE (OVINE) 200 UNIT/ML INJECTION SOLUTION [40449]

Facility

$120.83

Service Code	CPT J3471
Hospital Charge Code	1721153
Hospital Revenue Code	636
Min. Negotiated Rate	$66.46
Max. Negotiated Rate	$90.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.50
Rate for Payer: Aetna of CA Government/Medicare	$72.50
Rate for Payer: Cash Price	$54.37
Rate for Payer: Health Smart Auto/Commercial	$72.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.50
Rate for Payer: LLUH Dept of Risk Management WC	$66.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.62

HYALURONIDASE (OVINE) 200 UNIT/ML INJECTION SOLUTION [40449]

Facility

$120.83

Service Code	CPT J3471
Hospital Charge Code	1721153
Hospital Revenue Code	636
Min. Negotiated Rate	$66.46
Max. Negotiated Rate	$96.66
Rate for Payer: Cash Price	$54.37
Rate for Payer: Cigna of CA HMO/PPO	$96.66
Rate for Payer: Health Smart Auto/Commercial	$72.50
Rate for Payer: LLUH Dept of Risk Management WC	$66.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.62

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.28

Service Code	NDC 51079-074-01
Hospital Charge Code	1711080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.21
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	$0.13
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 Beech St/Commercial/PHCS	$0.21

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.23

Service Code	NDC 68084-447-01
Hospital Charge Code	1711080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.23

Service Code	NDC 68084-447-11
Hospital Charge Code	1711080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.05

Service Code	NDC 23155-001-01
Hospital Charge Code	1711080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.28

Service Code	NDC 51079-074-20
Hospital Charge Code	1711080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.21

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.23

Service Code	NDC 68084-447-01
Hospital Charge Code	1711080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.28

Service Code	NDC 51079-074-20
Hospital Charge Code	1711080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.21
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	$0.13
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 Beech St/Commercial/PHCS	$0.21

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.14

Service Code	NDC 50111-398-03
Hospital Charge Code	1711080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.05

Service Code	NDC 23155-001-01
Hospital Charge Code	1711080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.23

Service Code	NDC 68084-447-11
Hospital Charge Code	1711080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.14

Service Code	NDC 50111-398-01
Hospital Charge Code	1711080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.14

Service Code	NDC 50111-398-03
Hospital Charge Code	1711080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.13

Service Code	NDC 0904-6440-61
Hospital Charge Code	1711080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.13

Service Code	NDC 0904-6440-61
Hospital Charge Code	1711080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

HYDRALAZINE 10 MG TABLET [3698]

Facility

$0.14

Service Code	NDC 50111-398-01
Hospital Charge Code	1711080
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

Know your out-of-pocket cost for care.

All Charges