Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

Facility

$86.32

Service Code	CPT J1720
Hospital Charge Code	ERX121169
Hospital Revenue Code	636
Min. Negotiated Rate	$47.48
Max. Negotiated Rate	$64.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.79
Rate for Payer: Aetna of CA Government/Medicare	$51.79
Rate for Payer: Cash Price	$38.84
Rate for Payer: Health Smart Auto/Commercial	$51.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.79
Rate for Payer: LLUH Dept of Risk Management WC	$47.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$64.74

HYDROCORTISONE VALERATE 0.2 % TOPICAL CREAM [10218]

Facility

$1.93

Service Code	NDC 45802-455-42
Hospital Charge Code	1743278
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$0.87
Rate for Payer: Cigna of CA HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.45

HYDROCORTISONE VALERATE 0.2 % TOPICAL CREAM [10218]

Facility

$1.93

Service Code	NDC 45802-455-42
Hospital Charge Code	1743278
Hospital Revenue Code	259
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.16
Rate for Payer: Aetna of CA Government/Medicare	$1.16
Rate for Payer: Cash Price	$0.87
Rate for Payer: Health Smart Auto/Commercial	$1.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.45

HYDROCORTISONE VALERATE 0.2 % TOPICAL OINTMENT [10219]

Facility

$6.30

Service Code	NDC 51672-1292-1
Hospital Charge Code	NDG10219
Hospital Revenue Code	259
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$4.72
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	$2.84
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 Beech St/Commercial/PHCS	$4.72

HYDROCORTISONE VALERATE 0.2 % TOPICAL OINTMENT [10219]

Facility

$6.30

Service Code	NDC 51672-1292-1
Hospital Charge Code	NDG10219
Hospital Revenue Code	259
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$5.04
Rate for Payer: Cash Price	$2.84
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$4.72

HYDROMORPHONE 0.5 MG/0.5 ML INJECTION. [4082191]

Facility

$9.96

Service Code	CPT J1170
Hospital Charge Code	NDG202191
Hospital Revenue Code	636
Min. Negotiated Rate	$5.48
Max. Negotiated Rate	$7.97
Rate for Payer: Cash Price	$4.48
Rate for Payer: Cigna of CA HMO/PPO	$7.97
Rate for Payer: Health Smart Auto/Commercial	$5.98
Rate for Payer: LLUH Dept of Risk Management WC	$5.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.47

HYDROMORPHONE 0.5 MG/0.5 ML INJECTION. [4082191]

Facility

$9.96

Service Code	CPT J1170
Hospital Charge Code	NDG202191
Hospital Revenue Code	636
Min. Negotiated Rate	$5.48
Max. Negotiated Rate	$7.47
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: Cash Price	$4.48
Rate for Payer: Health Smart Auto/Commercial	$5.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.98
Rate for Payer: LLUH Dept of Risk Management WC	$5.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.47

HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE [202191]

Facility

$8.28

Service Code	CPT J1170
Hospital Charge Code	NDG202191
Hospital Revenue Code	636
Min. Negotiated Rate	$4.55
Max. Negotiated Rate	$6.62
Rate for Payer: Health Smart Auto/Commercial	$4.97
Rate for Payer: Cash Price	$3.73
Rate for Payer: Cigna of CA HMO/PPO	$6.62
Rate for Payer: LLUH Dept of Risk Management WC	$4.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.21

HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE [202191]

Facility

$8.28

Service Code	CPT J1170
Hospital Charge Code	NDG202191
Hospital Revenue Code	636
Min. Negotiated Rate	$4.55
Max. Negotiated Rate	$6.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.97
Rate for Payer: Aetna of CA Government/Medicare	$4.97
Rate for Payer: Cash Price	$3.73
Rate for Payer: Health Smart Auto/Commercial	$4.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.97
Rate for Payer: LLUH Dept of Risk Management WC	$4.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.21

HYDROMORPHONE 1 MG/ML INJECTION SOLUTION [216053]

Facility

$3.25

Service Code	CPT J1170
Hospital Charge Code	1734065
Hospital Revenue Code	636
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$2.60
Rate for Payer: Cash Price	$1.46
Rate for Payer: Cigna of CA HMO/PPO	$2.60
Rate for Payer: Health Smart Auto/Commercial	$1.95
Rate for Payer: LLUH Dept of Risk Management WC	$1.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.44

HYDROMORPHONE 1 MG/ML INJECTION SOLUTION [216053]

Facility

$3.25

Service Code	CPT J1170
Hospital Charge Code	1734065
Hospital Revenue Code	636
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$2.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.95
Rate for Payer: Aetna of CA Government/Medicare	$1.95
Rate for Payer: Cash Price	$1.46
Rate for Payer: Health Smart Auto/Commercial	$1.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.95
Rate for Payer: LLUH Dept of Risk Management WC	$1.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.44

HYDROMORPHONE 1 MG/ML ORAL LIQUID [10225]

Facility

$2.40

Service Code	NDC 60687-566-86
Hospital Charge Code	1734059
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Cash Price	$1.08
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80

HYDROMORPHONE 1 MG/ML ORAL LIQUID [10225]

Facility

$1.04

Service Code	NDC 9999-9102-25
Hospital Charge Code	1734059
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.83
Rate for Payer: Cash Price	$0.47
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.78

HYDROMORPHONE 1 MG/ML ORAL LIQUID [10225]

Facility

$2.40

Service Code	NDC 60687-566-40
Hospital Charge Code	1734059
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cigna of CA HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80

HYDROMORPHONE 1 MG/ML ORAL LIQUID [10225]

Facility

$0.58

Service Code	NDC 0054-0386-63
Hospital Charge Code	1734029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.44

HYDROMORPHONE 1 MG/ML ORAL LIQUID [10225]

Facility

$0.38

Service Code	NDC 42858-304-16
Hospital Charge Code	1734029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.29
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	$0.17
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 Beech St/Commercial/PHCS	$0.29

HYDROMORPHONE 1 MG/ML ORAL LIQUID [10225]

Facility

$2.40

Service Code	NDC 60687-566-40
Hospital Charge Code	1734059
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Cash Price	$1.08
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80

HYDROMORPHONE 1 MG/ML ORAL LIQUID [10225]

Facility

$0.58

Service Code	NDC 0054-0386-63
Hospital Charge Code	1734029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.44
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	$0.26
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 Beech St/Commercial/PHCS	$0.44

HYDROMORPHONE 1 MG/ML ORAL LIQUID [10225]

Facility

$0.38

Service Code	NDC 42858-304-16
Hospital Charge Code	1734029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.29

HYDROMORPHONE 1 MG/ML ORAL LIQUID [10225]

Facility

$1.04

Service Code	NDC 9999-9102-25
Hospital Charge Code	1734059
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.78
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	$0.47
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 Beech St/Commercial/PHCS	$0.78

HYDROMORPHONE 1 MG/ML ORAL LIQUID [10225]

Facility

$2.40

Service Code	NDC 60687-566-86
Hospital Charge Code	1734059
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cigna of CA HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80

HYDROMORPHONE 2 MG/ML INJECTION. [4081801]

Facility

$1.88

Service Code	CPT J1170
Hospital Charge Code	1737014
Hospital Revenue Code	636
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.50
Rate for Payer: Cash Price	$0.85
Rate for Payer: Cash Price	$1.04
Rate for Payer: Cigna of CA HMO/PPO	$1.50
Rate for Payer: Cigna of CA HMO/PPO	$1.84
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: Health Smart Auto/Commercial	$1.13
Rate for Payer: LLUH Dept of Risk Management WC	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.72

HYDROMORPHONE 2 MG/ML INJECTION. [4081801]

Facility

$1.88

Service Code	CPT J1170
Hospital Charge Code	1737014
Hospital Revenue Code	636
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.38
Rate for Payer: Aetna of CA Government/Medicare	$1.13
Rate for Payer: Aetna of CA Government/Medicare	$1.38
Rate for Payer: Cash Price	$1.04
Rate for Payer: Cash Price	$0.85
Rate for Payer: Health Smart Auto/Commercial	$1.13
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.13
Rate for Payer: LLUH Dept of Risk Management WC	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.41

HYDROMORPHONE 2 MG/ML INJECTION SOLUTION [3758]

Facility

$2.30

Service Code	CPT J1170
Hospital Charge Code	1737014
Hospital Revenue Code	636
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.84
Rate for Payer: Cash Price	$1.04
Rate for Payer: Cash Price	$0.85
Rate for Payer: Cigna of CA HMO/PPO	$1.84
Rate for Payer: Cigna of CA HMO/PPO	$1.50
Rate for Payer: Health Smart Auto/Commercial	$1.13
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: LLUH Dept of Risk Management WC	$1.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.72

HYDROMORPHONE 2 MG/ML INJECTION SOLUTION [3758]

Facility

$2.30

Service Code	CPT J1170
Hospital Charge Code	1737014
Hospital Revenue Code	636
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.13
Rate for Payer: Aetna of CA Government/Medicare	$1.38
Rate for Payer: Aetna of CA Government/Medicare	$1.13
Rate for Payer: Cash Price	$0.85
Rate for Payer: Cash Price	$1.04
Rate for Payer: Health Smart Auto/Commercial	$1.38
Rate for Payer: Health Smart Auto/Commercial	$1.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.38
Rate for Payer: LLUH Dept of Risk Management WC	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.72

Know your out-of-pocket cost for care.

All Charges