Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HYDROMORPHONE 2 MG TABLET [3760]

Facility

$0.25

Service Code	NDC 60687-579-01
Hospital Charge Code	1730096
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.19

HYDROMORPHONE 2 MG TABLET [3760]

Facility

$0.30

Service Code	NDC 60687-579-11
Hospital Charge Code	1730096
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.23

HYDROMORPHONE 2 MG TABLET [3760]

Facility

$0.25

Service Code	NDC 60687-579-01
Hospital Charge Code	1730096
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.19

HYDROMORPHONE 2 MG TABLET [3760]

Facility

$0.20

Service Code	NDC 42858-301-25
Hospital Charge Code	1730096
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.15
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	$0.09
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 Beech St/Commercial/PHCS	$0.15

HYDROMORPHONE 2 MG TABLET [3760]

Facility

$0.30

Service Code	NDC 60687-579-11
Hospital Charge Code	1730096
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
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	$0.14
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 Beech St/Commercial/PHCS	$0.23

HYDROMORPHONE 2 MG TABLET [3760]

Facility

$0.20

Service Code	NDC 42858-301-25
Hospital Charge Code	1730096
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.15

HYDROMORPHONE 3 MG RECTAL SUPPOSITORY [10227]

Facility

$11.78

Service Code	NDC 0574-7224-06
Hospital Charge Code	1736002
Hospital Revenue Code	259
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$9.42
Rate for Payer: Cash Price	$5.30
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$8.84

HYDROMORPHONE 3 MG RECTAL SUPPOSITORY [10227]

Facility

$11.78

Service Code	NDC 0574-7224-06
Hospital Charge Code	1736002
Hospital Revenue Code	259
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$8.84
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	$5.30
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 Beech St/Commercial/PHCS	$8.84

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.36

Service Code	NDC 60687-590-01
Hospital Charge Code	1730027
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.36

Service Code	NDC 60687-590-11
Hospital Charge Code	1730027
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.20

Service Code	NDC 0406-3244-01
Hospital Charge Code	1730027
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.15
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	$0.09
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 Beech St/Commercial/PHCS	$0.15

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.36

Service Code	NDC 60687-590-11
Hospital Charge Code	1730027
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.36

Service Code	NDC 60687-590-01
Hospital Charge Code	1730027
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.26

Service Code	NDC 42858-302-25
Hospital Charge Code	1730027
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
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	$0.12
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 Beech St/Commercial/PHCS	$0.20

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.20

Service Code	NDC 0406-3244-01
Hospital Charge Code	1730027
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.15

HYDROMORPHONE 4 MG TABLET [3761]

Facility

$0.26

Service Code	NDC 42858-302-25
Hospital Charge Code	1730027
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.20

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

Facility

$0.33

Service Code	CPT J1170
Hospital Charge Code	NDG214315
Hospital Revenue Code	636
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.25

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

Facility

$0.33

Service Code	CPT J1170
Hospital Charge Code	NDG214315
Hospital Revenue Code	636
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.25
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	$0.15
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 Beech St/Commercial/PHCS	$0.25

HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION [10224]

Facility

$5.64

Service Code	CPT J1170
Hospital Charge Code	NDG10224B
Hospital Revenue Code	636
Min. Negotiated Rate	$3.10
Max. Negotiated Rate	$4.51
Rate for Payer: Cash Price	$2.54
Rate for Payer: Cigna of CA HMO/PPO	$4.51
Rate for Payer: Health Smart Auto/Commercial	$3.38
Rate for Payer: LLUH Dept of Risk Management WC	$3.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.23

HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION [10224]

Facility

$2.45

Service Code	CPT J1170
Hospital Charge Code	NDG10224
Hospital Revenue Code	636
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.96
Rate for Payer: Cash Price	$1.10
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.84

HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION [10224]

Facility

$4.00

Service Code	CPT J1170
Hospital Charge Code	1737043
Hospital Revenue Code	636
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.36
Rate for Payer: Aetna of CA Government/Medicare	$1.36
Rate for Payer: Aetna of CA Government/Medicare	$2.40
Rate for Payer: Cash Price	$1.02
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.70

HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION [10224]

Facility

$2.26

Service Code	CPT J1170
Hospital Charge Code	1737043
Hospital Revenue Code	636
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$1.81
Rate for Payer: Cash Price	$1.02
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cigna of CA HMO/PPO	$1.81
Rate for Payer: Cigna of CA HMO/PPO	$3.20
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.00

HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION [10224]

Facility

$2.45

Service Code	CPT J1170
Hospital Charge Code	NDG10224
Hospital Revenue Code	636
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.47
Rate for Payer: Aetna of CA Government/Medicare	$1.47
Rate for Payer: Cash Price	$1.10
Rate for Payer: Health Smart Auto/Commercial	$1.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.47
Rate for Payer: LLUH Dept of Risk Management WC	$1.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.84

HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION [10224]

Facility

$5.64

Service Code	CPT J1170
Hospital Charge Code	NDG10224B
Hospital Revenue Code	636
Min. Negotiated Rate	$3.10
Max. Negotiated Rate	$4.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.38
Rate for Payer: Aetna of CA Government/Medicare	$3.38
Rate for Payer: Cash Price	$2.54
Rate for Payer: Health Smart Auto/Commercial	$3.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.38
Rate for Payer: LLUH Dept of Risk Management WC	$3.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.23

HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [118734]

Facility

$5.18

Service Code	CPT J1170
Hospital Charge Code	NDG118734
Hospital Revenue Code	636
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$3.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$3.11
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Cash Price	$2.33
Rate for Payer: Cash Price	$1.62
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Health Smart Auto/Commercial	$3.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.11
Rate for Payer: LLUH Dept of Risk Management WC	$2.85
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.88

Know your out-of-pocket cost for care.

All Charges