Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

Facility

$3.60

Service Code	CPT J1170
Hospital Charge Code	NDG118734
Hospital Revenue Code	636
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.62
Rate for Payer: Cash Price	$2.33
Rate for Payer: Cigna of CA HMO/PPO	$4.14
Rate for Payer: Cigna of CA HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Health Smart Auto/Commercial	$3.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$2.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.70

HYDROMORPHONE (PF) 50 MG/50 ML (1 MG/ML) IN 0.9 % NACL IV PCA SYRINGE [214315]

Facility

$0.67

Service Code	CPT J1170
Hospital Charge Code	NDG214315
Hospital Revenue Code	636
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cigna of CA HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50

HYDROMORPHONE (PF) 50 MG/50 ML (1 MG/ML) IN 0.9 % NACL IV PCA SYRINGE [214315]

Facility

$0.67

Service Code	CPT J1170
Hospital Charge Code	NDG214315
Hospital Revenue Code	636
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Cash Price	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50

HYDROMORPHONE (PF) 50 MG/50 ML (1 MG/ML) IN 0.9 % NACL IV PCA SYRINGE - ADULT DISCRETE [40820494]

Facility

$0.67

Service Code	CPT J1170
Hospital Charge Code	NDG214315
Hospital Revenue Code	636
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.54
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

HYDROMORPHONE (PF) 50 MG/50 ML (1 MG/ML) IN 0.9 % NACL IV PCA SYRINGE - ADULT DISCRETE [40820494]

Facility

$0.47

Service Code	CPT J1170
Hospital Charge Code	NDG214315
Hospital Revenue Code	636
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cash Price	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

HYDROMORPHONE (PF) 50 MG/50 ML IN NS IV PCA SYRINGE [40820378]

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) 50 MG/50 ML IN NS IV PCA SYRINGE [40820378]

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

HYDROXOCOBALAMIN 1,000 MCG/ML INTRAMUSCULAR SOLUTION [3768]

Facility

$1.00

Service Code	CPT J3425
Hospital Charge Code	1720964
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.60
Rate for Payer: Aetna of CA Government/Medicare	$0.60
Rate for Payer: Cash Price	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.75

HYDROXOCOBALAMIN 1,000 MCG/ML INTRAMUSCULAR SOLUTION [3768]

Facility

$1.00

Service Code	CPT J3425
Hospital Charge Code	1720964
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cigna of CA HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.75

HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION [188307]

Facility

$1,162.80

Service Code	CPT J3490
Hospital Charge Code	1720984
Hospital Revenue Code	636
Min. Negotiated Rate	$639.54
Max. Negotiated Rate	$930.24
Rate for Payer: Cash Price	$523.26
Rate for Payer: Cigna of CA HMO/PPO	$930.24
Rate for Payer: Health Smart Auto/Commercial	$697.68
Rate for Payer: LLUH Dept of Risk Management WC	$639.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$872.10

HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION [188307]

Facility

$1,162.80

Service Code	CPT J3490
Hospital Charge Code	1720984
Hospital Revenue Code	636
Min. Negotiated Rate	$639.54
Max. Negotiated Rate	$872.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$697.68
Rate for Payer: Aetna of CA Government/Medicare	$697.68
Rate for Payer: Cash Price	$523.26
Rate for Payer: Health Smart Auto/Commercial	$697.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$697.68
Rate for Payer: LLUH Dept of Risk Management WC	$639.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$872.10

HYDROXYCHLOROQUINE 200 MG TABLET [10235]

Facility

$0.83

Service Code	NDC 68382-096-01
Hospital Charge Code	1710362
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.62

HYDROXYCHLOROQUINE 200 MG TABLET [10235]

Facility

$2.34

Service Code	NDC 68084-269-01
Hospital Charge Code	1710362
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.40
Rate for Payer: Aetna of CA Government/Medicare	$1.40
Rate for Payer: Cash Price	$1.05
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.76

HYDROXYCHLOROQUINE 200 MG TABLET [10235]

Facility

$0.40

Service Code	NDC 69238-1544-1
Hospital Charge Code	1710362
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.30

HYDROXYCHLOROQUINE 200 MG TABLET [10235]

Facility

$2.34

Service Code	NDC 68084-269-11
Hospital Charge Code	1710362
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.40
Rate for Payer: Aetna of CA Government/Medicare	$1.40
Rate for Payer: Cash Price	$1.05
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.76

HYDROXYCHLOROQUINE 200 MG TABLET [10235]

Facility

$0.40

Service Code	NDC 69238-1544-1
Hospital Charge Code	1710362
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.30

HYDROXYCHLOROQUINE 200 MG TABLET [10235]

Facility

$0.83

Service Code	NDC 68382-096-01
Hospital Charge Code	1710362
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.66
Rate for Payer: Cash Price	$0.37
Rate for Payer: Cigna of CA HMO/PPO	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.62

HYDROXYCHLOROQUINE 200 MG TABLET [10235]

Facility

$2.34

Service Code	NDC 68084-269-01
Hospital Charge Code	1710362
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.87
Rate for Payer: Cash Price	$1.05
Rate for Payer: Cigna of CA HMO/PPO	$1.87
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.76

HYDROXYCHLOROQUINE 200 MG TABLET [10235]

Facility

$2.34

Service Code	NDC 68084-269-11
Hospital Charge Code	1710362
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.87
Rate for Payer: Cash Price	$1.05
Rate for Payer: Cigna of CA HMO/PPO	$1.87
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.76

HYDROXYCHLOROQUINE ORAL SOLUTION COMPOUND 25 MG/ML [4080282]

Facility

$4.36

Service Code	NDC 9994-0802-82
Hospital Charge Code	1715011
Hospital Revenue Code	259
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$3.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.62
Rate for Payer: Aetna of CA Government/Medicare	$2.62
Rate for Payer: Cash Price	$1.96
Rate for Payer: Health Smart Auto/Commercial	$2.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.62
Rate for Payer: LLUH Dept of Risk Management WC	$2.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.27

HYDROXYCHLOROQUINE ORAL SOLUTION COMPOUND 25 MG/ML [4080282]

Facility

$4.36

Service Code	NDC 9994-0802-82
Hospital Charge Code	1715011
Hospital Revenue Code	259
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$3.49
Rate for Payer: Cash Price	$1.96
Rate for Payer: Cigna of CA HMO/PPO	$3.49
Rate for Payer: Health Smart Auto/Commercial	$2.62
Rate for Payer: LLUH Dept of Risk Management WC	$2.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.27

HYDROXYPROGESTERONE CAPROATE 250 MG/ML INTRAMUSCULAR OIL [108013]

Facility

$409.09

Service Code	CPT J1729
Hospital Charge Code	ERX108013
Hospital Revenue Code	636
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$306.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$245.45
Rate for Payer: Aetna of CA Government/Medicare	$245.45
Rate for Payer: Cash Price	$184.09
Rate for Payer: Health Smart Auto/Commercial	$245.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$245.45
Rate for Payer: LLUH Dept of Risk Management WC	$225.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$306.82

HYDROXYPROGESTERONE CAPROATE 250 MG/ML INTRAMUSCULAR OIL [108013]

Facility

$409.09

Service Code	CPT J1729
Hospital Charge Code	ERX108013
Hospital Revenue Code	636
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$327.27
Rate for Payer: Cash Price	$184.09
Rate for Payer: Cigna of CA HMO/PPO	$327.27
Rate for Payer: Health Smart Auto/Commercial	$245.45
Rate for Payer: LLUH Dept of Risk Management WC	$225.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$306.82

HYDROXYPROGESTERONE (PF)(PREGNANCY PRESERVING) 250 MG/ML (1 ML) IM OIL [213746]

Facility

$342.00

Service Code	CPT J1726
Hospital Charge Code	NDG213746
Hospital Revenue Code	636
Min. Negotiated Rate	$188.10
Max. Negotiated Rate	$273.60
Rate for Payer: Cash Price	$153.90
Rate for Payer: Cigna of CA HMO/PPO	$273.60
Rate for Payer: Health Smart Auto/Commercial	$205.20
Rate for Payer: LLUH Dept of Risk Management WC	$188.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$256.50

HYDROXYPROGESTERONE (PF)(PREGNANCY PRESERVING) 250 MG/ML (1 ML) IM OIL [213746]

Facility

$342.00

Service Code	CPT J1726
Hospital Charge Code	NDG213746
Hospital Revenue Code	636
Min. Negotiated Rate	$188.10
Max. Negotiated Rate	$256.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$205.20
Rate for Payer: Aetna of CA Government/Medicare	$205.20
Rate for Payer: Cash Price	$153.90
Rate for Payer: Health Smart Auto/Commercial	$205.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$205.20
Rate for Payer: LLUH Dept of Risk Management WC	$188.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$256.50

Know your out-of-pocket cost for care.

All Charges