Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HYDROXYUREA 500 MG CAPSULE [10236]

Facility

$1.10

Service Code	CPT S0176
Hospital Charge Code	1710079
Hospital Revenue Code	259
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.88
Rate for Payer: Cash Price	$0.50
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cigna of CA HMO/PPO	$0.88
Rate for Payer: Cigna of CA HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.66
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.83

HYDROXYUREA 500 MG CAPSULE [10236]

Facility

$0.67

Service Code	CPT S0176
Hospital Charge Code	1710079
Hospital Revenue Code	259
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 EPO/HMO/POS/PPO	$0.66
Rate for Payer: Aetna of CA Government/Medicare	$0.66
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Cash Price	$0.50
Rate for Payer: Cash Price	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.66
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$0.61
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	$0.83

HYDROXYUREA ORAL SOLUTION 100 MG/ML [408102360]

Facility

$0.13

Service Code	CPT S0176
Hospital Charge Code	NDC408102360
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

HYDROXYUREA ORAL SOLUTION 100 MG/ML [408102360]

Facility

$0.13

Service Code	CPT S0176
Hospital Charge Code	NDC408102360
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

HYDROXYUREA (SICKLE CELL) 200 MG CAPSULE [23009]

Facility

$0.91

Service Code	NDC 0003-6335-17
Hospital Charge Code	1710989
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.73
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of CA HMO/PPO	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

HYDROXYUREA (SICKLE CELL) 200 MG CAPSULE [23009]

Facility

$0.91

Service Code	NDC 0003-6335-17
Hospital Charge Code	1710989
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.55
Rate for Payer: Aetna of CA Government/Medicare	$0.55
Rate for Payer: Cash Price	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

HYDROXYUREA (SICKLE CELL) 300 MG CAPSULE [23010]

Facility

$0.91

Service Code	NDC 0003-6336-17
Hospital Charge Code	1710990
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.73
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of CA HMO/PPO	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

HYDROXYUREA (SICKLE CELL) 300 MG CAPSULE [23010]

Facility

$0.91

Service Code	NDC 0003-6336-17
Hospital Charge Code	1710990
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.55
Rate for Payer: Aetna of CA Government/Medicare	$0.55
Rate for Payer: Cash Price	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.55
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.68

HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION [3771]

Facility

$0.16

Service Code	NDC 60432-150-04
Hospital Charge Code	NDG3771
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION [3771]

Facility

$0.16

Service Code	NDC 54838-502-80
Hospital Charge Code	1715474
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION [3771]

Facility

$0.16

Service Code	NDC 60432-150-04
Hospital Charge Code	NDG3771
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION [3771]

Facility

$0.16

Service Code	NDC 54838-502-80
Hospital Charge Code	1715474
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

HYDROXYZINE HCL 10 MG TABLET [3772]

Facility

$0.06

Service Code	NDC 23155-500-01
Hospital Charge Code	1711165
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

HYDROXYZINE HCL 10 MG TABLET [3772]

Facility

$0.06

Service Code	NDC 23155-500-01
Hospital Charge Code	1711165
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

HYDROXYZINE HCL 10 MG TABLET [3772]

Facility

$0.07

Service Code	NDC 0093-5060-01
Hospital Charge Code	1711165
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

HYDROXYZINE HCL 10 MG TABLET [3772]

Facility

$0.07

Service Code	NDC 0093-5060-01
Hospital Charge Code	1711165
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

HYDROXYZINE HCL 25 MG TABLET [3774]

Facility

$0.07

Service Code	NDC 23155-501-01
Hospital Charge Code	1711178
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

HYDROXYZINE HCL 25 MG TABLET [3774]

Facility

$0.31

Service Code	NDC 63739-486-10
Hospital Charge Code	1711178
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

HYDROXYZINE HCL 25 MG TABLET [3774]

Facility

$0.07

Service Code	NDC 23155-501-01
Hospital Charge Code	1711178
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

HYDROXYZINE HCL 25 MG TABLET [3774]

Facility

$0.30

Service Code	NDC 0904-6617-61
Hospital Charge Code	1711178
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

HYDROXYZINE HCL 25 MG TABLET [3774]

Facility

$0.30

Service Code	NDC 0904-6617-61
Hospital Charge Code	1711178
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

HYDROXYZINE HCL 25 MG TABLET [3774]

Facility

$0.31

Service Code	NDC 63739-486-10
Hospital Charge Code	1711178
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION [3770]

Facility

$23.25

Service Code	CPT J3410
Hospital Charge Code	1720155
Hospital Revenue Code	636
Min. Negotiated Rate	$12.79
Max. Negotiated Rate	$17.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.95
Rate for Payer: Aetna of CA Government/Medicare	$13.95
Rate for Payer: Cash Price	$10.46
Rate for Payer: Health Smart Auto/Commercial	$13.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.95
Rate for Payer: LLUH Dept of Risk Management WC	$12.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.44

HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION [3770]

Facility

$23.25

Service Code	CPT J3410
Hospital Charge Code	1720155
Hospital Revenue Code	636
Min. Negotiated Rate	$12.79
Max. Negotiated Rate	$18.60
Rate for Payer: Cash Price	$10.46
Rate for Payer: Cigna of CA HMO/PPO	$18.60
Rate for Payer: Health Smart Auto/Commercial	$13.95
Rate for Payer: LLUH Dept of Risk Management WC	$12.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.44

HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION [3770]

Facility

$33.19

Service Code	CPT J3410
Hospital Charge Code	NDG3770
Hospital Revenue Code	636
Min. Negotiated Rate	$18.25
Max. Negotiated Rate	$26.55
Rate for Payer: Cash Price	$14.94
Rate for Payer: Cigna of CA HMO/PPO	$26.55
Rate for Payer: Health Smart Auto/Commercial	$19.91
Rate for Payer: LLUH Dept of Risk Management WC	$18.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$24.89

Know your out-of-pocket cost for care.

All Charges