Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

$0.10

Service Code	NDC 23155-502-01
Hospital Charge Code	1711188
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

$0.46

Service Code	NDC 68084-255-11
Hospital Charge Code	1711188
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

$0.13

Service Code	NDC 0093-5062-01
Hospital Charge Code	1711188
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

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

$0.17

Service Code	NDC 10702-012-01
Hospital Charge Code	1711188
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
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	$0.13

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

$0.46

Service Code	NDC 68084-255-11
Hospital Charge Code	1711188
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.21
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: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

$0.17

Service Code	NDC 10702-012-01
Hospital Charge Code	1711188
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
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	$0.08
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	$0.13

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

$0.46

Service Code	NDC 68084-255-01
Hospital Charge Code	1711188
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

$0.17

Service Code	NDC 9992-0012-01
Hospital Charge Code	1711188
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
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	$0.08
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	$0.13

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

$0.17

Service Code	NDC 9992-0012-01
Hospital Charge Code	1711188
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
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	$0.13

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

$0.10

Service Code	NDC 23155-502-01
Hospital Charge Code	1711188
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

$0.46

Service Code	NDC 68084-255-01
Hospital Charge Code	1711188
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.21
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: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

$0.13

Service Code	NDC 0093-5062-01
Hospital Charge Code	1711188
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

HYDROXYZINE ORAL SOLUTION (IV FORM) 50 MG/ML [4080433]

Facility

$2.40

Service Code	NDC 9994-0804-33
Hospital Charge Code	1715147
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

HYDROXYZINE ORAL SOLUTION (IV FORM) 50 MG/ML [4080433]

Facility

$2.40

Service Code	NDC 9994-0804-33
Hospital Charge Code	1715147
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

HYDROXYZINE PAMOATE 25 MG CAPSULE [3777]

Facility

$0.18

Service Code	NDC 0555-0323-02
Hospital Charge Code	1711071
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

HYDROXYZINE PAMOATE 25 MG CAPSULE [3777]

Facility

$0.18

Service Code	NDC 0555-0323-02
Hospital Charge Code	1711071
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE [17381]

Facility

$273.92

Service Code	CPT J7325
Hospital Charge Code	1721174
Hospital Revenue Code	636
Min. Negotiated Rate	$150.66
Max. Negotiated Rate	$219.14
Rate for Payer: Cash Price	$123.26
Rate for Payer: Cigna of CA HMO/PPO	$219.14
Rate for Payer: Health Smart Auto/Commercial	$164.35
Rate for Payer: LLUH Dept of Risk Management WC	$150.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$205.44

HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE [17381]

Facility

$273.92

Service Code	CPT J7325
Hospital Charge Code	1721174
Hospital Revenue Code	636
Min. Negotiated Rate	$150.66
Max. Negotiated Rate	$205.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$164.35
Rate for Payer: Aetna of CA Government/Medicare	$164.35
Rate for Payer: Cash Price	$123.26
Rate for Payer: Health Smart Auto/Commercial	$164.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$164.35
Rate for Payer: LLUH Dept of Risk Management WC	$150.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$205.44

HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR [3781]

Facility

$0.22

Service Code	NDC 39328-048-16
Hospital Charge Code	NDG3781
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR [3781]

Facility

$0.22

Service Code	NDC 39328-048-16
Hospital Charge Code	NDG3781
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
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	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR [3781]

Facility

$0.08

Service Code	NDC 54838-511-80
Hospital Charge Code	NDG3781
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR [3781]

Facility

$0.08

Service Code	NDC 54838-511-80
Hospital Charge Code	NDG3781
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

HYOSCYAMINE 0.125 MG/ML ORAL DROPS [3782]

Facility

$2.65

Service Code	NDC 39328-047-15
Hospital Charge Code	1719158
Hospital Revenue Code	259
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$1.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.59
Rate for Payer: Aetna of CA Government/Medicare	$1.59
Rate for Payer: Cash Price	$1.19
Rate for Payer: Health Smart Auto/Commercial	$1.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.59
Rate for Payer: LLUH Dept of Risk Management WC	$1.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.99

HYOSCYAMINE 0.125 MG/ML ORAL DROPS [3782]

Facility

$2.65

Service Code	NDC 39328-047-15
Hospital Charge Code	1719158
Hospital Revenue Code	259
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$2.12
Rate for Payer: Cash Price	$1.19
Rate for Payer: Cigna of CA HMO/PPO	$2.12
Rate for Payer: Health Smart Auto/Commercial	$1.59
Rate for Payer: LLUH Dept of Risk Management WC	$1.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.99

Know your out-of-pocket cost for care.

All Charges