Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [203118]

Facility

$599.76

Service Code	HCPCS J1602
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$329.87
Max. Negotiated Rate	$479.81
Rate for Payer: Cash Price	$329.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$479.81
Rate for Payer: Health Smart Auto/Commercial	$359.86
Rate for Payer: LLUH Dept of Risk Management WC	$329.87
Rate for Payer: Multiplan Commercial	$449.82

GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]

Facility

$960.00

Service Code	HCPCS J1429
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$528.00
Max. Negotiated Rate	$768.00
Rate for Payer: Cash Price	$528.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$768.00
Rate for Payer: Health Smart Auto/Commercial	$576.00
Rate for Payer: LLUH Dept of Risk Management WC	$528.00
Rate for Payer: Multiplan Commercial	$720.00

GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]

Facility

$960.00

Service Code	HCPCS J1429
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$528.00
Max. Negotiated Rate	$768.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$576.00
Rate for Payer: Aetna of CA Government/Medicare	$576.00
Rate for Payer: Cash Price	$528.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$768.00
Rate for Payer: Health Smart Auto/Commercial	$576.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$576.00
Rate for Payer: LLUH Dept of Risk Management WC	$528.00
Rate for Payer: Multiplan Commercial	$720.00

GRANISETRON HCL 1 MG/ML (1 ML) INTRAVENOUS SOLUTION [12552]

Facility

$10.80

Service Code	HCPCS J1626
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.48
Rate for Payer: Aetna of CA Government/Medicare	$6.48
Rate for Payer: Cash Price	$5.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.64
Rate for Payer: Health Smart Auto/Commercial	$6.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.48
Rate for Payer: LLUH Dept of Risk Management WC	$5.94
Rate for Payer: Multiplan Commercial	$8.10

GRANISETRON HCL 1 MG/ML (1 ML) INTRAVENOUS SOLUTION [12552]

Facility

$10.80

Service Code	HCPCS J1626
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$8.64
Rate for Payer: Cash Price	$5.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.64
Rate for Payer: Health Smart Auto/Commercial	$6.48
Rate for Payer: LLUH Dept of Risk Management WC	$5.94
Rate for Payer: Multiplan Commercial	$8.10

GRANISETRON HCL 1 MG/ML INTRAVENOUS SOLUTION [92107]

Facility

$10.80

Service Code	HCPCS J1626
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$8.64
Rate for Payer: Cash Price	$5.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.64
Rate for Payer: Health Smart Auto/Commercial	$6.48
Rate for Payer: LLUH Dept of Risk Management WC	$5.94
Rate for Payer: Multiplan Commercial	$8.10

GRANISETRON HCL 1 MG/ML INTRAVENOUS SOLUTION [92107]

Facility

$10.80

Service Code	HCPCS J1626
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.48
Rate for Payer: Aetna of CA Government/Medicare	$6.48
Rate for Payer: Cash Price	$5.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.64
Rate for Payer: Health Smart Auto/Commercial	$6.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.48
Rate for Payer: LLUH Dept of Risk Management WC	$5.94
Rate for Payer: Multiplan Commercial	$8.10

GRANISETRON HCL 1 MG TABLET [14720]

Facility

$4.32

Service Code	NDC 51991-735-99
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$3.46
Rate for Payer: Cash Price	$2.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.46
Rate for Payer: Health Smart Auto/Commercial	$2.59
Rate for Payer: LLUH Dept of Risk Management WC	$2.38
Rate for Payer: Multiplan Commercial	$3.24

GRANISETRON HCL 1 MG TABLET [14720]

Facility

$4.32

Service Code	NDC 51991-735-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$3.46
Rate for Payer: Cash Price	$2.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.46
Rate for Payer: Health Smart Auto/Commercial	$2.59
Rate for Payer: LLUH Dept of Risk Management WC	$2.38
Rate for Payer: Multiplan Commercial	$3.24

GRANISETRON HCL 1 MG TABLET [14720]

Facility

$4.32

Service Code	NDC 51991-735-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$3.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.59
Rate for Payer: Aetna of CA Government/Medicare	$2.59
Rate for Payer: Cash Price	$2.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.46
Rate for Payer: Health Smart Auto/Commercial	$2.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.59
Rate for Payer: LLUH Dept of Risk Management WC	$2.38
Rate for Payer: Multiplan Commercial	$3.24

GRANISETRON HCL 1 MG TABLET [14720]

Facility

$4.32

Service Code	NDC 51991-735-99
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$3.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.59
Rate for Payer: Aetna of CA Government/Medicare	$2.59
Rate for Payer: Cash Price	$2.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.46
Rate for Payer: Health Smart Auto/Commercial	$2.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.59
Rate for Payer: LLUH Dept of Risk Management WC	$2.38
Rate for Payer: Multiplan Commercial	$3.24

GREEN GODDESS COMPOUND OS/UD [4082278]

Facility

$0.64

Service Code	NDC 9994-0822-78
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.48

GREEN GODDESS COMPOUND OS/UD [4082278]

Facility

$0.64

Service Code	NDC 9994-0822-78
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.48

GREEN GODDESS (HYOSCYAMINE) COMPOUND BULK [40802780]

Facility

$0.14

Service Code	NDC 99408-027-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

GREEN GODDESS (HYOSCYAMINE) COMPOUND BULK [40802780]

Facility

$0.14

Service Code	NDC 99408-027-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
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	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
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	$0.08
Rate for Payer: Multiplan Commercial	$0.11

GREEN GODDESS(HYOSCYAMINE) COMPOUND OS/UD [40822780]

Facility

$0.13

Service Code	NDC 9940-8227-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.10

GREEN GODDESS(HYOSCYAMINE) COMPOUND OS/UD [40822780]

Facility

$0.13

Service Code	NDC 9940-8227-80
Hospital Charge Code	901700029
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	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
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 Commercial	$0.10

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.38

Service Code	NDC 0121-1744-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.29

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.43

Service Code	NDC 60687-852-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.32

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.11

Service Code	NDC 9999-3542-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.11

Service Code	NDC 9999-3542-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.38

Service Code	NDC 0121-1744-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
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	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
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 Commercial	$0.29

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.43

Service Code	NDC 60687-852-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.32

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.38

Service Code	NDC 0121-1744-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
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	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
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 Commercial	$0.29

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.43

Service Code	NDC 60687-852-17
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.32

Know your out-of-pocket cost for care.

All Charges