Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

GUANFACINE 1 MG TABLET [10149]

Facility

$3.28

Service Code	NDC 68094-065-62
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$2.62
Rate for Payer: Cash Price	$1.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.62
Rate for Payer: Health Smart Auto/Commercial	$1.97
Rate for Payer: LLUH Dept of Risk Management WC	$1.80
Rate for Payer: Multiplan Commercial	$2.46

GUANFACINE 1 MG TABLET [10149]

Facility

$0.48

Service Code	NDC 59651-840-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36

GUANFACINE 1 MG TABLET [10149]

Facility

$3.28

Service Code	NDC 68094-065-62
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$2.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.97
Rate for Payer: Aetna of CA Government/Medicare	$1.97
Rate for Payer: Cash Price	$1.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.62
Rate for Payer: Health Smart Auto/Commercial	$1.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.97
Rate for Payer: LLUH Dept of Risk Management WC	$1.80
Rate for Payer: Multiplan Commercial	$2.46

GUANFACINE 1 MG TABLET [10149]

Facility

$3.32

Service Code	NDC 60687-710-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$2.66
Rate for Payer: Cash Price	$1.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.66
Rate for Payer: Health Smart Auto/Commercial	$1.99
Rate for Payer: LLUH Dept of Risk Management WC	$1.83
Rate for Payer: Multiplan Commercial	$2.49

GUANFACINE 1 MG TABLET [10149]

Facility

$3.28

Service Code	NDC 68094-065-59
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$2.62
Rate for Payer: Cash Price	$1.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.62
Rate for Payer: Health Smart Auto/Commercial	$1.97
Rate for Payer: LLUH Dept of Risk Management WC	$1.80
Rate for Payer: Multiplan Commercial	$2.46

GUANFACINE ER 1 MG TABLET,EXTENDED RELEASE 24 HR [99835]

Facility

$0.50

Service Code	HCPCS J8499
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

GUANFACINE ER 1 MG TABLET,EXTENDED RELEASE 24 HR [99835]

Facility

$0.50

Service Code	HCPCS J8499
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

GUAR GUM ORAL PACKET [30538]

Facility

$0.57

Service Code	NDC 4390097647
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.43

GUAR GUM ORAL PACKET [30538]

Facility

$0.57

Service Code	NDC 4390097647
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.34
Rate for Payer: Aetna of CA Government/Medicare	$0.34
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.43

GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION [242810]

Facility

$873.99

Service Code	HCPCS J1628
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$480.69
Max. Negotiated Rate	$699.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$524.39
Rate for Payer: Aetna of CA Government/Medicare	$524.39
Rate for Payer: Cash Price	$480.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$699.19
Rate for Payer: Health Smart Auto/Commercial	$524.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$524.39
Rate for Payer: LLUH Dept of Risk Management WC	$480.69
Rate for Payer: Multiplan Commercial	$655.49

GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION [242810]

Facility

$873.99

Service Code	HCPCS J1628
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$480.69
Max. Negotiated Rate	$699.19
Rate for Payer: Cash Price	$480.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$699.19
Rate for Payer: Health Smart Auto/Commercial	$524.39
Rate for Payer: LLUH Dept of Risk Management WC	$480.69
Rate for Payer: Multiplan Commercial	$655.49

HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN [11931]

Facility

$15.19

Service Code	HCPCS 90648
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.35
Max. Negotiated Rate	$176.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$176.80
Rate for Payer: Aetna of CA Government/Medicare	$176.80
Rate for Payer: Cash Price	$8.35
Rate for Payer: Cash Price	$8.36
Rate for Payer: Cash Price	$8.36
Rate for Payer: Cash Price	$8.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.15
Rate for Payer: Health Smart Auto/Commercial	$9.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.11
Rate for Payer: LLUH Dept of Risk Management WC	$8.35
Rate for Payer: Multiplan Commercial	$11.39

HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN [11931]

Facility

$15.19

Service Code	HCPCS 90648
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.35
Max. Negotiated Rate	$12.15
Rate for Payer: Cash Price	$8.35
Rate for Payer: Cash Price	$8.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.15
Rate for Payer: Health Smart Auto/Commercial	$9.11
Rate for Payer: LLUH Dept of Risk Management WC	$8.35
Rate for Payer: Multiplan Commercial	$11.39

HALOPERIDOL 0.5 MG TABLET [3578]

Facility

$0.35

Service Code	NDC 51079-733-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.21
Rate for Payer: Aetna of CA Government/Medicare	$0.21
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

HALOPERIDOL 0.5 MG TABLET [3578]

Facility

$0.35

Service Code	NDC 51079-733-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

HALOPERIDOL 0.5 MG TABLET [3578]

Facility

$0.35

Service Code	NDC 51079-733-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.21
Rate for Payer: Aetna of CA Government/Medicare	$0.21
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

HALOPERIDOL 0.5 MG TABLET [3578]

Facility

$0.35

Service Code	NDC 51079-733-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.28
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

HALOPERIDOL 10 MG TABLET [3580]

Facility

$0.78

Service Code	NDC 0832-1550-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

HALOPERIDOL 10 MG TABLET [3580]

Facility

$0.78

Service Code	NDC 0832-1550-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

HALOPERIDOL 10 MG TABLET [3580]

Facility

$1.56

Service Code	NDC 68084-249-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.94
Rate for Payer: Aetna of CA Government/Medicare	$0.94
Rate for Payer: Cash Price	$0.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.25
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Commercial	$1.17

HALOPERIDOL 10 MG TABLET [3580]

Facility

$1.56

Service Code	NDC 68084-249-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.94
Rate for Payer: Aetna of CA Government/Medicare	$0.94
Rate for Payer: Cash Price	$0.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.25
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Commercial	$1.17

HALOPERIDOL 10 MG TABLET [3580]

Facility

$1.56

Service Code	NDC 68084-249-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.25
Rate for Payer: Cash Price	$0.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.25
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Commercial	$1.17

HALOPERIDOL 10 MG TABLET [3580]

Facility

$1.56

Service Code	NDC 68084-249-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.25
Rate for Payer: Cash Price	$0.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.25
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Commercial	$1.17

HALOPERIDOL 1 MG TABLET [3579]

Facility

$0.44

Service Code	NDC 0378-0257-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
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	$0.33

HALOPERIDOL 1 MG TABLET [3579]

Facility

$0.49

Service Code	NDC 51079-734-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37

Know your out-of-pocket cost for care.

All Charges