Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

Facility

$10.80

Service Code	CPT J1626
Hospital Charge Code	NDG12552
Hospital Revenue Code	636
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$8.64
Rate for Payer: Cash Price	$4.86
Rate for Payer: Cash Price	$10.19
Rate for Payer: Cigna of CA HMO/PPO	$8.64
Rate for Payer: Cigna of CA HMO/PPO	$18.11
Rate for Payer: Health Smart Auto/Commercial	$6.48
Rate for Payer: Health Smart Auto/Commercial	$13.58
Rate for Payer: LLUH Dept of Risk Management WC	$12.45
Rate for Payer: LLUH Dept of Risk Management WC	$5.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.10

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

Facility

$10.80

Service Code	CPT J1626
Hospital Charge Code	NDG12552
Hospital Revenue Code	636
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.58
Rate for Payer: Aetna of CA Government/Medicare	$13.58
Rate for Payer: Aetna of CA Government/Medicare	$6.48
Rate for Payer: Cash Price	$4.86
Rate for Payer: Cash Price	$10.19
Rate for Payer: Health Smart Auto/Commercial	$13.58
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.58
Rate for Payer: LLUH Dept of Risk Management WC	$5.94
Rate for Payer: LLUH Dept of Risk Management WC	$12.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.98

GRANISETRON HCL 1 MG/ML INTRAVENOUS SOLUTION [92107]

Facility

$10.80

Service Code	CPT J1626
Hospital Charge Code	NDG92107
Hospital Revenue Code	636
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$8.10
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	$4.86
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 Beech St/Commercial/PHCS	$8.10

GRANISETRON HCL 1 MG/ML INTRAVENOUS SOLUTION [92107]

Facility

$10.80

Service Code	CPT J1626
Hospital Charge Code	NDG92107
Hospital Revenue Code	636
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$8.64
Rate for Payer: Health Smart Auto/Commercial	$6.48
Rate for Payer: Cash Price	$4.86
Rate for Payer: Cigna of CA HMO/PPO	$8.64
Rate for Payer: LLUH Dept of Risk Management WC	$5.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.10

GRANISETRON HCL 1 MG TABLET [14720]

Facility

$4.32

Service Code	NDC 51991-735-99
Hospital Charge Code	1712186
Hospital Revenue Code	259
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$3.24
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	$1.94
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 Beech St/Commercial/PHCS	$3.24

GRANISETRON HCL 1 MG TABLET [14720]

Facility

$4.32

Service Code	NDC 51991-735-99
Hospital Charge Code	1712186
Hospital Revenue Code	259
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$3.46
Rate for Payer: Cash Price	$1.94
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$3.24

GRANISETRON HCL 1 MG TABLET [14720]

Facility

$4.32

Service Code	NDC 51991-735-20
Hospital Charge Code	1712186
Hospital Revenue Code	259
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$3.24
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	$1.94
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 Beech St/Commercial/PHCS	$3.24

GRANISETRON HCL 1 MG TABLET [14720]

Facility

$4.32

Service Code	NDC 51991-735-20
Hospital Charge Code	1712186
Hospital Revenue Code	259
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$3.46
Rate for Payer: Cash Price	$1.94
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$3.24

GREEN GODDESS COMPOUND OS/UD [4082278]

Facility

$0.64

Service Code	NDC 9994-0822-78
Hospital Charge Code	NDG4082722
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.48
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	$0.29
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 Beech St/Commercial/PHCS	$0.48

GREEN GODDESS COMPOUND OS/UD [4082278]

Facility

$0.64

Service Code	NDC 9994-0822-78
Hospital Charge Code	NDG4082722
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.48

GREEN GODDESS (HYOSCYAMINE) COMPOUND BULK [40802780]

Facility

$0.14

Service Code	NDC 99408-027-80
Hospital Charge Code	1717093
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	$0.06
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	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

GREEN GODDESS (HYOSCYAMINE) COMPOUND BULK [40802780]

Facility

$0.14

Service Code	NDC 99408-027-80
Hospital Charge Code	1717093
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.11

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

Facility

$0.13

Service Code	NDC 9940-8227-80
Hospital Charge Code	NDC4082278B
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

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

Facility

$0.13

Service Code	NDC 9940-8227-80
Hospital Charge Code	NDC4082278B
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

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.11

Service Code	NDC 50383-063-05
Hospital Charge Code	1716015
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.08

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.11

Service Code	NDC 50383-063-07
Hospital Charge Code	1716015
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
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 Beech St/Commercial/PHCS	$0.08

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.26

Service Code	NDC 0121-1744-00
Hospital Charge Code	1716015
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.11

Service Code	NDC 9999-3542-00
Hospital Charge Code	1716015
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
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 Beech St/Commercial/PHCS	$0.08

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.11

Service Code	NDC 50383-063-07
Hospital Charge Code	1716015
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.08

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.11

Service Code	NDC 50383-063-05
Hospital Charge Code	1716015
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
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 Beech St/Commercial/PHCS	$0.08

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.26

Service Code	NDC 0121-1744-05
Hospital Charge Code	1716015
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.26

Service Code	NDC 0121-1744-00
Hospital Charge Code	1716015
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.26

Service Code	NDC 0121-1744-05
Hospital Charge Code	1716015
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

GUAIFENESIN 100 MG/5 ML ORAL LIQUID [3542]

Facility

$0.11

Service Code	NDC 9999-3542-00
Hospital Charge Code	1716015
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.08

GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR [205859]

Facility

$0.39

Service Code	NDC 46122-416-60
Hospital Charge Code	1711942
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.31
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA HMO/PPO	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29

Know your out-of-pocket cost for care.

All Charges