Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

GLIPIZIDE 5 MG TABLET [10117]

Facility

$0.06

Service Code	NDC 60505-0141-0
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.05

GLIPIZIDE 5 MG TABLET [10117]

Facility

$0.06

Service Code	NDC 60505-0141-0
Hospital Charge Code	901700029
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
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 Commercial	$0.05

GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR [37650]

Facility

$0.30

Service Code	NDC 64980-281-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
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	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
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 Commercial	$0.23

GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR [37650]

Facility

$0.30

Service Code	NDC 64980-281-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.23

GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR [37650]

Facility

$0.30

Service Code	NDC 59651-270-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
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	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
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 Commercial	$0.23

GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR [37650]

Facility

$0.30

Service Code	NDC 59651-270-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.23

GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR [37648]

Facility

$0.26

Service Code	NDC 64980-279-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.20

GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR [37648]

Facility

$0.26

Service Code	NDC 59651-268-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
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	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
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 Commercial	$0.20

GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR [37648]

Facility

$0.26

Service Code	NDC 64980-279-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
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	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
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 Commercial	$0.20

GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR [37648]

Facility

$0.26

Service Code	NDC 59651-268-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.20

GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [37649]

Facility

$0.72

Service Code	NDC 68084-111-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.54

GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [37649]

Facility

$0.72

Service Code	NDC 68084-111-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.54

GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [37649]

Facility

$0.72

Service Code	NDC 68084-111-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.54

GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [37649]

Facility

$0.72

Service Code	NDC 68084-111-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.54

GLUCAGON 1 MG INJ SOLUTION. [408121354]

Facility

$303.22

Service Code	HCPCS J1610
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$166.77
Max. Negotiated Rate	$242.58
Rate for Payer: Cash Price	$166.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$242.58
Rate for Payer: Health Smart Auto/Commercial	$181.93
Rate for Payer: LLUH Dept of Risk Management WC	$166.77
Rate for Payer: Multiplan Commercial	$227.41

GLUCAGON 1 MG INJ SOLUTION. [408121354]

Facility

$303.22

Service Code	HCPCS J1610
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$166.77
Max. Negotiated Rate	$242.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$181.93
Rate for Payer: Aetna of CA Government/Medicare	$181.93
Rate for Payer: Cash Price	$166.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$242.58
Rate for Payer: Health Smart Auto/Commercial	$181.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$181.93
Rate for Payer: LLUH Dept of Risk Management WC	$166.77
Rate for Payer: Multiplan Commercial	$227.41

GLUCAGON 1 MG SOLUTION FOR INJECTION [111859]

Facility

$336.00

Service Code	HCPCS J1610
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$184.80
Max. Negotiated Rate	$268.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$201.60
Rate for Payer: Aetna of CA Government/Medicare	$201.60
Rate for Payer: Cash Price	$184.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$268.80
Rate for Payer: Health Smart Auto/Commercial	$201.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$201.60
Rate for Payer: LLUH Dept of Risk Management WC	$184.80
Rate for Payer: Multiplan Commercial	$252.00

GLUCAGON 1 MG SOLUTION FOR INJECTION [111859]

Facility

$336.00

Service Code	HCPCS J1610
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$184.80
Max. Negotiated Rate	$268.80
Rate for Payer: Cash Price	$184.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$268.80
Rate for Payer: Health Smart Auto/Commercial	$201.60
Rate for Payer: LLUH Dept of Risk Management WC	$184.80
Rate for Payer: Multiplan Commercial	$252.00

GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION [209701]

Facility

$303.22

Service Code	HCPCS J1611
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$166.77
Max. Negotiated Rate	$242.58
Rate for Payer: Cash Price	$166.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$242.58
Rate for Payer: Health Smart Auto/Commercial	$181.93
Rate for Payer: LLUH Dept of Risk Management WC	$166.77
Rate for Payer: Multiplan Commercial	$227.41

GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION [209701]

Facility

$303.22

Service Code	HCPCS J1610
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$166.77
Max. Negotiated Rate	$242.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$181.93
Rate for Payer: Aetna of CA Government/Medicare	$181.93
Rate for Payer: Cash Price	$166.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$242.58
Rate for Payer: Health Smart Auto/Commercial	$181.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$181.93
Rate for Payer: LLUH Dept of Risk Management WC	$166.77
Rate for Payer: Multiplan Commercial	$227.41

GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION [209701]

Facility

$303.22

Service Code	HCPCS J1611
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$166.77
Max. Negotiated Rate	$242.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$181.93
Rate for Payer: Aetna of CA Government/Medicare	$181.93
Rate for Payer: Cash Price	$166.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$242.58
Rate for Payer: Health Smart Auto/Commercial	$181.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$181.93
Rate for Payer: LLUH Dept of Risk Management WC	$166.77
Rate for Payer: Multiplan Commercial	$227.41

GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION [209701]

Facility

$303.22

Service Code	HCPCS J1610
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$166.77
Max. Negotiated Rate	$242.58
Rate for Payer: Cash Price	$166.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$242.58
Rate for Payer: Health Smart Auto/Commercial	$181.93
Rate for Payer: LLUH Dept of Risk Management WC	$166.77
Rate for Payer: Multiplan Commercial	$227.41

GLUCAGON HCL 1 MG SOLUTION FOR INJECTION [226952]

Facility

$335.76

Service Code	HCPCS J1611
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$184.67
Max. Negotiated Rate	$268.61
Rate for Payer: Cash Price	$184.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$268.61
Rate for Payer: Health Smart Auto/Commercial	$201.46
Rate for Payer: LLUH Dept of Risk Management WC	$184.67
Rate for Payer: Multiplan Commercial	$251.82

GLUCAGON HCL 1 MG SOLUTION FOR INJECTION [226952]

Facility

$335.76

Service Code	HCPCS J1611
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$184.67
Max. Negotiated Rate	$268.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$201.46
Rate for Payer: Aetna of CA Government/Medicare	$201.46
Rate for Payer: Cash Price	$184.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$268.61
Rate for Payer: Health Smart Auto/Commercial	$201.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$201.46
Rate for Payer: LLUH Dept of Risk Management WC	$184.67
Rate for Payer: Multiplan Commercial	$251.82

GLUCOSE 4 GRAM CHEWABLE TABLET [16050]

Facility

$0.12

Service Code	NDC 8770142600
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	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

Know your out-of-pocket cost for care.

All Charges