Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.24

Service Code	NDC 70700-166-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.59
Rate for Payer: Cash Price	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.59
Rate for Payer: Health Smart Auto/Commercial	$1.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.78
Rate for Payer: Multiplan Commercial	$2.43

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.12

Service Code	NDC 70860-781-42
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.87
Rate for Payer: Aetna of CA Government/Medicare	$1.87
Rate for Payer: Cash Price	$1.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.50
Rate for Payer: Health Smart Auto/Commercial	$1.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.72
Rate for Payer: Multiplan Commercial	$2.34

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.24

Service Code	NDC 70700-166-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.94
Rate for Payer: Aetna of CA Government/Medicare	$1.94
Rate for Payer: Cash Price	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.59
Rate for Payer: Health Smart Auto/Commercial	$1.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.78
Rate for Payer: Multiplan Commercial	$2.43

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.12

Service Code	NDC 0143-9681-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.50
Rate for Payer: Cash Price	$1.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.50
Rate for Payer: Health Smart Auto/Commercial	$1.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.72
Rate for Payer: Multiplan Commercial	$2.34

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.12

Service Code	NDC 0143-9681-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.87
Rate for Payer: Aetna of CA Government/Medicare	$1.87
Rate for Payer: Cash Price	$1.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.50
Rate for Payer: Health Smart Auto/Commercial	$1.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.72
Rate for Payer: Multiplan Commercial	$2.34

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.12

Service Code	NDC 0143-9681-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.87
Rate for Payer: Aetna of CA Government/Medicare	$1.87
Rate for Payer: Cash Price	$1.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.50
Rate for Payer: Health Smart Auto/Commercial	$1.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.72
Rate for Payer: Multiplan Commercial	$2.34

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.12

Service Code	NDC 0143-9682-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.87
Rate for Payer: Aetna of CA Government/Medicare	$1.87
Rate for Payer: Cash Price	$1.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.50
Rate for Payer: Health Smart Auto/Commercial	$1.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.72
Rate for Payer: Multiplan Commercial	$2.34

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$0.84

Service Code	NDC 70860-781-41
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Commercial	$0.63

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.12

Service Code	NDC 0143-9681-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.50
Rate for Payer: Cash Price	$1.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.50
Rate for Payer: Health Smart Auto/Commercial	$1.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.72
Rate for Payer: Multiplan Commercial	$2.34

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.36

Service Code	NDC 0781-3825-71
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$2.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.02
Rate for Payer: Aetna of CA Government/Medicare	$2.02
Rate for Payer: Cash Price	$1.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.69
Rate for Payer: Health Smart Auto/Commercial	$2.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.02
Rate for Payer: LLUH Dept of Risk Management WC	$1.85
Rate for Payer: Multiplan Commercial	$2.52

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$2.40

Service Code	NDC 71839-124-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$1.80

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.12

Service Code	NDC 70860-781-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.87
Rate for Payer: Aetna of CA Government/Medicare	$1.87
Rate for Payer: Cash Price	$1.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.50
Rate for Payer: Health Smart Auto/Commercial	$1.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.72
Rate for Payer: Multiplan Commercial	$2.34

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$10.56

Service Code	NDC 0517-4605-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$5.81
Max. Negotiated Rate	$8.45
Rate for Payer: Cash Price	$5.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.45
Rate for Payer: Health Smart Auto/Commercial	$6.34
Rate for Payer: LLUH Dept of Risk Management WC	$5.81
Rate for Payer: Multiplan Commercial	$7.92

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$13.80

Service Code	NDC 0517-4602-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$7.59
Max. Negotiated Rate	$11.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.28
Rate for Payer: Aetna of CA Government/Medicare	$8.28
Rate for Payer: Cash Price	$7.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.04
Rate for Payer: Health Smart Auto/Commercial	$8.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.28
Rate for Payer: LLUH Dept of Risk Management WC	$7.59
Rate for Payer: Multiplan Commercial	$10.35

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.22

Service Code	NDC 16729-471-63
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$2.58
Rate for Payer: Cash Price	$1.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.58
Rate for Payer: Health Smart Auto/Commercial	$1.93
Rate for Payer: LLUH Dept of Risk Management WC	$1.77
Rate for Payer: Multiplan Commercial	$2.42

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.12

Service Code	NDC 0143-9682-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.50
Rate for Payer: Cash Price	$1.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.50
Rate for Payer: Health Smart Auto/Commercial	$1.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.72
Rate for Payer: Multiplan Commercial	$2.34

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.36

Service Code	NDC 0781-3825-96
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$2.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.02
Rate for Payer: Aetna of CA Government/Medicare	$2.02
Rate for Payer: Cash Price	$1.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.69
Rate for Payer: Health Smart Auto/Commercial	$2.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.02
Rate for Payer: LLUH Dept of Risk Management WC	$1.85
Rate for Payer: Multiplan Commercial	$2.52

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$2.40

Service Code	NDC 71839-124-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$1.80

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.12

Service Code	NDC 70860-781-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.50
Rate for Payer: Cash Price	$1.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.50
Rate for Payer: Health Smart Auto/Commercial	$1.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.72
Rate for Payer: Multiplan Commercial	$2.34

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$2.40

Service Code	NDC 71839-124-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
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	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
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 Commercial	$1.80

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.24

Service Code	NDC 70700-166-22
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.94
Rate for Payer: Aetna of CA Government/Medicare	$1.94
Rate for Payer: Cash Price	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.59
Rate for Payer: Health Smart Auto/Commercial	$1.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.78
Rate for Payer: Multiplan Commercial	$2.43

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$13.80

Service Code	NDC 0517-4602-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$7.59
Max. Negotiated Rate	$11.04
Rate for Payer: Cash Price	$7.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.04
Rate for Payer: Health Smart Auto/Commercial	$8.28
Rate for Payer: LLUH Dept of Risk Management WC	$7.59
Rate for Payer: Multiplan Commercial	$10.35

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$10.56

Service Code	NDC 0517-4605-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$5.81
Max. Negotiated Rate	$8.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.34
Rate for Payer: Aetna of CA Government/Medicare	$6.34
Rate for Payer: Cash Price	$5.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.45
Rate for Payer: Health Smart Auto/Commercial	$6.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.34
Rate for Payer: LLUH Dept of Risk Management WC	$5.81
Rate for Payer: Multiplan Commercial	$7.92

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.24

Service Code	NDC 70700-166-22
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.59
Rate for Payer: Cash Price	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.59
Rate for Payer: Health Smart Auto/Commercial	$1.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.78
Rate for Payer: Multiplan Commercial	$2.43

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$3.12

Service Code	NDC 0143-9682-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.87
Rate for Payer: Aetna of CA Government/Medicare	$1.87
Rate for Payer: Cash Price	$1.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.50
Rate for Payer: Health Smart Auto/Commercial	$1.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.72
Rate for Payer: Multiplan Commercial	$2.34

Know your out-of-pocket cost for care.

All Charges