Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

GENTIAN VIOLET 1 % TOPICAL SOLUTION [3430]

Facility

$0.07

Service Code	NDC 8770140073
Hospital Charge Code	NDG3430
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
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: 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	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

GENTIAN VIOLET 1 % TOPICAL SOLUTION [3430]

Facility

$0.07

Service Code	NDC 8770140073
Hospital Charge Code	NDG3430
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

GIVOSIRAN 189 MG/ML SUBCUTANEOUS SOLUTION [226473]

Facility

$49,650.00

Service Code	CPT J0223
Hospital Charge Code	NDG226473
Hospital Revenue Code	636
Min. Negotiated Rate	$27,307.50
Max. Negotiated Rate	$39,720.00
Rate for Payer: Cash Price	$22,342.50
Rate for Payer: Cigna of CA HMO/PPO	$39,720.00
Rate for Payer: Health Smart Auto/Commercial	$29,790.00
Rate for Payer: LLUH Dept of Risk Management WC	$27,307.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37,237.50

GIVOSIRAN 189 MG/ML SUBCUTANEOUS SOLUTION [226473]

Facility

$49,650.00

Service Code	CPT J0223
Hospital Charge Code	NDG226473
Hospital Revenue Code	636
Min. Negotiated Rate	$27,307.50
Max. Negotiated Rate	$37,237.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29,790.00
Rate for Payer: Aetna of CA Government/Medicare	$29,790.00
Rate for Payer: Cash Price	$22,342.50
Rate for Payer: Health Smart Auto/Commercial	$29,790.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29,790.00
Rate for Payer: LLUH Dept of Risk Management WC	$27,307.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37,237.50

GLIMEPIRIDE 1 MG TABLET [16355]

Facility

$1.01

Service Code	NDC 68084-788-25
Hospital Charge Code	1711766
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.76

GLIMEPIRIDE 1 MG TABLET [16355]

Facility

$0.11

Service Code	NDC 16729-001-01
Hospital Charge Code	1711766
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

GLIMEPIRIDE 1 MG TABLET [16355]

Facility

$0.11

Service Code	NDC 16729-001-01
Hospital Charge Code	1711766
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

GLIMEPIRIDE 1 MG TABLET [16355]

Facility

$1.01

Service Code	NDC 68084-788-25
Hospital Charge Code	1711766
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.81
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cigna of CA HMO/PPO	$0.81
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.76

GLIMEPIRIDE 2 MG TABLET [16356]

Facility

$0.65

Service Code	NDC 68084-326-01
Hospital Charge Code	1711767
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.52
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.49

GLIMEPIRIDE 2 MG TABLET [16356]

Facility

$0.65

Service Code	NDC 68084-326-01
Hospital Charge Code	1711767
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.39
Rate for Payer: Aetna of CA Government/Medicare	$0.39
Rate for Payer: Cash Price	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.49

GLIMEPIRIDE 2 MG TABLET [16356]

Facility

$0.65

Service Code	NDC 68084-326-11
Hospital Charge Code	1711767
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.39
Rate for Payer: Aetna of CA Government/Medicare	$0.39
Rate for Payer: Cash Price	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.49

GLIMEPIRIDE 2 MG TABLET [16356]

Facility

$0.65

Service Code	NDC 68084-326-11
Hospital Charge Code	1711767
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.52
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.49

GLIMEPIRIDE 4 MG TABLET [16357]

Facility

$0.52

Service Code	NDC 51079-426-01
Hospital Charge Code	1711788
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.39

GLIMEPIRIDE 4 MG TABLET [16357]

Facility

$0.10

Service Code	NDC 55111-322-01
Hospital Charge Code	1711788
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

GLIMEPIRIDE 4 MG TABLET [16357]

Facility

$0.10

Service Code	NDC 55111-322-01
Hospital Charge Code	1711788
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

GLIMEPIRIDE 4 MG TABLET [16357]

Facility

$0.52

Service Code	NDC 51079-426-01
Hospital Charge Code	1711788
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.39

GLIPIZIDE 10 MG TABLET [10116]

Facility

$0.09

Service Code	NDC 60505-0142-0
Hospital Charge Code	1711377
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

GLIPIZIDE 10 MG TABLET [10116]

Facility

$0.09

Service Code	NDC 60505-0142-0
Hospital Charge Code	1711377
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

GLIPIZIDE 10 MG TABLET [10116]

Facility

$0.73

Service Code	NDC 50268-362-11
Hospital Charge Code	1711377
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.33
Rate for Payer: Cigna of CA HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.55

GLIPIZIDE 10 MG TABLET [10116]

Facility

$0.76

Service Code	NDC 51079-811-01
Hospital Charge Code	1711377
Hospital Revenue Code	259
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.46
Rate for Payer: Aetna of CA Government/Medicare	$0.46
Rate for Payer: Cash Price	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$0.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.57

GLIPIZIDE 10 MG TABLET [10116]

Facility

$0.73

Service Code	NDC 50268-362-15
Hospital Charge Code	1711377
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Cash Price	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.55

GLIPIZIDE 10 MG TABLET [10116]

Facility

$0.73

Service Code	NDC 50268-362-15
Hospital Charge Code	1711377
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.33
Rate for Payer: Cigna of CA HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.55

GLIPIZIDE 10 MG TABLET [10116]

Facility

$0.73

Service Code	NDC 50268-362-11
Hospital Charge Code	1711377
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Cash Price	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.55

GLIPIZIDE 10 MG TABLET [10116]

Facility

$0.76

Service Code	NDC 51079-811-01
Hospital Charge Code	1711377
Hospital Revenue Code	259
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.61
Rate for Payer: Cash Price	$0.34
Rate for Payer: Cigna of CA HMO/PPO	$0.61
Rate for Payer: Health Smart Auto/Commercial	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$0.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.57

GLIPIZIDE 5 MG TABLET [10117]

Facility

$0.38

Service Code	NDC 51079-810-01
Hospital Charge Code	1711376
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.29

Know your out-of-pocket cost for care.

All Charges