Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

GLIPIZIDE 5 MG TABLET [10117]

Facility

$0.06

Service Code	NDC 60505-0141-0
Hospital Charge Code	1711376
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: 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 Beech St/Commercial/PHCS	$0.05

GLIPIZIDE 5 MG TABLET [10117]

Facility

$0.06

Service Code	NDC 60505-0141-0
Hospital Charge Code	1711376
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.05

GLIPIZIDE 5 MG TABLET [10117]

Facility

$0.38

Service Code	NDC 51079-810-20
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

GLIPIZIDE 5 MG TABLET [10117]

Facility

$0.38

Service Code	NDC 51079-810-20
Hospital Charge Code	1711376
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Cash Price	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29

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

Facility

$0.30

Service Code	NDC 59651-270-01
Hospital Charge Code	1710894
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.23

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

Facility

$0.30

Service Code	NDC 59651-270-01
Hospital Charge Code	1710894
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
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	$0.14
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 Beech St/Commercial/PHCS	$0.23

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

Facility

$0.30

Service Code	NDC 64980-281-01
Hospital Charge Code	1710894
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
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	$0.14
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 Beech St/Commercial/PHCS	$0.23

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

Facility

$0.30

Service Code	NDC 64980-281-01
Hospital Charge Code	1710894
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.23

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

Facility

$0.26

Service Code	NDC 59651-268-30
Hospital Charge Code	1711811
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

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

Facility

$0.26

Service Code	NDC 59651-268-30
Hospital Charge Code	1711811
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

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

Facility

$0.26

Service Code	NDC 64980-279-03
Hospital Charge Code	1711811
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

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

Facility

$0.26

Service Code	NDC 64980-279-03
Hospital Charge Code	1711811
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

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

Facility

$0.72

Service Code	NDC 68084-111-11
Hospital Charge Code	1711632
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.54

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

Facility

$0.72

Service Code	NDC 68084-111-11
Hospital Charge Code	1711632
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.54
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	$0.32
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 Beech St/Commercial/PHCS	$0.54

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

Facility

$0.72

Service Code	NDC 68084-111-01
Hospital Charge Code	1711632
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.54

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

Facility

$0.72

Service Code	NDC 68084-111-01
Hospital Charge Code	1711632
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.54
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	$0.32
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 Beech St/Commercial/PHCS	$0.54

GLUCAGON 1 MG INJ SOLUTION. [408121354]

Facility

$265.98

Service Code	CPT J1610
Hospital Charge Code	1720502
Hospital Revenue Code	636
Min. Negotiated Rate	$146.29
Max. Negotiated Rate	$199.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$159.59
Rate for Payer: Aetna of CA Government/Medicare	$159.59
Rate for Payer: Cash Price	$119.69
Rate for Payer: Health Smart Auto/Commercial	$159.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$159.59
Rate for Payer: LLUH Dept of Risk Management WC	$146.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$199.48

GLUCAGON 1 MG INJ SOLUTION. [408121354]

Facility

$265.98

Service Code	CPT J1610
Hospital Charge Code	1720502
Hospital Revenue Code	636
Min. Negotiated Rate	$146.29
Max. Negotiated Rate	$212.78
Rate for Payer: Cash Price	$119.69
Rate for Payer: Cigna of CA HMO/PPO	$212.78
Rate for Payer: Health Smart Auto/Commercial	$159.59
Rate for Payer: LLUH Dept of Risk Management WC	$146.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$199.48

GLUCAGON 1 MG/ML SOLUTION FOR INJECTION [121354]

Facility

$205.92

Service Code	CPT J1610
Hospital Charge Code	ERX121354
Hospital Revenue Code	636
Min. Negotiated Rate	$113.26
Max. Negotiated Rate	$154.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$123.55
Rate for Payer: Aetna of CA Government/Medicare	$123.55
Rate for Payer: Cash Price	$92.66
Rate for Payer: Health Smart Auto/Commercial	$123.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$123.55
Rate for Payer: LLUH Dept of Risk Management WC	$113.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$154.44

GLUCAGON 1 MG/ML SOLUTION FOR INJECTION [121354]

Facility

$205.92

Service Code	CPT J1610
Hospital Charge Code	ERX121354
Hospital Revenue Code	636
Min. Negotiated Rate	$113.26
Max. Negotiated Rate	$164.74
Rate for Payer: Cash Price	$92.66
Rate for Payer: Cigna of CA HMO/PPO	$164.74
Rate for Payer: Health Smart Auto/Commercial	$123.55
Rate for Payer: LLUH Dept of Risk Management WC	$113.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$154.44

GLUCAGON 1 MG SOLUTION FOR INJECTION [111859]

Facility

$336.00

Service Code	CPT J1610
Hospital Revenue Code	636
Min. Negotiated Rate	$184.80
Max. Negotiated Rate	$268.80
Rate for Payer: Cash Price	$151.20
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$252.00

GLUCAGON 1 MG SOLUTION FOR INJECTION [111859]

Facility

$336.00

Service Code	CPT J1610
Hospital Revenue Code	636
Min. Negotiated Rate	$184.80
Max. Negotiated Rate	$252.00
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	$151.20
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 Beech St/Commercial/PHCS	$252.00

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

Facility

$265.98

Service Code	CPT J1611
Hospital Charge Code	ERX209701
Hospital Revenue Code	636
Min. Negotiated Rate	$146.29
Max. Negotiated Rate	$199.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$159.59
Rate for Payer: Aetna of CA Government/Medicare	$159.59
Rate for Payer: Cash Price	$119.69
Rate for Payer: Health Smart Auto/Commercial	$159.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$159.59
Rate for Payer: LLUH Dept of Risk Management WC	$146.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$199.48

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

Facility

$265.98

Service Code	CPT J1611
Hospital Charge Code	ERX209701
Hospital Revenue Code	636
Min. Negotiated Rate	$146.29
Max. Negotiated Rate	$212.78
Rate for Payer: Cash Price	$119.69
Rate for Payer: Cigna of CA HMO/PPO	$212.78
Rate for Payer: Health Smart Auto/Commercial	$159.59
Rate for Payer: LLUH Dept of Risk Management WC	$146.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$199.48

Know your out-of-pocket cost for care.

All Charges