Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [14953]

Facility

$2.29

Service Code	NDC 68462-421-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.37
Rate for Payer: Aetna of CA Government/Medicare	$1.37
Rate for Payer: Cash Price	$1.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.83
Rate for Payer: Health Smart Auto/Commercial	$1.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.37
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Commercial	$1.72

ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [14953]

Facility

$2.29

Service Code	NDC 0121-0956-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.37
Rate for Payer: Aetna of CA Government/Medicare	$1.37
Rate for Payer: Cash Price	$1.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.83
Rate for Payer: Health Smart Auto/Commercial	$1.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.37
Rate for Payer: LLUH Dept of Risk Management WC	$1.26
Rate for Payer: Multiplan Commercial	$1.72

ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION [9168]

Facility

$1.92

Service Code	NDC 25021-659-05
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Cash Price	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Commercial	$1.44

ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION [9168]

Facility

$1.92

Service Code	NDC 25021-659-05
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.15
Rate for Payer: Aetna of CA Government/Medicare	$1.15
Rate for Payer: Cash Price	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.54
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: Multiplan Commercial	$1.44

ATROPINE 0.1 MG/ML INJECTION SYRINGE [730]

Facility

$1.22

Service Code	HCPCS J0461
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.98
Rate for Payer: Cash Price	$0.67
Rate for Payer: Cash Price	$0.66
Rate for Payer: Cash Price	$0.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Commercial	$0.92
Rate for Payer: Multiplan Commercial	$0.90
Rate for Payer: Multiplan Commercial	$1.03

ATROPINE 0.1 MG/ML INJECTION SYRINGE [730]

Facility

$1.22

Service Code	HCPCS J0461
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.73
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.82
Rate for Payer: Aetna of CA Government/Medicare	$0.73
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$0.82
Rate for Payer: Cash Price	$0.76
Rate for Payer: Cash Price	$0.66
Rate for Payer: Cash Price	$0.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.10
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Commercial	$0.90
Rate for Payer: Multiplan Commercial	$0.92
Rate for Payer: Multiplan Commercial	$1.03

ATROPINE 0.4 MG/ML INJECTION SOLUTION [731]

Facility

$4.58

Service Code	HCPCS J0461
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$3.66
Rate for Payer: Cash Price	$2.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.66
Rate for Payer: Health Smart Auto/Commercial	$2.75
Rate for Payer: LLUH Dept of Risk Management WC	$2.52
Rate for Payer: Multiplan Commercial	$3.44

ATROPINE 0.4 MG/ML INJECTION SOLUTION [731]

Facility

$4.58

Service Code	HCPCS J0461
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$3.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.75
Rate for Payer: Aetna of CA Government/Medicare	$2.75
Rate for Payer: Cash Price	$2.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.66
Rate for Payer: Health Smart Auto/Commercial	$2.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.75
Rate for Payer: LLUH Dept of Risk Management WC	$2.52
Rate for Payer: Multiplan Commercial	$3.44

ATROPINE 0.4 MG/ML INTRAVENOUS SOLUTION [230343]

Facility

$2.11

Service Code	HCPCS J0461
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.69
Rate for Payer: Cash Price	$1.16
Rate for Payer: Cash Price	$7.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.69
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: Health Smart Auto/Commercial	$8.09
Rate for Payer: LLUH Dept of Risk Management WC	$7.41
Rate for Payer: LLUH Dept of Risk Management WC	$1.16
Rate for Payer: Multiplan Commercial	$10.11
Rate for Payer: Multiplan Commercial	$1.58

ATROPINE 0.4 MG/ML INTRAVENOUS SOLUTION [230343]

Facility

$13.48

Service Code	HCPCS J0461
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.41
Max. Negotiated Rate	$10.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.27
Rate for Payer: Aetna of CA Government/Medicare	$1.27
Rate for Payer: Aetna of CA Government/Medicare	$8.09
Rate for Payer: Cash Price	$1.16
Rate for Payer: Cash Price	$7.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.69
Rate for Payer: Health Smart Auto/Commercial	$8.09
Rate for Payer: Health Smart Auto/Commercial	$1.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.27
Rate for Payer: LLUH Dept of Risk Management WC	$7.41
Rate for Payer: LLUH Dept of Risk Management WC	$1.16
Rate for Payer: Multiplan Commercial	$1.58
Rate for Payer: Multiplan Commercial	$10.11

ATROPINE 0.5 MG/5 ML OR 0.1 MG/1 ML SYRINGE - CODE [4080579]

Facility

$4.68

Service Code	HCPCS J0461
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$3.74
Rate for Payer: Cash Price	$2.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.74
Rate for Payer: Health Smart Auto/Commercial	$2.81
Rate for Payer: LLUH Dept of Risk Management WC	$2.57
Rate for Payer: Multiplan Commercial	$3.51

ATROPINE 0.5 MG/5 ML OR 0.1 MG/1 ML SYRINGE - CODE [4080579]

Facility

$4.68

Service Code	HCPCS J0461
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$3.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.81
Rate for Payer: Aetna of CA Government/Medicare	$2.81
Rate for Payer: Cash Price	$2.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.74
Rate for Payer: Health Smart Auto/Commercial	$2.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.81
Rate for Payer: LLUH Dept of Risk Management WC	$2.57
Rate for Payer: Multiplan Commercial	$3.51

ATROPINE 1 % EYE DROPS < 2 ML (PROCEDURAL) [408736]

Facility

$14.51

Service Code	NDC 0065-0817-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$11.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.71
Rate for Payer: Aetna of CA Government/Medicare	$8.71
Rate for Payer: Cash Price	$7.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.61
Rate for Payer: Health Smart Auto/Commercial	$8.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.71
Rate for Payer: LLUH Dept of Risk Management WC	$7.98
Rate for Payer: Multiplan Commercial	$10.88

ATROPINE 1 % EYE DROPS < 2 ML (PROCEDURAL) [408736]

Facility

$14.51

Service Code	NDC 0065-0817-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$11.61
Rate for Payer: Cash Price	$7.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.61
Rate for Payer: Health Smart Auto/Commercial	$8.71
Rate for Payer: LLUH Dept of Risk Management WC	$7.98
Rate for Payer: Multiplan Commercial	$10.88

ATROPINE 1 % EYE DROPS [736]

Facility

$21.82

Service Code	NDC 60505-6226-0
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$17.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.09
Rate for Payer: Aetna of CA Government/Medicare	$13.09
Rate for Payer: Cash Price	$12.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.46
Rate for Payer: Health Smart Auto/Commercial	$13.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.09
Rate for Payer: LLUH Dept of Risk Management WC	$12.00
Rate for Payer: Multiplan Commercial	$16.36

ATROPINE 1 % EYE DROPS [736]

Facility

$21.82

Service Code	NDC 60505-6226-0
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$12.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.46
Rate for Payer: Health Smart Auto/Commercial	$13.09
Rate for Payer: LLUH Dept of Risk Management WC	$12.00
Rate for Payer: Multiplan Commercial	$16.36

AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION [216945]

Facility

$251.28

Service Code	HCPCS J9023
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$138.20
Max. Negotiated Rate	$201.02
Rate for Payer: Cash Price	$138.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$201.02
Rate for Payer: Health Smart Auto/Commercial	$150.77
Rate for Payer: LLUH Dept of Risk Management WC	$138.20
Rate for Payer: Multiplan Commercial	$188.46

AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION [216945]

Facility

$251.28

Service Code	HCPCS J9023
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$138.20
Max. Negotiated Rate	$201.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$150.77
Rate for Payer: Aetna of CA Government/Medicare	$150.77
Rate for Payer: Cash Price	$138.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$201.02
Rate for Payer: Health Smart Auto/Commercial	$150.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$150.77
Rate for Payer: LLUH Dept of Risk Management WC	$138.20
Rate for Payer: Multiplan Commercial	$188.46

AZACITIDINE 100 MG (10 MG/ML) INTRAVENOUS INJECTION [40878420]

Facility

$702.29

Service Code	HCPCS J9025
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$386.26
Max. Negotiated Rate	$561.83
Rate for Payer: Cash Price	$386.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$561.83
Rate for Payer: Health Smart Auto/Commercial	$421.37
Rate for Payer: LLUH Dept of Risk Management WC	$386.26
Rate for Payer: Multiplan Commercial	$526.72

AZACITIDINE 100 MG (10 MG/ML) INTRAVENOUS INJECTION [40878420]

Facility

$702.29

Service Code	HCPCS J9025
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$386.26
Max. Negotiated Rate	$561.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$421.37
Rate for Payer: Aetna of CA Government/Medicare	$421.37
Rate for Payer: Cash Price	$386.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$561.83
Rate for Payer: Health Smart Auto/Commercial	$421.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$421.37
Rate for Payer: LLUH Dept of Risk Management WC	$386.26
Rate for Payer: Multiplan Commercial	$526.72

AZACITIDINE 100 MG (25 MG/ML) SUBCUTANEOUS INJECTION [408000276]

Facility

$210.00

Service Code	HCPCS J9025
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$168.00
Rate for Payer: Cash Price	$115.50
Rate for Payer: Cash Price	$29.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$168.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.20
Rate for Payer: Health Smart Auto/Commercial	$126.00
Rate for Payer: Health Smart Auto/Commercial	$32.40
Rate for Payer: LLUH Dept of Risk Management WC	$29.70
Rate for Payer: LLUH Dept of Risk Management WC	$115.50
Rate for Payer: Multiplan Commercial	$157.50
Rate for Payer: Multiplan Commercial	$40.50

AZACITIDINE 100 MG (25 MG/ML) SUBCUTANEOUS INJECTION [408000276]

Facility

$54.00

Service Code	HCPCS J9025
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$32.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$126.00
Rate for Payer: Aetna of CA Government/Medicare	$32.40
Rate for Payer: Aetna of CA Government/Medicare	$126.00
Rate for Payer: Cash Price	$115.50
Rate for Payer: Cash Price	$29.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$168.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.20
Rate for Payer: Health Smart Auto/Commercial	$32.40
Rate for Payer: Health Smart Auto/Commercial	$126.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$32.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$126.00
Rate for Payer: LLUH Dept of Risk Management WC	$115.50
Rate for Payer: LLUH Dept of Risk Management WC	$29.70
Rate for Payer: Multiplan Commercial	$157.50
Rate for Payer: Multiplan Commercial	$40.50

AZACITIDINE 100 MG INJECTION [78420]

Facility

$210.00

Service Code	HCPCS J9025
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$168.00
Rate for Payer: Cash Price	$115.50
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$29.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$168.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$192.00
Rate for Payer: Health Smart Auto/Commercial	$126.00
Rate for Payer: Health Smart Auto/Commercial	$144.00
Rate for Payer: Health Smart Auto/Commercial	$32.40
Rate for Payer: LLUH Dept of Risk Management WC	$115.50
Rate for Payer: LLUH Dept of Risk Management WC	$132.00
Rate for Payer: LLUH Dept of Risk Management WC	$29.70
Rate for Payer: Multiplan Commercial	$157.50
Rate for Payer: Multiplan Commercial	$40.50
Rate for Payer: Multiplan Commercial	$180.00

AZACITIDINE 100 MG INJECTION [78420]

Facility

$240.00

Service Code	HCPCS J9025
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$132.00
Max. Negotiated Rate	$192.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$144.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$126.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$32.40
Rate for Payer: Aetna of CA Government/Medicare	$126.00
Rate for Payer: Aetna of CA Government/Medicare	$32.40
Rate for Payer: Aetna of CA Government/Medicare	$144.00
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cash Price	$115.50
Rate for Payer: Cash Price	$132.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$168.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$192.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.20
Rate for Payer: Health Smart Auto/Commercial	$32.40
Rate for Payer: Health Smart Auto/Commercial	$144.00
Rate for Payer: Health Smart Auto/Commercial	$126.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$32.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$126.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$144.00
Rate for Payer: LLUH Dept of Risk Management WC	$132.00
Rate for Payer: LLUH Dept of Risk Management WC	$115.50
Rate for Payer: LLUH Dept of Risk Management WC	$29.70
Rate for Payer: Multiplan Commercial	$157.50
Rate for Payer: Multiplan Commercial	$40.50
Rate for Payer: Multiplan Commercial	$180.00

AZATHIOPRINE 25 MG 1/2 TAB [4081407]

Facility

$0.81

Service Code	HCPCS J7500
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.61
Rate for Payer: Multiplan Commercial	$0.31

Know your out-of-pocket cost for care.

All Charges