Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

AZATHIOPRINE 25 MG 1/2 TAB [4081407]

Facility

$0.81

Service Code	CPT J7500
Hospital Charge Code	ERX4081407
Hospital Revenue Code	636
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cash Price	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50

AZATHIOPRINE 25 MG 1/2 TAB [4081407]

Facility

$0.81

Service Code	CPT J7500
Hospital Charge Code	NDC4081407
Hospital Revenue Code	636
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.49
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: Multiplan Beech St/Commercial/PHCS	$0.61

AZATHIOPRINE 50 MG TABLET [9183]

Facility

$0.66

Service Code	CPT J7500
Hospital Charge Code	1710262
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
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	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
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	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50

AZATHIOPRINE 50 MG TABLET [9183]

Facility

$0.66

Service Code	CPT J7500
Hospital Charge Code	1710262
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.53
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA HMO/PPO	$0.33
Rate for Payer: Cigna of CA HMO/PPO	$0.65
Rate for Payer: Cigna of CA HMO/PPO	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.31

AZATHIOPRINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080245]

Facility

$0.81

Service Code	CPT J7500
Hospital Charge Code	NDG4080245
Hospital Revenue Code	636
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.49
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: Multiplan Beech St/Commercial/PHCS	$0.61

AZATHIOPRINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080245]

Facility

$0.81

Service Code	CPT J7500
Hospital Charge Code	NDG4080245
Hospital Revenue Code	636
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.61

AZELASTINE 0.05 % EYE DROPS [28351]

Facility

$7.00

Service Code	NDC 61314-308-02
Hospital Charge Code	1740346
Hospital Revenue Code	259
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$5.60
Rate for Payer: Cash Price	$3.15
Rate for Payer: Cigna of CA HMO/PPO	$5.60
Rate for Payer: Health Smart Auto/Commercial	$4.20
Rate for Payer: LLUH Dept of Risk Management WC	$3.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.25

AZELASTINE 0.05 % EYE DROPS [28351]

Facility

$7.00

Service Code	NDC 61314-308-02
Hospital Charge Code	1740346
Hospital Revenue Code	259
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$5.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.20
Rate for Payer: Aetna of CA Government/Medicare	$4.20
Rate for Payer: Cash Price	$3.15
Rate for Payer: Health Smart Auto/Commercial	$4.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.20
Rate for Payer: LLUH Dept of Risk Management WC	$3.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.25

AZELASTINE 137 MCG (0.1 %) NASAL SPRAY AEROSOL [19179]

Facility

$0.87

Service Code	NDC 60505-0833-5
Hospital Charge Code	1744085
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna of CA HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

AZELASTINE 137 MCG (0.1 %) NASAL SPRAY AEROSOL [19179]

Facility

$0.87

Service Code	NDC 47335-779-91
Hospital Charge Code	1744085
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna of CA HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

AZELASTINE 137 MCG (0.1 %) NASAL SPRAY AEROSOL [19179]

Facility

$0.87

Service Code	NDC 47335-779-91
Hospital Charge Code	1744085
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

AZELASTINE 137 MCG (0.1 %) NASAL SPRAY AEROSOL [19179]

Facility

$0.87

Service Code	NDC 60505-0833-5
Hospital Charge Code	1744085
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

AZELASTINE 137 MCG (0.1 %) NASAL SPRAY AEROSOL [19179]

Facility

$0.72

Service Code	NDC 59651-214-30
Hospital Charge Code	1744085
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

AZELASTINE 137 MCG (0.1 %) NASAL SPRAY AEROSOL [19179]

Facility

$0.72

Service Code	NDC 59651-214-30
Hospital Charge Code	1744085
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

AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]

Facility

$1.05

Service Code	NDC 0093-2026-31
Hospital Charge Code	NDG15797A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.84
Rate for Payer: Cash Price	$0.47
Rate for Payer: Cigna of CA HMO/PPO	$0.84
Rate for Payer: Health Smart Auto/Commercial	$0.63
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.79

AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]

Facility

$1.06

Service Code	NDC 0069-3140-19
Hospital Charge Code	NDG15797A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.85
Rate for Payer: Cash Price	$0.48
Rate for Payer: Cigna of CA HMO/PPO	$0.85
Rate for Payer: Health Smart Auto/Commercial	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.80

AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]

Facility

$1.05

Service Code	NDC 0093-2026-31
Hospital Charge Code	NDG15797A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.63
Rate for Payer: Aetna of CA Government/Medicare	$0.63
Rate for Payer: Cash Price	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.63
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.79

AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]

Facility

$1.06

Service Code	NDC 0069-3140-19
Hospital Charge Code	NDG15797A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.64
Rate for Payer: Aetna of CA Government/Medicare	$0.64
Rate for Payer: Cash Price	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.80

AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]

Facility

$0.60

Service Code	NDC 42806-151-34
Hospital Charge Code	NDG15797A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.45

AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]

Facility

$0.60

Service Code	NDC 42806-151-34
Hospital Charge Code	NDG15797A
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of CA HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.45

AZITHROMYCIN 250 MG TABLET [20943]

Facility

$2.60

Service Code	NDC 0781-8089-26
Hospital Charge Code	1711545
Hospital Revenue Code	259
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.56
Rate for Payer: Aetna of CA Government/Medicare	$1.56
Rate for Payer: Cash Price	$1.17
Rate for Payer: Health Smart Auto/Commercial	$1.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.56
Rate for Payer: LLUH Dept of Risk Management WC	$1.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.95

AZITHROMYCIN 250 MG TABLET [20943]

Facility

$2.53

Service Code	NDC 51224-022-30
Hospital Charge Code	1711545
Hospital Revenue Code	259
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$1.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.52
Rate for Payer: Aetna of CA Government/Medicare	$1.52
Rate for Payer: Cash Price	$1.14
Rate for Payer: Health Smart Auto/Commercial	$1.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.52
Rate for Payer: LLUH Dept of Risk Management WC	$1.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.90

AZITHROMYCIN 250 MG TABLET [20943]

Facility

$2.55

Service Code	NDC 50111-787-10
Hospital Charge Code	1711545
Hospital Revenue Code	259
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$2.04
Rate for Payer: Cash Price	$1.15
Rate for Payer: Cigna of CA HMO/PPO	$2.04
Rate for Payer: Health Smart Auto/Commercial	$1.53
Rate for Payer: LLUH Dept of Risk Management WC	$1.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.91

AZITHROMYCIN 250 MG TABLET [20943]

Facility

$1.87

Service Code	NDC 60687-282-65
Hospital Charge Code	1711545
Hospital Revenue Code	259
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.12
Rate for Payer: Aetna of CA Government/Medicare	$1.12
Rate for Payer: Cash Price	$0.84
Rate for Payer: Health Smart Auto/Commercial	$1.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.12
Rate for Payer: LLUH Dept of Risk Management WC	$1.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.40

AZITHROMYCIN 250 MG TABLET [20943]

Facility

$3.00

Service Code	NDC 50111-787-51
Hospital Charge Code	1711545
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.80
Rate for Payer: Aetna of CA Government/Medicare	$1.80
Rate for Payer: Cash Price	$1.35
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.25

Know your out-of-pocket cost for care.

All Charges