Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

AZITHROMYCIN 250 MG TABLET [20943]

Facility

$1.06

Service Code	NDC 65862-641-30
Hospital Charge Code	1711545
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 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	$2.08
Rate for Payer: Cash Price	$1.17
Rate for Payer: Cigna of CA HMO/PPO	$2.08
Rate for Payer: Health Smart Auto/Commercial	$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

$3.00

Service Code	NDC 50111-787-51
Hospital Charge Code	1711545
Hospital Revenue Code	259
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.40
Rate for Payer: Cash Price	$1.35
Rate for Payer: Cigna of CA HMO/PPO	$2.40
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.25

AZITHROMYCIN 250 MG TABLET [20943]

Facility

$2.08

Service Code	NDC 60687-282-11
Hospital Charge Code	1711545
Hospital Revenue Code	259
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$1.66
Rate for Payer: Cash Price	$0.94
Rate for Payer: Cigna of CA HMO/PPO	$1.66
Rate for Payer: Health Smart Auto/Commercial	$1.25
Rate for Payer: LLUH Dept of Risk Management WC	$1.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.56

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	$1.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.53
Rate for Payer: Aetna of CA Government/Medicare	$1.53
Rate for Payer: Cash Price	$1.15
Rate for Payer: Health Smart Auto/Commercial	$1.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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

$1.06

Service Code	NDC 65862-641-30
Hospital Charge Code	1711545
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 250 MG TABLET [20943]

Facility

$2.08

Service Code	NDC 60687-282-11
Hospital Charge Code	1711545
Hospital Revenue Code	259
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$1.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.25
Rate for Payer: Aetna of CA Government/Medicare	$1.25
Rate for Payer: Cash Price	$0.94
Rate for Payer: Health Smart Auto/Commercial	$1.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.25
Rate for Payer: LLUH Dept of Risk Management WC	$1.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.56

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

$2.53

Service Code	NDC 51224-022-30
Hospital Charge Code	1711545
Hospital Revenue Code	259
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$2.02
Rate for Payer: Cash Price	$1.14
Rate for Payer: Cigna of CA HMO/PPO	$2.02
Rate for Payer: Health Smart Auto/Commercial	$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

$2.53

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

$1.87

Service Code	NDC 60687-282-65
Hospital Charge Code	1711545
Hospital Revenue Code	259
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.50
Rate for Payer: Cash Price	$0.84
Rate for Payer: Cigna of CA HMO/PPO	$1.50
Rate for Payer: Health Smart Auto/Commercial	$1.12
Rate for Payer: LLUH Dept of Risk Management WC	$1.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.40

AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]

Facility

$5.64

Service Code	CPT J0456
Hospital Charge Code	1753436
Hospital Revenue Code	636
Min. Negotiated Rate	$3.10
Max. Negotiated Rate	$4.51
Rate for Payer: Cash Price	$2.54
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cash Price	$3.35
Rate for Payer: Cigna of CA HMO/PPO	$4.51
Rate for Payer: Cigna of CA HMO/PPO	$4.80
Rate for Payer: Cigna of CA HMO/PPO	$5.95
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Health Smart Auto/Commercial	$4.46
Rate for Payer: Health Smart Auto/Commercial	$3.38
Rate for Payer: LLUH Dept of Risk Management WC	$3.10
Rate for Payer: LLUH Dept of Risk Management WC	$4.09
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.23

AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]

Facility

$6.00

Service Code	CPT J0456
Hospital Charge Code	1753436
Hospital Revenue Code	636
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.38
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.38
Rate for Payer: Aetna of CA Government/Medicare	$4.46
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cash Price	$3.35
Rate for Payer: Cash Price	$2.54
Rate for Payer: Health Smart Auto/Commercial	$3.38
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Health Smart Auto/Commercial	$4.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.46
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: LLUH Dept of Risk Management WC	$3.10
Rate for Payer: LLUH Dept of Risk Management WC	$4.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

AZITHROMYCIN 500 MG TABLET [17482]

Facility

$4.40

Service Code	NDC 60687-271-21
Hospital Charge Code	1710984
Hospital Revenue Code	259
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$3.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.64
Rate for Payer: Aetna of CA Government/Medicare	$2.64
Rate for Payer: Cash Price	$1.98
Rate for Payer: Health Smart Auto/Commercial	$2.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$2.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.30

AZITHROMYCIN 500 MG TABLET [17482]

Facility

$5.73

Service Code	NDC 51224-122-30
Hospital Charge Code	1710984
Hospital Revenue Code	259
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$4.58
Rate for Payer: Cash Price	$2.58
Rate for Payer: Cigna of CA HMO/PPO	$4.58
Rate for Payer: Health Smart Auto/Commercial	$3.44
Rate for Payer: LLUH Dept of Risk Management WC	$3.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.30

AZITHROMYCIN 500 MG TABLET [17482]

Facility

$4.40

Service Code	NDC 60687-271-11
Hospital Charge Code	1710984
Hospital Revenue Code	259
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$3.52
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cigna of CA HMO/PPO	$3.52
Rate for Payer: Health Smart Auto/Commercial	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$2.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.30

AZITHROMYCIN 500 MG TABLET [17482]

Facility

$4.40

Service Code	NDC 60687-271-11
Hospital Charge Code	1710984
Hospital Revenue Code	259
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$3.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.64
Rate for Payer: Aetna of CA Government/Medicare	$2.64
Rate for Payer: Cash Price	$1.98
Rate for Payer: Health Smart Auto/Commercial	$2.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$2.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.30

AZITHROMYCIN 500 MG TABLET [17482]

Facility

$5.73

Service Code	NDC 51224-122-30
Hospital Charge Code	1710984
Hospital Revenue Code	259
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$4.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.44
Rate for Payer: Aetna of CA Government/Medicare	$3.44
Rate for Payer: Cash Price	$2.58
Rate for Payer: Health Smart Auto/Commercial	$3.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.44
Rate for Payer: LLUH Dept of Risk Management WC	$3.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.30

AZITHROMYCIN 500 MG TABLET [17482]

Facility

$4.40

Service Code	NDC 60687-271-21
Hospital Charge Code	1710984
Hospital Revenue Code	259
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$3.52
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cigna of CA HMO/PPO	$3.52
Rate for Payer: Health Smart Auto/Commercial	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$2.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.30

AZITHROMYCIN 600 MG TABLET [17387]

Facility

$5.53

Service Code	NDC 51224-222-30
Hospital Charge Code	1710985
Hospital Revenue Code	259
Min. Negotiated Rate	$3.04
Max. Negotiated Rate	$4.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.32
Rate for Payer: Aetna of CA Government/Medicare	$3.32
Rate for Payer: Cash Price	$2.49
Rate for Payer: Health Smart Auto/Commercial	$3.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.32
Rate for Payer: LLUH Dept of Risk Management WC	$3.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.15

AZITHROMYCIN 600 MG TABLET [17387]

Facility

$6.37

Service Code	NDC 60687-314-25
Hospital Charge Code	1710985
Hospital Revenue Code	259
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$4.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.82
Rate for Payer: Aetna of CA Government/Medicare	$3.82
Rate for Payer: Cash Price	$2.87
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.78

AZITHROMYCIN 600 MG TABLET [17387]

Facility

$6.37

Service Code	NDC 60687-314-95
Hospital Charge Code	1710985
Hospital Revenue Code	259
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.10
Rate for Payer: Cash Price	$2.87
Rate for Payer: Cigna of CA HMO/PPO	$5.10
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.78

AZITHROMYCIN 600 MG TABLET [17387]

Facility

$6.37

Service Code	NDC 60687-314-25
Hospital Charge Code	1710985
Hospital Revenue Code	259
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.10
Rate for Payer: Cash Price	$2.87
Rate for Payer: Cigna of CA HMO/PPO	$5.10
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.78

AZITHROMYCIN 600 MG TABLET [17387]

Facility

$6.37

Service Code	NDC 60687-314-95
Hospital Charge Code	1710985
Hospital Revenue Code	259
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$4.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.82
Rate for Payer: Aetna of CA Government/Medicare	$3.82
Rate for Payer: Cash Price	$2.87
Rate for Payer: Health Smart Auto/Commercial	$3.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.78

AZITHROMYCIN 600 MG TABLET [17387]

Facility

$5.53

Service Code	NDC 51224-222-30
Hospital Charge Code	1710985
Hospital Revenue Code	259
Min. Negotiated Rate	$3.04
Max. Negotiated Rate	$4.42
Rate for Payer: Cash Price	$2.49
Rate for Payer: Cigna of CA HMO/PPO	$4.42
Rate for Payer: Health Smart Auto/Commercial	$3.32
Rate for Payer: LLUH Dept of Risk Management WC	$3.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.15

Know your out-of-pocket cost for care.

All Charges