Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

OFLOXACIN 0.3 % EAR DROPS [22257]

Facility

$3.60

Service Code	NDC 70756-609-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70

OFLOXACIN 0.3 % EYE DROPS [19746]

Facility

$2.44

Service Code	NDC 72485-613-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.46
Rate for Payer: Aetna of CA Government/Medicare	$1.46
Rate for Payer: Cash Price	$1.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.95
Rate for Payer: Health Smart Auto/Commercial	$1.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.46
Rate for Payer: LLUH Dept of Risk Management WC	$1.34
Rate for Payer: Multiplan Commercial	$1.83

OFLOXACIN 0.3 % EYE DROPS [19746]

Facility

$3.60

Service Code	NDC 70756-607-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70

OFLOXACIN 0.3 % EYE DROPS [19746]

Facility

$2.44

Service Code	NDC 72485-613-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$1.95
Rate for Payer: Cash Price	$1.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.95
Rate for Payer: Health Smart Auto/Commercial	$1.46
Rate for Payer: LLUH Dept of Risk Management WC	$1.34
Rate for Payer: Multiplan Commercial	$1.83

OFLOXACIN 0.3 % EYE DROPS [19746]

Facility

$29.77

Service Code	NDC 11980-779-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$16.37
Max. Negotiated Rate	$23.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.86
Rate for Payer: Aetna of CA Government/Medicare	$17.86
Rate for Payer: Cash Price	$16.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.82
Rate for Payer: Health Smart Auto/Commercial	$17.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.86
Rate for Payer: LLUH Dept of Risk Management WC	$16.37
Rate for Payer: Multiplan Commercial	$22.33

OFLOXACIN 0.3 % EYE DROPS [19746]

Facility

$3.60

Service Code	NDC 70756-607-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70

OFLOXACIN 0.3 % EYE DROPS [19746]

Facility

$29.77

Service Code	NDC 11980-779-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$16.37
Max. Negotiated Rate	$23.82
Rate for Payer: Cash Price	$16.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.82
Rate for Payer: Health Smart Auto/Commercial	$17.86
Rate for Payer: LLUH Dept of Risk Management WC	$16.37
Rate for Payer: Multiplan Commercial	$22.33

OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]

Facility

$3.15

Service Code	NDC 60505-3276-0
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$2.52
Rate for Payer: Cash Price	$1.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.52
Rate for Payer: Health Smart Auto/Commercial	$1.89
Rate for Payer: LLUH Dept of Risk Management WC	$1.73
Rate for Payer: Multiplan Commercial	$2.36

OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]

Facility

$1.51

Service Code	NDC 60505-3276-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.91
Rate for Payer: Aetna of CA Government/Medicare	$0.91
Rate for Payer: Cash Price	$0.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.21
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$1.13

OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]

Facility

$3.15

Service Code	NDC 60505-3276-0
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$2.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.89
Rate for Payer: Aetna of CA Government/Medicare	$1.89
Rate for Payer: Cash Price	$1.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.52
Rate for Payer: Health Smart Auto/Commercial	$1.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.89
Rate for Payer: LLUH Dept of Risk Management WC	$1.73
Rate for Payer: Multiplan Commercial	$2.36

OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]

Facility

$1.51

Service Code	NDC 60505-3276-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.21
Rate for Payer: Cash Price	$0.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.21
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$1.13

OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]

Facility

$24.00

Service Code	HCPCS J2359
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
Rate for Payer: Cash Price	$13.20
Rate for Payer: Cash Price	$18.53
Rate for Payer: Cash Price	$26.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$37.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.94
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: Health Smart Auto/Commercial	$20.21
Rate for Payer: Health Smart Auto/Commercial	$28.43
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$18.52
Rate for Payer: LLUH Dept of Risk Management WC	$26.06
Rate for Payer: Multiplan Commercial	$18.00
Rate for Payer: Multiplan Commercial	$35.54
Rate for Payer: Multiplan Commercial	$25.26

OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]

Facility

$33.68

Service Code	HCPCS J2359
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$18.52
Max. Negotiated Rate	$26.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.43
Rate for Payer: Aetna of CA Government/Medicare	$14.40
Rate for Payer: Aetna of CA Government/Medicare	$28.43
Rate for Payer: Aetna of CA Government/Medicare	$20.21
Rate for Payer: Cash Price	$26.06
Rate for Payer: Cash Price	$13.20
Rate for Payer: Cash Price	$18.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$37.91
Rate for Payer: Health Smart Auto/Commercial	$28.43
Rate for Payer: Health Smart Auto/Commercial	$20.21
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.21
Rate for Payer: LLUH Dept of Risk Management WC	$18.52
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$26.06
Rate for Payer: Multiplan Commercial	$18.00
Rate for Payer: Multiplan Commercial	$35.54
Rate for Payer: Multiplan Commercial	$25.26

OLANZAPINE 10 MG TABLET [17937]

Facility

$0.42

Service Code	NDC 60505-3113-0
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
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: Multiplan Commercial	$0.32

OLANZAPINE 10 MG TABLET [17937]

Facility

$0.29

Service Code	NDC 43598-166-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

OLANZAPINE 10 MG TABLET [17937]

Facility

$0.29

Service Code	NDC 43598-166-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.22

OLANZAPINE 10 MG TABLET [17937]

Facility

$0.42

Service Code	NDC 60505-3113-0
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.32

OLANZAPINE 10 MG TABLET [17937]

Facility

$0.58

Service Code	NDC 0904-6376-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

OLANZAPINE 10 MG TABLET [17937]

Facility

$0.58

Service Code	NDC 0904-6376-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$0.17

Service Code	NDC 55111-163-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.13

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$0.23

Service Code	NDC 60505-3110-0
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.17

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$0.53

Service Code	NDC 68084-525-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.40

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$0.23

Service Code	NDC 60505-3110-0
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.17

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$0.53

Service Code	NDC 68084-525-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.40

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$0.53

Service Code	NDC 68084-525-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.40

Know your out-of-pocket cost for care.

All Charges