Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]

Facility

$1.51

Service Code	NDC 60505-3276-3
Hospital Charge Code	1712250
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.21
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.13

OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]

Facility

$1.51

Service Code	NDC 60505-3276-3
Hospital Charge Code	1712250
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.13
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	$0.68
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 Beech St/Commercial/PHCS	$1.13

OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]

Facility

$1.51

Service Code	NDC 49884-321-52
Hospital Charge Code	1712250
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.13
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	$0.68
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 Beech St/Commercial/PHCS	$1.13

OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]

Facility

$3.15

Service Code	NDC 60505-3276-0
Hospital Charge Code	1712250
Hospital Revenue Code	259
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$2.36
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	$1.42
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 Beech St/Commercial/PHCS	$2.36

OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]

Facility

$1.51

Service Code	NDC 49884-321-52
Hospital Charge Code	1712250
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.21
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.13

OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]

Facility

$1.51

Service Code	NDC 59746-307-32
Hospital Charge Code	1712250
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.13
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	$0.68
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 Beech St/Commercial/PHCS	$1.13

OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]

Facility

$1.51

Service Code	NDC 59746-307-32
Hospital Charge Code	1712250
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.21
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.13

OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]

Facility

$1.51

Service Code	NDC 59746-307-12
Hospital Charge Code	1712250
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.21
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.13

OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]

Facility

$1.51

Service Code	NDC 49884-321-55
Hospital Charge Code	1712250
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.21
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.13

OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]

Facility

$45.22

Service Code	CPT J2359
Hospital Charge Code	1720945
Hospital Revenue Code	636
Min. Negotiated Rate	$24.87
Max. Negotiated Rate	$33.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.73
Rate for Payer: Aetna of CA Government/Medicare	$27.13
Rate for Payer: Aetna of CA Government/Medicare	$16.73
Rate for Payer: Cash Price	$12.55
Rate for Payer: Cash Price	$20.35
Rate for Payer: Health Smart Auto/Commercial	$16.73
Rate for Payer: Health Smart Auto/Commercial	$27.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.73
Rate for Payer: LLUH Dept of Risk Management WC	$24.87
Rate for Payer: LLUH Dept of Risk Management WC	$15.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.92

OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]

Facility

$45.22

Service Code	CPT J2359
Hospital Charge Code	1720945
Hospital Revenue Code	636
Min. Negotiated Rate	$24.87
Max. Negotiated Rate	$36.18
Rate for Payer: Cash Price	$20.35
Rate for Payer: Cash Price	$12.55
Rate for Payer: Cigna of CA HMO/PPO	$36.18
Rate for Payer: Cigna of CA HMO/PPO	$22.31
Rate for Payer: Health Smart Auto/Commercial	$27.13
Rate for Payer: Health Smart Auto/Commercial	$16.73
Rate for Payer: LLUH Dept of Risk Management WC	$24.87
Rate for Payer: LLUH Dept of Risk Management WC	$15.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.92

OLANZAPINE 10 MG TABLET [17937]

Facility

$0.42

Service Code	NDC 60505-3113-0
Hospital Charge Code	1713143
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.32
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	$0.19
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 Beech St/Commercial/PHCS	$0.32

OLANZAPINE 10 MG TABLET [17937]

Facility

$0.58

Service Code	NDC 0904-6376-61
Hospital Charge Code	1713143
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.44

OLANZAPINE 10 MG TABLET [17937]

Facility

$0.42

Service Code	NDC 43598-166-30
Hospital Charge Code	1713143
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.32

OLANZAPINE 10 MG TABLET [17937]

Facility

$0.28

Service Code	NDC 69543-383-90
Hospital Charge Code	1713143
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.21
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	$0.13
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	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.21

OLANZAPINE 10 MG TABLET [17937]

Facility

$0.42

Service Code	NDC 43598-166-30
Hospital Charge Code	1713143
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.32
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	$0.19
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 Beech St/Commercial/PHCS	$0.32

OLANZAPINE 10 MG TABLET [17937]

Facility

$0.28

Service Code	NDC 69543-383-90
Hospital Charge Code	1713143
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cigna of CA HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.21

OLANZAPINE 10 MG TABLET [17937]

Facility

$0.29

Service Code	NDC 69543-383-30
Hospital Charge Code	1713143
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.23
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.22

OLANZAPINE 10 MG TABLET [17937]

Facility

$0.58

Service Code	NDC 0904-6376-61
Hospital Charge Code	1713143
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.44
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	$0.26
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 Beech St/Commercial/PHCS	$0.44

OLANZAPINE 10 MG TABLET [17937]

Facility

$0.29

Service Code	NDC 69543-383-30
Hospital Charge Code	1713143
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.22
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	$0.13
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 Beech St/Commercial/PHCS	$0.22

OLANZAPINE 10 MG TABLET [17937]

Facility

$0.42

Service Code	NDC 60505-3113-0
Hospital Charge Code	1713143
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.32

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$0.53

Service Code	NDC 68084-525-11
Hospital Charge Code	1710896
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.40

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$0.53

Service Code	NDC 68084-525-01
Hospital Charge Code	1710896
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.40

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$0.53

Service Code	NDC 68084-525-01
Hospital Charge Code	1710896
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.40
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	$0.24
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 Beech St/Commercial/PHCS	$0.40

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$0.24

Service Code	NDC 55111-163-30
Hospital Charge Code	1710896
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

Know your out-of-pocket cost for care.

All Charges