Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$0.17

Service Code	NDC 69543-380-30
Hospital Charge Code	1710896
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.13

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$0.24

Service Code	NDC 60505-3110-0
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

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	$0.40
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	$0.18
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	$0.11
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 Beech St/Commercial/PHCS	$0.18

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$0.17

Service Code	NDC 69543-380-30
Hospital Charge Code	1710896
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
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	$0.08
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 Beech St/Commercial/PHCS	$0.13

OLANZAPINE 2.5 MG TABLET [21057]

Facility

$0.24

Service Code	NDC 60505-3110-0
Hospital Charge Code	1710896
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	$0.11
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 Beech St/Commercial/PHCS	$0.18

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$1.03

Service Code	NDC 0378-5510-93
Hospital Charge Code	1712249
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$1.03

Service Code	NDC 60505-3275-3
Hospital Charge Code	1712249
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$1.03

Service Code	NDC 59746-306-32
Hospital Charge Code	1712249
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$20.08

Service Code	NDC 0002-4453-85
Hospital Charge Code	1712249
Hospital Revenue Code	259
Min. Negotiated Rate	$11.04
Max. Negotiated Rate	$16.06
Rate for Payer: Cash Price	$9.04
Rate for Payer: Cigna of CA HMO/PPO	$16.06
Rate for Payer: Health Smart Auto/Commercial	$12.05
Rate for Payer: LLUH Dept of Risk Management WC	$11.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.06

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$1.03

Service Code	NDC 49884-320-55
Hospital Charge Code	1712249
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$20.08

Service Code	NDC 0002-4453-85
Hospital Charge Code	1712249
Hospital Revenue Code	259
Min. Negotiated Rate	$11.04
Max. Negotiated Rate	$15.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.05
Rate for Payer: Aetna of CA Government/Medicare	$12.05
Rate for Payer: Cash Price	$9.04
Rate for Payer: Health Smart Auto/Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.05
Rate for Payer: LLUH Dept of Risk Management WC	$11.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.06

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$1.03

Service Code	NDC 60505-3275-3
Hospital Charge Code	1712249
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.62
Rate for Payer: Aetna of CA Government/Medicare	$0.62
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$2.08

Service Code	NDC 55111-262-79
Hospital Charge Code	1712249
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

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$2.08

Service Code	NDC 55111-262-79
Hospital Charge Code	1712249
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

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$1.03

Service Code	NDC 0378-5510-93
Hospital Charge Code	1712249
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.62
Rate for Payer: Aetna of CA Government/Medicare	$0.62
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$20.08

Service Code	NDC 0002-4453-01
Hospital Charge Code	1712249
Hospital Revenue Code	259
Min. Negotiated Rate	$11.04
Max. Negotiated Rate	$16.06
Rate for Payer: Cash Price	$9.04
Rate for Payer: Cigna of CA HMO/PPO	$16.06
Rate for Payer: Health Smart Auto/Commercial	$12.05
Rate for Payer: LLUH Dept of Risk Management WC	$11.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.06

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$1.03

Service Code	NDC 59746-306-12
Hospital Charge Code	1712249
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.62
Rate for Payer: Aetna of CA Government/Medicare	$0.62
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$1.03

Service Code	NDC 49884-320-55
Hospital Charge Code	1712249
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.62
Rate for Payer: Aetna of CA Government/Medicare	$0.62
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$20.08

Service Code	NDC 0002-4453-01
Hospital Charge Code	1712249
Hospital Revenue Code	259
Min. Negotiated Rate	$11.04
Max. Negotiated Rate	$15.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.05
Rate for Payer: Aetna of CA Government/Medicare	$12.05
Rate for Payer: Cash Price	$9.04
Rate for Payer: Health Smart Auto/Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.05
Rate for Payer: LLUH Dept of Risk Management WC	$11.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.06

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$1.03

Service Code	NDC 59746-306-12
Hospital Charge Code	1712249
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$2.08

Service Code	NDC 55111-262-81
Hospital Charge Code	1712249
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

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$1.03

Service Code	NDC 59746-306-32
Hospital Charge Code	1712249
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.62
Rate for Payer: Aetna of CA Government/Medicare	$0.62
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]

Facility

$2.08

Service Code	NDC 55111-262-81
Hospital Charge Code	1712249
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

OLANZAPINE 5 MG TABLET [17936]

Facility

$0.19

Service Code	NDC 69543-381-90
Hospital Charge Code	1713141
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

Know your out-of-pocket cost for care.

All Charges