Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

RALOXIFENE 60 MG TABLET [22143]

Facility

$3.73

Service Code	NDC 50268-694-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.24
Rate for Payer: Aetna of CA Government/Medicare	$2.24
Rate for Payer: Cash Price	$2.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.98
Rate for Payer: Health Smart Auto/Commercial	$2.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.24
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: Multiplan Commercial	$2.80

RALOXIFENE 60 MG TABLET [22143]

Facility

$3.73

Service Code	NDC 50268-694-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.24
Rate for Payer: Aetna of CA Government/Medicare	$2.24
Rate for Payer: Cash Price	$2.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.98
Rate for Payer: Health Smart Auto/Commercial	$2.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.24
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: Multiplan Commercial	$2.80

RALOXIFENE 60 MG TABLET [22143]

Facility

$0.78

Service Code	NDC 43598-505-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

RALOXIFENE 60 MG TABLET [22143]

Facility

$3.73

Service Code	NDC 50268-694-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.98
Rate for Payer: Cash Price	$2.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.98
Rate for Payer: Health Smart Auto/Commercial	$2.24
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: Multiplan Commercial	$2.80

RALOXIFENE 60 MG TABLET [22143]

Facility

$3.73

Service Code	NDC 50268-694-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.98
Rate for Payer: Cash Price	$2.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.98
Rate for Payer: Health Smart Auto/Commercial	$2.24
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: Multiplan Commercial	$2.80

RALOXIFENE 60 MG TABLET [22143]

Facility

$0.78

Service Code	NDC 43598-505-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

RALTEGRAVIR 400 MG TABLET [88608]

Facility

$41.66

Service Code	NDC 0006-0227-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$22.91
Max. Negotiated Rate	$33.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.00
Rate for Payer: Aetna of CA Government/Medicare	$25.00
Rate for Payer: Cash Price	$22.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.33
Rate for Payer: Health Smart Auto/Commercial	$25.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.00
Rate for Payer: LLUH Dept of Risk Management WC	$22.91
Rate for Payer: Multiplan Commercial	$31.25

RALTEGRAVIR 400 MG TABLET [88608]

Facility

$41.66

Service Code	NDC 0006-0227-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$22.91
Max. Negotiated Rate	$33.33
Rate for Payer: Cash Price	$22.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.33
Rate for Payer: Health Smart Auto/Commercial	$25.00
Rate for Payer: LLUH Dept of Risk Management WC	$22.91
Rate for Payer: Multiplan Commercial	$31.25

RAMIPRIL 5 MG CAPSULE [11261]

Facility

$0.24

Service Code	NDC 65862-476-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.18

RAMIPRIL 5 MG CAPSULE [11261]

Facility

$0.24

Service Code	NDC 65862-476-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
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	$0.19
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	$0.18

RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION [205590]

Facility

$180.09

Service Code	HCPCS J9308
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$99.05
Max. Negotiated Rate	$144.07
Rate for Payer: Cash Price	$99.05
Rate for Payer: Cash Price	$99.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$144.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$144.08
Rate for Payer: Health Smart Auto/Commercial	$108.05
Rate for Payer: Health Smart Auto/Commercial	$108.06
Rate for Payer: LLUH Dept of Risk Management WC	$99.06
Rate for Payer: LLUH Dept of Risk Management WC	$99.05
Rate for Payer: Multiplan Commercial	$135.07
Rate for Payer: Multiplan Commercial	$135.07

RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION [205590]

Facility

$180.09

Service Code	HCPCS J9308
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$99.05
Max. Negotiated Rate	$144.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$108.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$108.06
Rate for Payer: Aetna of CA Government/Medicare	$108.05
Rate for Payer: Aetna of CA Government/Medicare	$108.06
Rate for Payer: Cash Price	$99.05
Rate for Payer: Cash Price	$99.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$144.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$144.08
Rate for Payer: Health Smart Auto/Commercial	$108.05
Rate for Payer: Health Smart Auto/Commercial	$108.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$108.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$108.06
Rate for Payer: LLUH Dept of Risk Management WC	$99.06
Rate for Payer: LLUH Dept of Risk Management WC	$99.05
Rate for Payer: Multiplan Commercial	$135.07
Rate for Payer: Multiplan Commercial	$135.07

RANOLAZINE ER 1,000 MG TABLET,EXTENDED RELEASE,12 HR [88007]

Facility

$0.34

Service Code	NDC 42291-774-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

RANOLAZINE ER 1,000 MG TABLET,EXTENDED RELEASE,12 HR [88007]

Facility

$0.34

Service Code	NDC 42291-774-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

RANOLAZINE ER 1,000 MG TABLET,EXTENDED RELEASE,12 HR [88007]

Facility

$1.00

Service Code	NDC 27241-126-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

RANOLAZINE ER 1,000 MG TABLET,EXTENDED RELEASE,12 HR [88007]

Facility

$1.00

Service Code	NDC 27241-126-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.60
Rate for Payer: Aetna of CA Government/Medicare	$0.60
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR [70434]

Facility

$1.68

Service Code	NDC 60687-549-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.26

RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR [70434]

Facility

$0.60

Service Code	NDC 27241-125-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
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	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
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 Commercial	$0.45

RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR [70434]

Facility

$1.68

Service Code	NDC 60687-549-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.01
Rate for Payer: Aetna of CA Government/Medicare	$1.01
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.26

RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR [70434]

Facility

$0.60

Service Code	NDC 27241-125-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.45

RASAGILINE 0.5 MG TABLET [76480]

Facility

$3.44

Service Code	NDC 23155-746-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$2.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.06
Rate for Payer: Aetna of CA Government/Medicare	$2.06
Rate for Payer: Cash Price	$1.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.75
Rate for Payer: Health Smart Auto/Commercial	$2.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.06
Rate for Payer: LLUH Dept of Risk Management WC	$1.89
Rate for Payer: Multiplan Commercial	$2.58

RASAGILINE 0.5 MG TABLET [76480]

Facility

$17.80

Service Code	NDC 47781-683-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.79
Max. Negotiated Rate	$14.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.68
Rate for Payer: Aetna of CA Government/Medicare	$10.68
Rate for Payer: Cash Price	$9.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.24
Rate for Payer: Health Smart Auto/Commercial	$10.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.68
Rate for Payer: LLUH Dept of Risk Management WC	$9.79
Rate for Payer: Multiplan Commercial	$13.35

RASAGILINE 0.5 MG TABLET [76480]

Facility

$8.25

Service Code	NDC 0093-3060-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.54
Max. Negotiated Rate	$6.60
Rate for Payer: Cash Price	$4.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.60
Rate for Payer: Health Smart Auto/Commercial	$4.95
Rate for Payer: LLUH Dept of Risk Management WC	$4.54
Rate for Payer: Multiplan Commercial	$6.19

RASAGILINE 0.5 MG TABLET [76480]

Facility

$3.44

Service Code	NDC 23155-746-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$2.75
Rate for Payer: Cash Price	$1.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.75
Rate for Payer: Health Smart Auto/Commercial	$2.06
Rate for Payer: LLUH Dept of Risk Management WC	$1.89
Rate for Payer: Multiplan Commercial	$2.58

RASAGILINE 0.5 MG TABLET [76480]

Facility

$8.25

Service Code	NDC 0093-3060-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.54
Max. Negotiated Rate	$6.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.95
Rate for Payer: Aetna of CA Government/Medicare	$4.95
Rate for Payer: Cash Price	$4.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.60
Rate for Payer: Health Smart Auto/Commercial	$4.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.95
Rate for Payer: LLUH Dept of Risk Management WC	$4.54
Rate for Payer: Multiplan Commercial	$6.19

Know your out-of-pocket cost for care.

All Charges