Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]

Facility

$147.00

Service Code	NDC 0143-9392-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$80.85
Max. Negotiated Rate	$117.60
Rate for Payer: Cash Price	$80.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$117.60
Rate for Payer: Health Smart Auto/Commercial	$88.20
Rate for Payer: LLUH Dept of Risk Management WC	$80.85
Rate for Payer: Multiplan Commercial	$110.25

REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]

Facility

$154.34

Service Code	NDC 63323-724-05
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$84.89
Max. Negotiated Rate	$123.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$92.60
Rate for Payer: Aetna of CA Government/Medicare	$92.60
Rate for Payer: Cash Price	$84.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$123.47
Rate for Payer: Health Smart Auto/Commercial	$92.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$92.60
Rate for Payer: LLUH Dept of Risk Management WC	$84.89
Rate for Payer: Multiplan Commercial	$115.75

REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]

Facility

$161.66

Service Code	NDC 72078-035-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$88.91
Max. Negotiated Rate	$129.33
Rate for Payer: Cash Price	$88.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$129.33
Rate for Payer: Health Smart Auto/Commercial	$97.00
Rate for Payer: LLUH Dept of Risk Management WC	$88.91
Rate for Payer: Multiplan Commercial	$121.25

REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]

Facility

$154.34

Service Code	NDC 63323-724-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$84.89
Max. Negotiated Rate	$123.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$92.60
Rate for Payer: Aetna of CA Government/Medicare	$92.60
Rate for Payer: Cash Price	$84.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$123.47
Rate for Payer: Health Smart Auto/Commercial	$92.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$92.60
Rate for Payer: LLUH Dept of Risk Management WC	$84.89
Rate for Payer: Multiplan Commercial	$115.75

REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]

Facility

$147.00

Service Code	NDC 0143-9392-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$80.85
Max. Negotiated Rate	$117.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$88.20
Rate for Payer: Aetna of CA Government/Medicare	$88.20
Rate for Payer: Cash Price	$80.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$117.60
Rate for Payer: Health Smart Auto/Commercial	$88.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$88.20
Rate for Payer: LLUH Dept of Risk Management WC	$80.85
Rate for Payer: Multiplan Commercial	$110.25

REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]

Facility

$154.34

Service Code	NDC 63323-724-05
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$84.89
Max. Negotiated Rate	$123.47
Rate for Payer: Cash Price	$84.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$123.47
Rate for Payer: Health Smart Auto/Commercial	$92.60
Rate for Payer: LLUH Dept of Risk Management WC	$84.89
Rate for Payer: Multiplan Commercial	$115.75

REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]

Facility

$161.66

Service Code	NDC 72078-035-00
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$88.91
Max. Negotiated Rate	$129.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$97.00
Rate for Payer: Aetna of CA Government/Medicare	$97.00
Rate for Payer: Cash Price	$88.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$129.33
Rate for Payer: Health Smart Auto/Commercial	$97.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$97.00
Rate for Payer: LLUH Dept of Risk Management WC	$88.91
Rate for Payer: Multiplan Commercial	$121.25

REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]

Facility

$154.34

Service Code	NDC 63323-724-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$84.89
Max. Negotiated Rate	$123.47
Rate for Payer: Cash Price	$84.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$123.47
Rate for Payer: Health Smart Auto/Commercial	$92.60
Rate for Payer: LLUH Dept of Risk Management WC	$84.89
Rate for Payer: Multiplan Commercial	$115.75

REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]

Facility

$147.00

Service Code	NDC 0143-9392-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$80.85
Max. Negotiated Rate	$117.60
Rate for Payer: Cash Price	$80.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$117.60
Rate for Payer: Health Smart Auto/Commercial	$88.20
Rate for Payer: LLUH Dept of Risk Management WC	$80.85
Rate for Payer: Multiplan Commercial	$110.25

REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]

Facility

$161.66

Service Code	NDC 72078-035-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$88.91
Max. Negotiated Rate	$129.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$97.00
Rate for Payer: Aetna of CA Government/Medicare	$97.00
Rate for Payer: Cash Price	$88.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$129.33
Rate for Payer: Health Smart Auto/Commercial	$97.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$97.00
Rate for Payer: LLUH Dept of Risk Management WC	$88.91
Rate for Payer: Multiplan Commercial	$121.25

REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]

Facility

$147.00

Service Code	NDC 0143-9392-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$80.85
Max. Negotiated Rate	$117.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$88.20
Rate for Payer: Aetna of CA Government/Medicare	$88.20
Rate for Payer: Cash Price	$80.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$117.60
Rate for Payer: Health Smart Auto/Commercial	$88.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$88.20
Rate for Payer: LLUH Dept of Risk Management WC	$80.85
Rate for Payer: Multiplan Commercial	$110.25

REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]

Facility

$161.66

Service Code	NDC 72078-035-00
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$88.91
Max. Negotiated Rate	$129.33
Rate for Payer: Cash Price	$88.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$129.33
Rate for Payer: Health Smart Auto/Commercial	$97.00
Rate for Payer: LLUH Dept of Risk Management WC	$88.91
Rate for Payer: Multiplan Commercial	$121.25

RESP ONLY: HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION 30 ML [40810176]

Facility

$0.27

Service Code	HCPCS J1644
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20
Rate for Payer: Multiplan Commercial	$0.23

RESP ONLY: HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION 30 ML [40810176]

Facility

$0.27

Service Code	HCPCS J1644
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.20
Rate for Payer: Multiplan Commercial	$0.23

RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION [237494]

Facility

$884.58

Service Code	HCPCS J9345
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$486.52
Max. Negotiated Rate	$707.66
Rate for Payer: Cash Price	$486.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$707.66
Rate for Payer: Health Smart Auto/Commercial	$530.75
Rate for Payer: LLUH Dept of Risk Management WC	$486.52
Rate for Payer: Multiplan Commercial	$663.43

RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION [237494]

Facility

$884.58

Service Code	HCPCS J9345
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$486.52
Max. Negotiated Rate	$707.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$530.75
Rate for Payer: Aetna of CA Government/Medicare	$530.75
Rate for Payer: Cash Price	$486.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$707.66
Rate for Payer: Health Smart Auto/Commercial	$530.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$530.75
Rate for Payer: LLUH Dept of Risk Management WC	$486.52
Rate for Payer: Multiplan Commercial	$663.43

RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE [38072]

Facility

$102.09

Service Code	HCPCS J2791
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$56.15
Max. Negotiated Rate	$81.67
Rate for Payer: Cash Price	$56.15
Rate for Payer: Cash Price	$51.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$81.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$74.25
Rate for Payer: Health Smart Auto/Commercial	$61.25
Rate for Payer: Health Smart Auto/Commercial	$55.69
Rate for Payer: LLUH Dept of Risk Management WC	$51.05
Rate for Payer: LLUH Dept of Risk Management WC	$56.15
Rate for Payer: Multiplan Commercial	$76.57
Rate for Payer: Multiplan Commercial	$69.61

RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE [38072]

Facility

$102.09

Service Code	HCPCS J2791
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$56.15
Max. Negotiated Rate	$81.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$61.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$55.69
Rate for Payer: Aetna of CA Government/Medicare	$61.25
Rate for Payer: Aetna of CA Government/Medicare	$55.69
Rate for Payer: Cash Price	$56.15
Rate for Payer: Cash Price	$51.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$81.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$74.25
Rate for Payer: Health Smart Auto/Commercial	$61.25
Rate for Payer: Health Smart Auto/Commercial	$55.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$61.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$55.69
Rate for Payer: LLUH Dept of Risk Management WC	$51.05
Rate for Payer: LLUH Dept of Risk Management WC	$56.15
Rate for Payer: Multiplan Commercial	$76.57
Rate for Payer: Multiplan Commercial	$69.61

RHO(D) IMMUNE GLOBULIN-MALTOSE 5,000 UNIT (1,000 MCG)/4.4 ML INJ. SOLN [70574]

Facility

$508.62

Service Code	HCPCS J2792
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$279.74
Max. Negotiated Rate	$406.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$305.17
Rate for Payer: Aetna of CA Government/Medicare	$305.17
Rate for Payer: Cash Price	$279.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$406.90
Rate for Payer: Health Smart Auto/Commercial	$305.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$305.17
Rate for Payer: LLUH Dept of Risk Management WC	$279.74
Rate for Payer: Multiplan Commercial	$381.46

RHO(D) IMMUNE GLOBULIN-MALTOSE 5,000 UNIT (1,000 MCG)/4.4 ML INJ. SOLN [70574]

Facility

$508.62

Service Code	HCPCS J2792
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$279.74
Max. Negotiated Rate	$406.90
Rate for Payer: Cash Price	$279.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$406.90
Rate for Payer: Health Smart Auto/Commercial	$305.17
Rate for Payer: LLUH Dept of Risk Management WC	$279.74
Rate for Payer: Multiplan Commercial	$381.46

RIBAVIRIN 200 MG TABLET [11287]

Facility

$0.74

Service Code	NDC 65862-207-68
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.56

RIBAVIRIN 200 MG TABLET [11287]

Facility

$0.74

Service Code	NDC 65862-207-68
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.59
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.56

RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]

Facility

$0.09

Service Code	NDC 1184571401
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]

Facility

$0.04

Service Code	NDC 4329256000
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]

Facility

$0.06

Service Code	NDC 7985420195
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

Know your out-of-pocket cost for care.

All Charges