Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$4.41

Service Code	NDC 68180-659-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$3.53
Rate for Payer: Cash Price	$2.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.53
Rate for Payer: Health Smart Auto/Commercial	$2.65
Rate for Payer: LLUH Dept of Risk Management WC	$2.43
Rate for Payer: Multiplan Commercial	$3.31

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$2.23

Service Code	NDC 60687-586-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.78
Rate for Payer: Cash Price	$1.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.78
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Commercial	$1.67

RIFAMPIN 600 MG INTRAVENOUS SOLUTION [11291]

Facility

$184.92

Service Code	HCPCS J2804
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$101.71
Max. Negotiated Rate	$147.94
Rate for Payer: Cash Price	$101.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$147.94
Rate for Payer: Health Smart Auto/Commercial	$110.95
Rate for Payer: LLUH Dept of Risk Management WC	$101.71
Rate for Payer: Multiplan Commercial	$138.69

RIFAMPIN 600 MG INTRAVENOUS SOLUTION [11291]

Facility

$184.92

Service Code	HCPCS J2804
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$101.71
Max. Negotiated Rate	$147.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$110.95
Rate for Payer: Aetna of CA Government/Medicare	$110.95
Rate for Payer: Cash Price	$101.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$147.94
Rate for Payer: Health Smart Auto/Commercial	$110.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$110.95
Rate for Payer: LLUH Dept of Risk Management WC	$101.71
Rate for Payer: Multiplan Commercial	$138.69

RIFAMPIN ORAL SUSPENSION COMPOUND 10 MG/ML [4080331]

Facility

$0.04

Service Code	NDC 9994-0803-31
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

RIFAMPIN ORAL SUSPENSION COMPOUND 10 MG/ML [4080331]

Facility

$0.04

Service Code	NDC 9994-0803-31
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.03

RIFAPENTINE 150 MG TABLET [23365]

Facility

$5.96

Service Code	NDC 0088-2102-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$4.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.58
Rate for Payer: Aetna of CA Government/Medicare	$3.58
Rate for Payer: Cash Price	$3.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.77
Rate for Payer: Health Smart Auto/Commercial	$3.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.58
Rate for Payer: LLUH Dept of Risk Management WC	$3.28
Rate for Payer: Multiplan Commercial	$4.47

RIFAPENTINE 150 MG TABLET [23365]

Facility

$5.96

Service Code	NDC 0088-2102-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$4.77
Rate for Payer: Cash Price	$3.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.77
Rate for Payer: Health Smart Auto/Commercial	$3.58
Rate for Payer: LLUH Dept of Risk Management WC	$3.28
Rate for Payer: Multiplan Commercial	$4.47

RIFAXIMIN 200 MG TABLET [39063]

Facility

$13.47

Service Code	NDC 65649-301-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.41
Max. Negotiated Rate	$10.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.08
Rate for Payer: Aetna of CA Government/Medicare	$8.08
Rate for Payer: Cash Price	$7.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.78
Rate for Payer: Health Smart Auto/Commercial	$8.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.08
Rate for Payer: LLUH Dept of Risk Management WC	$7.41
Rate for Payer: Multiplan Commercial	$10.10

RIFAXIMIN 200 MG TABLET [39063]

Facility

$13.47

Service Code	NDC 65649-301-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.41
Max. Negotiated Rate	$10.78
Rate for Payer: Cash Price	$7.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.78
Rate for Payer: Health Smart Auto/Commercial	$8.08
Rate for Payer: LLUH Dept of Risk Management WC	$7.41
Rate for Payer: Multiplan Commercial	$10.10

RIFAXIMIN 550 MG TABLET [104604]

Facility

$69.26

Service Code	NDC 65649-303-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$38.09
Max. Negotiated Rate	$55.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$41.56
Rate for Payer: Aetna of CA Government/Medicare	$41.56
Rate for Payer: Cash Price	$38.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$55.41
Rate for Payer: Health Smart Auto/Commercial	$41.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$41.56
Rate for Payer: LLUH Dept of Risk Management WC	$38.09
Rate for Payer: Multiplan Commercial	$51.95

RIFAXIMIN 550 MG TABLET [104604]

Facility

$69.26

Service Code	NDC 65649-303-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$38.09
Max. Negotiated Rate	$55.41
Rate for Payer: Cash Price	$38.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$55.41
Rate for Payer: Health Smart Auto/Commercial	$41.56
Rate for Payer: LLUH Dept of Risk Management WC	$38.09
Rate for Payer: Multiplan Commercial	$51.95

RIFAXIMIN 550 MG TABLET [104604]

Facility

$69.26

Service Code	NDC 65649-303-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$38.09
Max. Negotiated Rate	$55.41
Rate for Payer: Cash Price	$38.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$55.41
Rate for Payer: Health Smart Auto/Commercial	$41.56
Rate for Payer: LLUH Dept of Risk Management WC	$38.09
Rate for Payer: Multiplan Commercial	$51.95

RIFAXIMIN 550 MG TABLET [104604]

Facility

$69.26

Service Code	NDC 65649-303-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$38.09
Max. Negotiated Rate	$55.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$41.56
Rate for Payer: Aetna of CA Government/Medicare	$41.56
Rate for Payer: Cash Price	$38.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$55.41
Rate for Payer: Health Smart Auto/Commercial	$41.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$41.56
Rate for Payer: LLUH Dept of Risk Management WC	$38.09
Rate for Payer: Multiplan Commercial	$51.95

RIFAXIMIN ORAL SUSPENSION COMPOUND 20 MG/ML [4080332]

Facility

$1.32

Service Code	NDC 9994-0803-32
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$0.99

RIFAXIMIN ORAL SUSPENSION COMPOUND 20 MG/ML [4080332]

Facility

$1.32

Service Code	NDC 9994-0803-32
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$0.99

RILPIVIRINE HCL 25 MG TABLET [109909]

Facility

$59.33

Service Code	NDC 59676-278-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$32.63
Max. Negotiated Rate	$47.46
Rate for Payer: Cash Price	$32.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.46
Rate for Payer: Health Smart Auto/Commercial	$35.60
Rate for Payer: LLUH Dept of Risk Management WC	$32.63
Rate for Payer: Multiplan Commercial	$44.50

RILPIVIRINE HCL 25 MG TABLET [109909]

Facility

$59.33

Service Code	NDC 59676-278-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$32.63
Max. Negotiated Rate	$47.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.60
Rate for Payer: Aetna of CA Government/Medicare	$35.60
Rate for Payer: Cash Price	$32.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.46
Rate for Payer: Health Smart Auto/Commercial	$35.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.60
Rate for Payer: LLUH Dept of Risk Management WC	$32.63
Rate for Payer: Multiplan Commercial	$44.50

RILUZOLE 50 MG TABLET [16124]

Facility

$0.80

Service Code	NDC 67877-286-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

RILUZOLE 50 MG TABLET [16124]

Facility

$1.58

Service Code	NDC 62756-538-86
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.95
Rate for Payer: Aetna of CA Government/Medicare	$0.95
Rate for Payer: Cash Price	$0.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.26
Rate for Payer: Health Smart Auto/Commercial	$0.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.87
Rate for Payer: Multiplan Commercial	$1.19

RILUZOLE 50 MG TABLET [16124]

Facility

$1.58

Service Code	NDC 68462-381-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.26
Rate for Payer: Cash Price	$0.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.26
Rate for Payer: Health Smart Auto/Commercial	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.87
Rate for Payer: Multiplan Commercial	$1.19

RILUZOLE 50 MG TABLET [16124]

Facility

$1.58

Service Code	NDC 68462-381-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.95
Rate for Payer: Aetna of CA Government/Medicare	$0.95
Rate for Payer: Cash Price	$0.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.26
Rate for Payer: Health Smart Auto/Commercial	$0.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.87
Rate for Payer: Multiplan Commercial	$1.19

RILUZOLE 50 MG TABLET [16124]

Facility

$1.58

Service Code	NDC 62756-538-86
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.26
Rate for Payer: Cash Price	$0.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.26
Rate for Payer: Health Smart Auto/Commercial	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.87
Rate for Payer: Multiplan Commercial	$1.19

RILUZOLE 50 MG TABLET [16124]

Facility

$0.80

Service Code	NDC 67877-286-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

RIMABOTULINUMTOXINB 2,500 UNIT/0.5 ML INTRAMUSCULAR SOLUTION [108078]

Facility

$762.10

Service Code	HCPCS J0587
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$419.15
Max. Negotiated Rate	$609.68
Rate for Payer: Cash Price	$419.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$609.68
Rate for Payer: Health Smart Auto/Commercial	$457.26
Rate for Payer: LLUH Dept of Risk Management WC	$419.15
Rate for Payer: Multiplan Commercial	$571.58

Know your out-of-pocket cost for care.

All Charges