Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS [22149]

Facility

$112.74

Service Code	HCPCS J9312
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$62.01
Max. Negotiated Rate	$90.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$67.64
Rate for Payer: Aetna of CA Government/Medicare	$67.64
Rate for Payer: Cash Price	$62.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$90.19
Rate for Payer: Health Smart Auto/Commercial	$67.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$67.64
Rate for Payer: LLUH Dept of Risk Management WC	$62.01
Rate for Payer: Multiplan Commercial	$84.56

RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS [22149]

Facility

$112.74

Service Code	HCPCS J9312
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$62.01
Max. Negotiated Rate	$90.19
Rate for Payer: Cash Price	$62.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$90.19
Rate for Payer: Health Smart Auto/Commercial	$67.64
Rate for Payer: LLUH Dept of Risk Management WC	$62.01
Rate for Payer: Multiplan Commercial	$84.56

RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS NON-ONCOLOGY [4081336]

Facility

$112.74

Service Code	HCPCS J9312
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$62.01
Max. Negotiated Rate	$90.19
Rate for Payer: Cash Price	$62.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$90.19
Rate for Payer: Health Smart Auto/Commercial	$67.64
Rate for Payer: LLUH Dept of Risk Management WC	$62.01
Rate for Payer: Multiplan Commercial	$84.56

RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS NON-ONCOLOGY [4081336]

Facility

$112.74

Service Code	HCPCS J9312
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$62.01
Max. Negotiated Rate	$90.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$67.64
Rate for Payer: Aetna of CA Government/Medicare	$67.64
Rate for Payer: Cash Price	$62.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$90.19
Rate for Payer: Health Smart Auto/Commercial	$67.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$67.64
Rate for Payer: LLUH Dept of Risk Management WC	$62.01
Rate for Payer: Multiplan Commercial	$84.56

RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN [218742]

Facility

$674.52

Service Code	HCPCS J9311
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$370.99
Max. Negotiated Rate	$539.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$404.71
Rate for Payer: Aetna of CA Government/Medicare	$404.71
Rate for Payer: Cash Price	$370.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$539.62
Rate for Payer: Health Smart Auto/Commercial	$404.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$404.71
Rate for Payer: LLUH Dept of Risk Management WC	$370.99
Rate for Payer: Multiplan Commercial	$505.89

RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN [218742]

Facility

$674.52

Service Code	HCPCS J9311
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$370.99
Max. Negotiated Rate	$539.62
Rate for Payer: Cash Price	$370.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$539.62
Rate for Payer: Health Smart Auto/Commercial	$404.71
Rate for Payer: LLUH Dept of Risk Management WC	$370.99
Rate for Payer: Multiplan Commercial	$505.89

RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN [218821]

Facility

$673.08

Service Code	HCPCS J9311
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$370.19
Max. Negotiated Rate	$538.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$403.85
Rate for Payer: Aetna of CA Government/Medicare	$403.85
Rate for Payer: Cash Price	$370.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$538.46
Rate for Payer: Health Smart Auto/Commercial	$403.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$403.85
Rate for Payer: LLUH Dept of Risk Management WC	$370.19
Rate for Payer: Multiplan Commercial	$504.81

RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN [218821]

Facility

$673.08

Service Code	HCPCS J9311
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$370.19
Max. Negotiated Rate	$538.46
Rate for Payer: Cash Price	$370.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$538.46
Rate for Payer: Health Smart Auto/Commercial	$403.85
Rate for Payer: LLUH Dept of Risk Management WC	$370.19
Rate for Payer: Multiplan Commercial	$504.81

RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION [229898]

Facility

$86.02

Service Code	HCPCS Q5123
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$47.31
Max. Negotiated Rate	$68.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.61
Rate for Payer: Aetna of CA Government/Medicare	$51.61
Rate for Payer: Cash Price	$47.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.82
Rate for Payer: Health Smart Auto/Commercial	$51.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.61
Rate for Payer: LLUH Dept of Risk Management WC	$47.31
Rate for Payer: Multiplan Commercial	$64.52

RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION [229898]

Facility

$86.02

Service Code	HCPCS Q5123
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$47.31
Max. Negotiated Rate	$68.82
Rate for Payer: Cash Price	$47.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.82
Rate for Payer: Health Smart Auto/Commercial	$51.61
Rate for Payer: LLUH Dept of Risk Management WC	$47.31
Rate for Payer: Multiplan Commercial	$64.52

RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION [226878]

Facility

$86.02

Service Code	HCPCS Q5119
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$47.31
Max. Negotiated Rate	$68.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.61
Rate for Payer: Aetna of CA Government/Medicare	$51.61
Rate for Payer: Cash Price	$47.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.82
Rate for Payer: Health Smart Auto/Commercial	$51.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.61
Rate for Payer: LLUH Dept of Risk Management WC	$47.31
Rate for Payer: Multiplan Commercial	$64.52

RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION [226878]

Facility

$86.02

Service Code	HCPCS Q5119
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$47.31
Max. Negotiated Rate	$68.82
Rate for Payer: Cash Price	$47.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.82
Rate for Payer: Health Smart Auto/Commercial	$51.61
Rate for Payer: LLUH Dept of Risk Management WC	$47.31
Rate for Payer: Multiplan Commercial	$64.52

RIVAROXABAN 10 MG TABLET [153876]

Facility

$23.92

Service Code	NDC 50458-580-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.16
Max. Negotiated Rate	$19.14
Rate for Payer: Cash Price	$13.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.14
Rate for Payer: Health Smart Auto/Commercial	$14.35
Rate for Payer: LLUH Dept of Risk Management WC	$13.16
Rate for Payer: Multiplan Commercial	$17.94

RIVAROXABAN 10 MG TABLET [153876]

Facility

$23.92

Service Code	NDC 50458-580-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.16
Max. Negotiated Rate	$19.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.35
Rate for Payer: Aetna of CA Government/Medicare	$14.35
Rate for Payer: Cash Price	$13.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.14
Rate for Payer: Health Smart Auto/Commercial	$14.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.35
Rate for Payer: LLUH Dept of Risk Management WC	$13.16
Rate for Payer: Multiplan Commercial	$17.94

RIVAROXABAN 15 MG TABLET [153877]

Facility

$23.92

Service Code	NDC 50458-578-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.16
Max. Negotiated Rate	$19.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.35
Rate for Payer: Aetna of CA Government/Medicare	$14.35
Rate for Payer: Cash Price	$13.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.14
Rate for Payer: Health Smart Auto/Commercial	$14.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.35
Rate for Payer: LLUH Dept of Risk Management WC	$13.16
Rate for Payer: Multiplan Commercial	$17.94

RIVAROXABAN 15 MG TABLET [153877]

Facility

$23.92

Service Code	NDC 50458-578-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.16
Max. Negotiated Rate	$19.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.35
Rate for Payer: Aetna of CA Government/Medicare	$14.35
Rate for Payer: Cash Price	$13.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.14
Rate for Payer: Health Smart Auto/Commercial	$14.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.35
Rate for Payer: LLUH Dept of Risk Management WC	$13.16
Rate for Payer: Multiplan Commercial	$17.94

RIVAROXABAN 15 MG TABLET [153877]

Facility

$23.92

Service Code	NDC 50458-578-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.16
Max. Negotiated Rate	$19.14
Rate for Payer: Cash Price	$13.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.14
Rate for Payer: Health Smart Auto/Commercial	$14.35
Rate for Payer: LLUH Dept of Risk Management WC	$13.16
Rate for Payer: Multiplan Commercial	$17.94

RIVAROXABAN 15 MG TABLET [153877]

Facility

$23.92

Service Code	NDC 50458-578-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.16
Max. Negotiated Rate	$19.14
Rate for Payer: Cash Price	$13.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.14
Rate for Payer: Health Smart Auto/Commercial	$14.35
Rate for Payer: LLUH Dept of Risk Management WC	$13.16
Rate for Payer: Multiplan Commercial	$17.94

RIVAROXABAN 20 MG TABLET [153878]

Facility

$23.92

Service Code	NDC 50458-579-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.16
Max. Negotiated Rate	$19.14
Rate for Payer: Cash Price	$13.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.14
Rate for Payer: Health Smart Auto/Commercial	$14.35
Rate for Payer: LLUH Dept of Risk Management WC	$13.16
Rate for Payer: Multiplan Commercial	$17.94

RIVAROXABAN 20 MG TABLET [153878]

Facility

$23.92

Service Code	NDC 50458-579-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.16
Max. Negotiated Rate	$19.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.35
Rate for Payer: Aetna of CA Government/Medicare	$14.35
Rate for Payer: Cash Price	$13.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.14
Rate for Payer: Health Smart Auto/Commercial	$14.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.35
Rate for Payer: LLUH Dept of Risk Management WC	$13.16
Rate for Payer: Multiplan Commercial	$17.94

RIVAROXABAN 20 MG TABLET [153878]

Facility

$23.92

Service Code	NDC 50458-579-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.16
Max. Negotiated Rate	$19.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.35
Rate for Payer: Aetna of CA Government/Medicare	$14.35
Rate for Payer: Cash Price	$13.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.14
Rate for Payer: Health Smart Auto/Commercial	$14.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.35
Rate for Payer: LLUH Dept of Risk Management WC	$13.16
Rate for Payer: Multiplan Commercial	$17.94

RIVAROXABAN 20 MG TABLET [153878]

Facility

$23.92

Service Code	NDC 50458-579-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.16
Max. Negotiated Rate	$19.14
Rate for Payer: Cash Price	$13.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.14
Rate for Payer: Health Smart Auto/Commercial	$14.35
Rate for Payer: LLUH Dept of Risk Management WC	$13.16
Rate for Payer: Multiplan Commercial	$17.94

RIVAROXABAN 2.5 MG TABLET [222768]

Facility

$6.15

Service Code	NDC 68180-709-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$4.92
Rate for Payer: Cash Price	$3.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.92
Rate for Payer: Health Smart Auto/Commercial	$3.69
Rate for Payer: LLUH Dept of Risk Management WC	$3.38
Rate for Payer: Multiplan Commercial	$4.61

RIVAROXABAN 2.5 MG TABLET [222768]

Facility

$11.96

Service Code	NDC 50458-577-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.58
Max. Negotiated Rate	$9.57
Rate for Payer: Cash Price	$6.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.57
Rate for Payer: Health Smart Auto/Commercial	$7.18
Rate for Payer: LLUH Dept of Risk Management WC	$6.58
Rate for Payer: Multiplan Commercial	$8.97

RIVAROXABAN 2.5 MG TABLET [222768]

Facility

$6.15

Service Code	NDC 68180-709-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$4.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.69
Rate for Payer: Aetna of CA Government/Medicare	$3.69
Rate for Payer: Cash Price	$3.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.92
Rate for Payer: Health Smart Auto/Commercial	$3.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.69
Rate for Payer: LLUH Dept of Risk Management WC	$3.38
Rate for Payer: Multiplan Commercial	$4.61

Know your out-of-pocket cost for care.

All Charges