Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

Facility

$1.00

Service Code	NDC 27241-126-02
Hospital Charge Code	1711990
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.75
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	$0.45
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 Beech St/Commercial/PHCS	$0.75

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

Facility

$0.34

Service Code	NDC 42291-774-60
Hospital Charge Code	1711990
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$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	1711990
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.75

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

Facility

$1.68

Service Code	NDC 60687-549-11
Hospital Charge Code	1711999
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.26
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	$0.76
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 Beech St/Commercial/PHCS	$1.26

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

Facility

$8.22

Service Code	NDC 61958-1003-1
Hospital Charge Code	1711999
Hospital Revenue Code	259
Min. Negotiated Rate	$4.52
Max. Negotiated Rate	$6.58
Rate for Payer: Cash Price	$3.70
Rate for Payer: Cigna of CA HMO/PPO	$6.58
Rate for Payer: Health Smart Auto/Commercial	$4.93
Rate for Payer: LLUH Dept of Risk Management WC	$4.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.16

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

Facility

$0.60

Service Code	NDC 27241-125-02
Hospital Charge Code	1711999
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.45
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	$0.27
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 Beech St/Commercial/PHCS	$0.45

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

Facility

$1.68

Service Code	NDC 60687-549-11
Hospital Charge Code	1711999
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Cash Price	$0.76
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.26

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

Facility

$8.22

Service Code	NDC 61958-1003-1
Hospital Charge Code	1711999
Hospital Revenue Code	259
Min. Negotiated Rate	$4.52
Max. Negotiated Rate	$6.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.93
Rate for Payer: Aetna of CA Government/Medicare	$4.93
Rate for Payer: Cash Price	$3.70
Rate for Payer: Health Smart Auto/Commercial	$4.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.93
Rate for Payer: LLUH Dept of Risk Management WC	$4.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.16

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

Facility

$0.60

Service Code	NDC 27241-125-02
Hospital Charge Code	1711999
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.45

RASAGILINE 0.5 MG TABLET [76480]

Facility

$17.80

Service Code	NDC 47781-683-30
Hospital Charge Code	1711909
Hospital Revenue Code	259
Min. Negotiated Rate	$9.79
Max. Negotiated Rate	$14.24
Rate for Payer: Cash Price	$8.01
Rate for Payer: Cigna of CA HMO/PPO	$14.24
Rate for Payer: Health Smart Auto/Commercial	$10.68
Rate for Payer: LLUH Dept of Risk Management WC	$9.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.35

RASAGILINE 0.5 MG TABLET [76480]

Facility

$3.44

Service Code	NDC 23155-746-03
Hospital Charge Code	1711909
Hospital Revenue Code	259
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$2.58
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	$1.55
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 Beech St/Commercial/PHCS	$2.58

RASAGILINE 0.5 MG TABLET [76480]

Facility

$8.25

Service Code	NDC 0093-3060-56
Hospital Charge Code	1711909
Hospital Revenue Code	259
Min. Negotiated Rate	$4.54
Max. Negotiated Rate	$6.60
Rate for Payer: Cash Price	$3.71
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$6.19

RASAGILINE 0.5 MG TABLET [76480]

Facility

$17.80

Service Code	NDC 47781-683-30
Hospital Charge Code	1711909
Hospital Revenue Code	259
Min. Negotiated Rate	$9.79
Max. Negotiated Rate	$13.35
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	$8.01
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 Beech St/Commercial/PHCS	$13.35

RASAGILINE 0.5 MG TABLET [76480]

Facility

$8.25

Service Code	NDC 0093-3060-56
Hospital Charge Code	1711909
Hospital Revenue Code	259
Min. Negotiated Rate	$4.54
Max. Negotiated Rate	$6.19
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	$3.71
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 Beech St/Commercial/PHCS	$6.19

RASAGILINE 0.5 MG TABLET [76480]

Facility

$3.44

Service Code	NDC 23155-746-03
Hospital Charge Code	1711909
Hospital Revenue Code	259
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$2.75
Rate for Payer: Cash Price	$1.55
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$2.58

RASAGILINE 1 MG TABLET [76481]

Facility

$8.25

Service Code	NDC 0093-3061-56
Hospital Charge Code	1711908
Hospital Revenue Code	259
Min. Negotiated Rate	$4.54
Max. Negotiated Rate	$6.60
Rate for Payer: Cash Price	$3.71
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$6.19

RASAGILINE 1 MG TABLET [76481]

Facility

$3.44

Service Code	NDC 23155-747-03
Hospital Charge Code	1711908
Hospital Revenue Code	259
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$2.58
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	$1.55
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 Beech St/Commercial/PHCS	$2.58

RASAGILINE 1 MG TABLET [76481]

Facility

$41.81

Service Code	NDC 68546-229-56
Hospital Charge Code	1711908
Hospital Revenue Code	259
Min. Negotiated Rate	$23.00
Max. Negotiated Rate	$31.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.09
Rate for Payer: Aetna of CA Government/Medicare	$25.09
Rate for Payer: Cash Price	$18.81
Rate for Payer: Health Smart Auto/Commercial	$25.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.09
Rate for Payer: LLUH Dept of Risk Management WC	$23.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.36

RASAGILINE 1 MG TABLET [76481]

Facility

$17.80

Service Code	NDC 47781-690-30
Hospital Charge Code	1711908
Hospital Revenue Code	259
Min. Negotiated Rate	$9.79
Max. Negotiated Rate	$13.35
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	$8.01
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 Beech St/Commercial/PHCS	$13.35

RASAGILINE 1 MG TABLET [76481]

Facility

$3.44

Service Code	NDC 23155-747-03
Hospital Charge Code	1711908
Hospital Revenue Code	259
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$2.75
Rate for Payer: Cash Price	$1.55
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$2.58

RASAGILINE 1 MG TABLET [76481]

Facility

$8.25

Service Code	NDC 0093-3061-56
Hospital Charge Code	1711908
Hospital Revenue Code	259
Min. Negotiated Rate	$4.54
Max. Negotiated Rate	$6.19
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	$3.71
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 Beech St/Commercial/PHCS	$6.19

RASAGILINE 1 MG TABLET [76481]

Facility

$41.81

Service Code	NDC 68546-229-56
Hospital Charge Code	1711908
Hospital Revenue Code	259
Min. Negotiated Rate	$23.00
Max. Negotiated Rate	$33.45
Rate for Payer: Cash Price	$18.81
Rate for Payer: Cigna of CA HMO/PPO	$33.45
Rate for Payer: Health Smart Auto/Commercial	$25.09
Rate for Payer: LLUH Dept of Risk Management WC	$23.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.36

RASAGILINE 1 MG TABLET [76481]

Facility

$17.80

Service Code	NDC 47781-690-30
Hospital Charge Code	1711908
Hospital Revenue Code	259
Min. Negotiated Rate	$9.79
Max. Negotiated Rate	$14.24
Rate for Payer: Cash Price	$8.01
Rate for Payer: Cigna of CA HMO/PPO	$14.24
Rate for Payer: Health Smart Auto/Commercial	$10.68
Rate for Payer: LLUH Dept of Risk Management WC	$9.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.35

RASBURICASE 1.5 MG INTRAVENOUS SOLUTION [33591]

Facility

$1,276.65

Service Code	CPT J2783
Hospital Charge Code	1722030
Hospital Revenue Code	636
Min. Negotiated Rate	$702.16
Max. Negotiated Rate	$1,021.32
Rate for Payer: Cash Price	$574.49
Rate for Payer: Cigna of CA HMO/PPO	$1,021.32
Rate for Payer: Health Smart Auto/Commercial	$765.99
Rate for Payer: LLUH Dept of Risk Management WC	$702.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$957.49

RASBURICASE 1.5 MG INTRAVENOUS SOLUTION [33591]

Facility

$1,276.65

Service Code	CPT J2783
Hospital Charge Code	1722030
Hospital Revenue Code	636
Min. Negotiated Rate	$702.16
Max. Negotiated Rate	$957.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$765.99
Rate for Payer: Aetna of CA Government/Medicare	$765.99
Rate for Payer: Cash Price	$574.49
Rate for Payer: Health Smart Auto/Commercial	$765.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$765.99
Rate for Payer: LLUH Dept of Risk Management WC	$702.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$957.49

Know your out-of-pocket cost for care.

All Charges