Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

RIFAMPIN 600 MG INTRAVENOUS SOLUTION [11291]

Facility

$184.92

Service Code	NDC 67457-445-60
Hospital Charge Code	1753334
Hospital Revenue Code	250
Min. Negotiated Rate	$101.71
Max. Negotiated Rate	$147.94
Rate for Payer: Cash Price	$83.21
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$138.69

RIFAMPIN ORAL SUSPENSION COMPOUND 10 MG/ML [4080331]

Facility

$0.05

Service Code	NDC 9994-0803-31
Hospital Charge Code	1715511
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

RIFAMPIN ORAL SUSPENSION COMPOUND 10 MG/ML [4080331]

Facility

$0.05

Service Code	NDC 9994-0803-31
Hospital Charge Code	1715511
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

RIFAPENTINE 150 MG TABLET [23365]

Facility

$5.54

Service Code	NDC 0088-2102-01
Hospital Charge Code	ERX23365
Hospital Revenue Code	259
Min. Negotiated Rate	$3.05
Max. Negotiated Rate	$4.43
Rate for Payer: Cash Price	$2.49
Rate for Payer: Cigna of CA HMO/PPO	$4.43
Rate for Payer: Health Smart Auto/Commercial	$3.32
Rate for Payer: LLUH Dept of Risk Management WC	$3.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.16

RIFAPENTINE 150 MG TABLET [23365]

Facility

$5.54

Service Code	NDC 0088-2102-01
Hospital Charge Code	ERX23365
Hospital Revenue Code	259
Min. Negotiated Rate	$3.05
Max. Negotiated Rate	$4.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.32
Rate for Payer: Aetna of CA Government/Medicare	$3.32
Rate for Payer: Cash Price	$2.49
Rate for Payer: Health Smart Auto/Commercial	$3.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.32
Rate for Payer: LLUH Dept of Risk Management WC	$3.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.16

RIFAXIMIN 200 MG TABLET [39063]

Facility

$12.29

Service Code	NDC 65649-301-03
Hospital Charge Code	1710937
Hospital Revenue Code	259
Min. Negotiated Rate	$6.76
Max. Negotiated Rate	$9.83
Rate for Payer: Cash Price	$5.53
Rate for Payer: Cigna of CA HMO/PPO	$9.83
Rate for Payer: Health Smart Auto/Commercial	$7.37
Rate for Payer: LLUH Dept of Risk Management WC	$6.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.22

RIFAXIMIN 200 MG TABLET [39063]

Facility

$12.29

Service Code	NDC 65649-301-03
Hospital Charge Code	1710937
Hospital Revenue Code	259
Min. Negotiated Rate	$6.76
Max. Negotiated Rate	$9.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.37
Rate for Payer: Aetna of CA Government/Medicare	$7.37
Rate for Payer: Cash Price	$5.53
Rate for Payer: Health Smart Auto/Commercial	$7.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.37
Rate for Payer: LLUH Dept of Risk Management WC	$6.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.22

RIFAXIMIN 550 MG TABLET [104604]

Facility

$63.20

Service Code	NDC 65649-303-03
Hospital Charge Code	1712455
Hospital Revenue Code	259
Min. Negotiated Rate	$34.76
Max. Negotiated Rate	$47.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$37.92
Rate for Payer: Aetna of CA Government/Medicare	$37.92
Rate for Payer: Cash Price	$28.44
Rate for Payer: Health Smart Auto/Commercial	$37.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$37.92
Rate for Payer: LLUH Dept of Risk Management WC	$34.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$47.40

RIFAXIMIN 550 MG TABLET [104604]

Facility

$63.20

Service Code	NDC 65649-303-02
Hospital Charge Code	1712455
Hospital Revenue Code	259
Min. Negotiated Rate	$34.76
Max. Negotiated Rate	$50.56
Rate for Payer: Cash Price	$28.44
Rate for Payer: Cigna of CA HMO/PPO	$50.56
Rate for Payer: Health Smart Auto/Commercial	$37.92
Rate for Payer: LLUH Dept of Risk Management WC	$34.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$47.40

RIFAXIMIN 550 MG TABLET [104604]

Facility

$63.20

Service Code	NDC 65649-303-02
Hospital Charge Code	1712455
Hospital Revenue Code	259
Min. Negotiated Rate	$34.76
Max. Negotiated Rate	$47.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$37.92
Rate for Payer: Aetna of CA Government/Medicare	$37.92
Rate for Payer: Cash Price	$28.44
Rate for Payer: Health Smart Auto/Commercial	$37.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$37.92
Rate for Payer: LLUH Dept of Risk Management WC	$34.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$47.40

RIFAXIMIN 550 MG TABLET [104604]

Facility

$63.20

Service Code	NDC 65649-303-03
Hospital Charge Code	1712455
Hospital Revenue Code	259
Min. Negotiated Rate	$34.76
Max. Negotiated Rate	$50.56
Rate for Payer: Cash Price	$28.44
Rate for Payer: Cigna of CA HMO/PPO	$50.56
Rate for Payer: Health Smart Auto/Commercial	$37.92
Rate for Payer: LLUH Dept of Risk Management WC	$34.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$47.40

RIFAXIMIN ORAL SUSPENSION COMPOUND 20 MG/ML [4080332]

Facility

$1.33

Service Code	NDC 9994-0803-32
Hospital Charge Code	1715270
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.80
Rate for Payer: Aetna of CA Government/Medicare	$0.80
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.00

RIFAXIMIN ORAL SUSPENSION COMPOUND 20 MG/ML [4080332]

Facility

$1.33

Service Code	NDC 9994-0803-32
Hospital Charge Code	1715270
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cigna of CA HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.00

RILPIVIRINE HCL 25 MG TABLET [109909]

Facility

$54.01

Service Code	NDC 59676-278-01
Hospital Charge Code	1712619
Hospital Revenue Code	259
Min. Negotiated Rate	$29.71
Max. Negotiated Rate	$40.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$32.41
Rate for Payer: Aetna of CA Government/Medicare	$32.41
Rate for Payer: Cash Price	$24.30
Rate for Payer: Health Smart Auto/Commercial	$32.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$32.41
Rate for Payer: LLUH Dept of Risk Management WC	$29.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$40.51

RILPIVIRINE HCL 25 MG TABLET [109909]

Facility

$54.01

Service Code	NDC 59676-278-01
Hospital Charge Code	1712619
Hospital Revenue Code	259
Min. Negotiated Rate	$29.71
Max. Negotiated Rate	$43.21
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna of CA HMO/PPO	$43.21
Rate for Payer: Health Smart Auto/Commercial	$32.41
Rate for Payer: LLUH Dept of Risk Management WC	$29.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$40.51

RILUZOLE 50 MG TABLET [16124]

Facility

$0.80

Service Code	NDC 67877-286-60
Hospital Charge Code	1712269
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.60
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	$0.36
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 Beech St/Commercial/PHCS	$0.60

RILUZOLE 50 MG TABLET [16124]

Facility

$1.58

Service Code	NDC 68462-381-60
Hospital Charge Code	1712269
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.18
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	$0.71
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 Beech St/Commercial/PHCS	$1.18

RILUZOLE 50 MG TABLET [16124]

Facility

$1.58

Service Code	NDC 62756-538-86
Hospital Charge Code	1712269
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.26
Rate for Payer: Cash Price	$0.71
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.18

RILUZOLE 50 MG TABLET [16124]

Facility

$1.58

Service Code	NDC 62756-538-86
Hospital Charge Code	1712269
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.18
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	$0.71
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 Beech St/Commercial/PHCS	$1.18

RILUZOLE 50 MG TABLET [16124]

Facility

$0.80

Service Code	NDC 67877-286-60
Hospital Charge Code	1712269
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.60

RILUZOLE 50 MG TABLET [16124]

Facility

$1.58

Service Code	NDC 68462-381-60
Hospital Charge Code	1712269
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.26
Rate for Payer: Cash Price	$0.71
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.18

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

Facility

$747.14

Service Code	CPT J0587
Hospital Charge Code	NDG108078
Hospital Revenue Code	636
Min. Negotiated Rate	$410.93
Max. Negotiated Rate	$560.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$448.28
Rate for Payer: Aetna of CA Government/Medicare	$448.28
Rate for Payer: Cash Price	$336.21
Rate for Payer: Health Smart Auto/Commercial	$448.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$448.28
Rate for Payer: LLUH Dept of Risk Management WC	$410.93
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$560.36

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

Facility

$747.14

Service Code	CPT J0587
Hospital Charge Code	NDG108078
Hospital Revenue Code	636
Min. Negotiated Rate	$410.93
Max. Negotiated Rate	$597.71
Rate for Payer: Cash Price	$336.21
Rate for Payer: Cigna of CA HMO/PPO	$597.71
Rate for Payer: Health Smart Auto/Commercial	$448.28
Rate for Payer: LLUH Dept of Risk Management WC	$410.93
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$560.36

RINGER'S INTRAVENOUS SOLUTION [11295]

Facility

$0.01

Service Code	NDC 0264-7780-00
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01

RINGER'S INTRAVENOUS SOLUTION [11295]

Facility

$0.01

Service Code	NDC 0264-7780-00
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01

Know your out-of-pocket cost for care.

All Charges