Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

ROSUVASTATIN 20 MG TABLET [35135]

Facility

$11.06

Service Code	NDC 0310-0752-90
Hospital Charge Code	1712305
Hospital Revenue Code	259
Min. Negotiated Rate	$6.08
Max. Negotiated Rate	$8.85
Rate for Payer: Cash Price	$4.98
Rate for Payer: Cigna of CA HMO/PPO	$8.85
Rate for Payer: Health Smart Auto/Commercial	$6.64
Rate for Payer: LLUH Dept of Risk Management WC	$6.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.30

ROSUVASTATIN 20 MG TABLET [35135]

Facility

$11.06

Service Code	NDC 0310-0752-90
Hospital Charge Code	1712305
Hospital Revenue Code	259
Min. Negotiated Rate	$6.08
Max. Negotiated Rate	$8.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.64
Rate for Payer: Aetna of CA Government/Medicare	$6.64
Rate for Payer: Cash Price	$4.98
Rate for Payer: Health Smart Auto/Commercial	$6.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.64
Rate for Payer: LLUH Dept of Risk Management WC	$6.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.30

ROSUVASTATIN 40 MG TABLET [35136]

Facility

$0.23

Service Code	NDC 68462-264-30
Hospital Charge Code	1712306
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

ROSUVASTATIN 40 MG TABLET [35136]

Facility

$17.90

Service Code	NDC 71205-078-30
Hospital Charge Code	1712306
Hospital Revenue Code	259
Min. Negotiated Rate	$9.84
Max. Negotiated Rate	$13.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.74
Rate for Payer: Aetna of CA Government/Medicare	$10.74
Rate for Payer: Cash Price	$8.06
Rate for Payer: Health Smart Auto/Commercial	$10.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.74
Rate for Payer: LLUH Dept of Risk Management WC	$9.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.42

ROSUVASTATIN 40 MG TABLET [35136]

Facility

$0.23

Service Code	NDC 68462-264-30
Hospital Charge Code	1712306
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

ROSUVASTATIN 40 MG TABLET [35136]

Facility

$17.90

Service Code	NDC 71205-078-30
Hospital Charge Code	1712306
Hospital Revenue Code	259
Min. Negotiated Rate	$9.84
Max. Negotiated Rate	$14.32
Rate for Payer: Cash Price	$8.06
Rate for Payer: Cigna of CA HMO/PPO	$14.32
Rate for Payer: Health Smart Auto/Commercial	$10.74
Rate for Payer: LLUH Dept of Risk Management WC	$9.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.42

ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION [70476]

Facility

$55.46

Service Code	CPT 90680
Hospital Charge Code	1716082
Hospital Revenue Code	636
Min. Negotiated Rate	$30.50
Max. Negotiated Rate	$41.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.28
Rate for Payer: Aetna of CA Government/Medicare	$33.28
Rate for Payer: Cash Price	$24.96
Rate for Payer: Health Smart Auto/Commercial	$33.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.28
Rate for Payer: LLUH Dept of Risk Management WC	$30.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.60

ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION [70476]

Facility

$55.46

Service Code	CPT 90680
Hospital Charge Code	1716082
Hospital Revenue Code	636
Min. Negotiated Rate	$30.50
Max. Negotiated Rate	$44.37
Rate for Payer: Cash Price	$24.96
Rate for Payer: Cigna of CA HMO/PPO	$44.37
Rate for Payer: Health Smart Auto/Commercial	$33.28
Rate for Payer: LLUH Dept of Risk Management WC	$30.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.60

ROTIGOTINE 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH [82100]

Facility

$32.26

Service Code	NDC 50474-802-03
Hospital Charge Code	ERX82100
Hospital Revenue Code	259
Min. Negotiated Rate	$17.74
Max. Negotiated Rate	$24.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$19.36
Rate for Payer: Aetna of CA Government/Medicare	$19.36
Rate for Payer: Cash Price	$14.52
Rate for Payer: Health Smart Auto/Commercial	$19.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$19.36
Rate for Payer: LLUH Dept of Risk Management WC	$17.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$24.20

ROTIGOTINE 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH [82100]

Facility

$32.26

Service Code	NDC 50474-802-03
Hospital Charge Code	ERX82100
Hospital Revenue Code	259
Min. Negotiated Rate	$17.74
Max. Negotiated Rate	$25.81
Rate for Payer: Cash Price	$14.52
Rate for Payer: Cigna of CA HMO/PPO	$25.81
Rate for Payer: Health Smart Auto/Commercial	$19.36
Rate for Payer: LLUH Dept of Risk Management WC	$17.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$24.20

ROTIGOTINE 4 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH [82101]

Facility

$32.26

Service Code	NDC 50474-804-03
Hospital Charge Code	ERX82101
Hospital Revenue Code	259
Min. Negotiated Rate	$17.74
Max. Negotiated Rate	$24.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$19.36
Rate for Payer: Aetna of CA Government/Medicare	$19.36
Rate for Payer: Cash Price	$14.52
Rate for Payer: Health Smart Auto/Commercial	$19.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$19.36
Rate for Payer: LLUH Dept of Risk Management WC	$17.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$24.20

ROTIGOTINE 4 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH [82101]

Facility

$32.26

Service Code	NDC 50474-804-03
Hospital Charge Code	ERX82101
Hospital Revenue Code	259
Min. Negotiated Rate	$17.74
Max. Negotiated Rate	$25.81
Rate for Payer: Cash Price	$14.52
Rate for Payer: Cigna of CA HMO/PPO	$25.81
Rate for Payer: Health Smart Auto/Commercial	$19.36
Rate for Payer: LLUH Dept of Risk Management WC	$17.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$24.20

RUFINAMIDE 200 MG TABLET [95691]

Facility

$3.69

Service Code	NDC 0054-0425-23
Hospital Charge Code	1712406
Hospital Revenue Code	259
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$2.95
Rate for Payer: Cash Price	$1.66
Rate for Payer: Cigna of CA HMO/PPO	$2.95
Rate for Payer: Health Smart Auto/Commercial	$2.21
Rate for Payer: LLUH Dept of Risk Management WC	$2.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.77

RUFINAMIDE 200 MG TABLET [95691]

Facility

$3.69

Service Code	NDC 68462-713-08
Hospital Charge Code	1712406
Hospital Revenue Code	259
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$2.95
Rate for Payer: Cash Price	$1.66
Rate for Payer: Cigna of CA HMO/PPO	$2.95
Rate for Payer: Health Smart Auto/Commercial	$2.21
Rate for Payer: LLUH Dept of Risk Management WC	$2.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.77

RUFINAMIDE 200 MG TABLET [95691]

Facility

$3.69

Service Code	NDC 68462-713-08
Hospital Charge Code	1712406
Hospital Revenue Code	259
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$2.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.21
Rate for Payer: Aetna of CA Government/Medicare	$2.21
Rate for Payer: Cash Price	$1.66
Rate for Payer: Health Smart Auto/Commercial	$2.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.21
Rate for Payer: LLUH Dept of Risk Management WC	$2.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.77

RUFINAMIDE 200 MG TABLET [95691]

Facility

$3.69

Service Code	NDC 0054-0425-23
Hospital Charge Code	1712406
Hospital Revenue Code	259
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$2.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.21
Rate for Payer: Aetna of CA Government/Medicare	$2.21
Rate for Payer: Cash Price	$1.66
Rate for Payer: Health Smart Auto/Commercial	$2.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.21
Rate for Payer: LLUH Dept of Risk Management WC	$2.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.77

RUFINAMIDE 400 MG TABLET [95692]

Facility

$7.37

Service Code	NDC 0054-0426-23
Hospital Charge Code	1712407
Hospital Revenue Code	259
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$5.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.42
Rate for Payer: Aetna of CA Government/Medicare	$4.42
Rate for Payer: Cash Price	$3.32
Rate for Payer: Health Smart Auto/Commercial	$4.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.42
Rate for Payer: LLUH Dept of Risk Management WC	$4.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.53

RUFINAMIDE 400 MG TABLET [95692]

Facility

$7.37

Service Code	NDC 0054-0426-23
Hospital Charge Code	1712407
Hospital Revenue Code	259
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$5.90
Rate for Payer: Cash Price	$3.32
Rate for Payer: Cigna of CA HMO/PPO	$5.90
Rate for Payer: Health Smart Auto/Commercial	$4.42
Rate for Payer: LLUH Dept of Risk Management WC	$4.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.53

RUFINAMIDE 40 MG/ML ORAL SUSPENSION [108804]

Facility

$4.59

Service Code	NDC 62856-584-46
Hospital Charge Code	1715258
Hospital Revenue Code	259
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$3.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.75
Rate for Payer: Aetna of CA Government/Medicare	$2.75
Rate for Payer: Cash Price	$2.07
Rate for Payer: Health Smart Auto/Commercial	$2.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.75
Rate for Payer: LLUH Dept of Risk Management WC	$2.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.44

RUFINAMIDE 40 MG/ML ORAL SUSPENSION [108804]

Facility

$4.59

Service Code	NDC 62856-584-46
Hospital Charge Code	1715258
Hospital Revenue Code	259
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$3.67
Rate for Payer: Cash Price	$2.07
Rate for Payer: Cigna of CA HMO/PPO	$3.67
Rate for Payer: Health Smart Auto/Commercial	$2.75
Rate for Payer: LLUH Dept of Risk Management WC	$2.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.44

RUXOLITINIB 10 MG TABLET [153887]

Facility

$333.72

Service Code	NDC 50881-010-60
Hospital Charge Code	ERX153887
Hospital Revenue Code	259
Min. Negotiated Rate	$183.55
Max. Negotiated Rate	$250.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$200.23
Rate for Payer: Aetna of CA Government/Medicare	$200.23
Rate for Payer: Cash Price	$150.17
Rate for Payer: Health Smart Auto/Commercial	$200.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$200.23
Rate for Payer: LLUH Dept of Risk Management WC	$183.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.29

RUXOLITINIB 10 MG TABLET [153887]

Facility

$333.72

Service Code	NDC 50881-010-60
Hospital Charge Code	ERX153887
Hospital Revenue Code	259
Min. Negotiated Rate	$183.55
Max. Negotiated Rate	$266.98
Rate for Payer: Health Smart Auto/Commercial	$200.23
Rate for Payer: Cash Price	$150.17
Rate for Payer: Cigna of CA HMO/PPO	$266.98
Rate for Payer: LLUH Dept of Risk Management WC	$183.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.29

RUXOLITINIB 15 MG TABLET [153888]

Facility

$333.72

Service Code	NDC 50881-015-60
Hospital Charge Code	ERX153888
Hospital Revenue Code	259
Min. Negotiated Rate	$183.55
Max. Negotiated Rate	$250.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$200.23
Rate for Payer: Aetna of CA Government/Medicare	$200.23
Rate for Payer: Cash Price	$150.17
Rate for Payer: Health Smart Auto/Commercial	$200.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$200.23
Rate for Payer: LLUH Dept of Risk Management WC	$183.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.29

RUXOLITINIB 15 MG TABLET [153888]

Facility

$333.72

Service Code	NDC 50881-015-60
Hospital Charge Code	ERX153888
Hospital Revenue Code	259
Min. Negotiated Rate	$183.55
Max. Negotiated Rate	$266.98
Rate for Payer: Cash Price	$150.17
Rate for Payer: Cigna of CA HMO/PPO	$266.98
Rate for Payer: Health Smart Auto/Commercial	$200.23
Rate for Payer: LLUH Dept of Risk Management WC	$183.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.29

RUXOLITINIB 20 MG TABLET [153889]

Facility

$333.72

Service Code	NDC 50881-020-60
Hospital Charge Code	ERX153889
Hospital Revenue Code	259
Min. Negotiated Rate	$183.55
Max. Negotiated Rate	$266.98
Rate for Payer: Cash Price	$150.17
Rate for Payer: Cigna of CA HMO/PPO	$266.98
Rate for Payer: Health Smart Auto/Commercial	$200.23
Rate for Payer: LLUH Dept of Risk Management WC	$183.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.29

Know your out-of-pocket cost for care.

All Charges