Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]

Facility

$0.06

Service Code	NDC 0761003220
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]

Facility

$0.04

Service Code	NDC 4329256000
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

RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]

Facility

$0.06

Service Code	NDC 7985420195
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]

Facility

$0.09

Service Code	NDC 1184571401
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]

Facility

$0.06

Service Code	NDC 0761003220
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

RIBOFLAVIN (VITAMIN B2) 25 MG TABLET [110350]

Facility

$0.05

Service Code	NDC 54629-0055-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.04

RIBOFLAVIN (VITAMIN B2) 25 MG TABLET [110350]

Facility

$0.05

Service Code	NDC 54629-0055-01
Hospital Charge Code	901700029
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	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
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 Commercial	$0.04

RIBOFLAVIN (VITAMIN B2) 25 MG TABLET [110350]

Facility

$0.05

Service Code	NDC 7985420025
Hospital Charge Code	901700029
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	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
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 Commercial	$0.04

RIBOFLAVIN (VITAMIN B2) 25 MG TABLET [110350]

Facility

$0.05

Service Code	NDC 7985420025
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.04

RIBOFLAVIN (VITAMIN B2) 50 MG TABLET [11289]

Facility

$0.05

Service Code	NDC 3504600120
Hospital Charge Code	901700029
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	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
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 Commercial	$0.04

RIBOFLAVIN (VITAMIN B2) 50 MG TABLET [11289]

Facility

$0.05

Service Code	NDC 3504600120
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.04

RIFABUTIN 150 MG CAPSULE [11290]

Facility

$15.12

Service Code	NDC 70954-041-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.32
Max. Negotiated Rate	$12.10
Rate for Payer: Cash Price	$8.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.10
Rate for Payer: Health Smart Auto/Commercial	$9.07
Rate for Payer: LLUH Dept of Risk Management WC	$8.32
Rate for Payer: Multiplan Commercial	$11.34

RIFABUTIN 150 MG CAPSULE [11290]

Facility

$15.12

Service Code	NDC 70954-041-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.32
Max. Negotiated Rate	$12.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.07
Rate for Payer: Aetna of CA Government/Medicare	$9.07
Rate for Payer: Cash Price	$8.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.10
Rate for Payer: Health Smart Auto/Commercial	$9.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.07
Rate for Payer: LLUH Dept of Risk Management WC	$8.32
Rate for Payer: Multiplan Commercial	$11.34

RIFABUTIN 150 MG CAPSULE [11290]

Facility

$16.79

Service Code	NDC 59762-1350-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.23
Max. Negotiated Rate	$13.43
Rate for Payer: Cash Price	$9.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.43
Rate for Payer: Health Smart Auto/Commercial	$10.07
Rate for Payer: LLUH Dept of Risk Management WC	$9.23
Rate for Payer: Multiplan Commercial	$12.59

RIFABUTIN 150 MG CAPSULE [11290]

Facility

$16.79

Service Code	NDC 59762-1350-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.23
Max. Negotiated Rate	$13.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.07
Rate for Payer: Aetna of CA Government/Medicare	$10.07
Rate for Payer: Cash Price	$9.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.43
Rate for Payer: Health Smart Auto/Commercial	$10.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.07
Rate for Payer: LLUH Dept of Risk Management WC	$9.23
Rate for Payer: Multiplan Commercial	$12.59

RIFAMPIN 150 MG CAPSULE [11292]

Facility

$3.82

Service Code	NDC 60687-575-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$3.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.29
Rate for Payer: Aetna of CA Government/Medicare	$2.29
Rate for Payer: Cash Price	$2.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.06
Rate for Payer: Health Smart Auto/Commercial	$2.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.29
Rate for Payer: LLUH Dept of Risk Management WC	$2.10
Rate for Payer: Multiplan Commercial	$2.87

RIFAMPIN 150 MG CAPSULE [11292]

Facility

$3.82

Service Code	NDC 60687-575-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$3.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.29
Rate for Payer: Aetna of CA Government/Medicare	$2.29
Rate for Payer: Cash Price	$2.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.06
Rate for Payer: Health Smart Auto/Commercial	$2.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.29
Rate for Payer: LLUH Dept of Risk Management WC	$2.10
Rate for Payer: Multiplan Commercial	$2.87

RIFAMPIN 150 MG CAPSULE [11292]

Facility

$3.82

Service Code	NDC 60687-575-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$3.06
Rate for Payer: Cash Price	$2.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.06
Rate for Payer: Health Smart Auto/Commercial	$2.29
Rate for Payer: LLUH Dept of Risk Management WC	$2.10
Rate for Payer: Multiplan Commercial	$2.87

RIFAMPIN 150 MG CAPSULE [11292]

Facility

$3.82

Service Code	NDC 60687-575-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$3.06
Rate for Payer: Cash Price	$2.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.06
Rate for Payer: Health Smart Auto/Commercial	$2.29
Rate for Payer: LLUH Dept of Risk Management WC	$2.10
Rate for Payer: Multiplan Commercial	$2.87

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: Aetna of CA EPO/HMO/POS/PPO	$2.65
Rate for Payer: Aetna of CA Government/Medicare	$2.65
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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 60687-586-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.34
Rate for Payer: Aetna of CA Government/Medicare	$1.34
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Commercial	$1.67

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$4.41

Service Code	NDC 68180-659-07
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 60687-586-01
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 300 MG CAPSULE [11293]

Facility

$4.41

Service Code	NDC 68180-659-07
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$3.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.65
Rate for Payer: Aetna of CA Government/Medicare	$2.65
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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: Aetna of CA EPO/HMO/POS/PPO	$1.34
Rate for Payer: Aetna of CA Government/Medicare	$1.34
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Commercial	$1.67

Know your out-of-pocket cost for care.

All Charges