Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]

Facility

$0.09

Service Code	NDC 1184571401
Hospital Charge Code	1712617
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]

Facility

$0.05

Service Code	NDC 761003220
Hospital Charge Code	1712617
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

RIBOFLAVIN (VITAMIN B2) 50 MG TABLET [11289]

Facility

$0.05

Service Code	NDC 3504600120
Hospital Charge Code	ERX11289
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

RIBOFLAVIN (VITAMIN B2) 50 MG TABLET [11289]

Facility

$0.05

Service Code	NDC 3504600120
Hospital Charge Code	ERX11289
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

RIFABUTIN 150 MG CAPSULE [11290]

Facility

$16.79

Service Code	NDC 59762-1350-1
Hospital Charge Code	1712193
Hospital Revenue Code	259
Min. Negotiated Rate	$9.23
Max. Negotiated Rate	$12.59
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	$7.56
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 Beech St/Commercial/PHCS	$12.59

RIFABUTIN 150 MG CAPSULE [11290]

Facility

$16.79

Service Code	NDC 59762-1350-1
Hospital Charge Code	1712193
Hospital Revenue Code	259
Min. Negotiated Rate	$9.23
Max. Negotiated Rate	$13.43
Rate for Payer: Cash Price	$7.56
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$12.59

RIFAMPIN 150 MG CAPSULE [11292]

Facility

$1.91

Service Code	NDC 60687-575-21
Hospital Charge Code	1712082
Hospital Revenue Code	259
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.53
Rate for Payer: Cash Price	$0.86
Rate for Payer: Cigna of CA HMO/PPO	$1.53
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.43

RIFAMPIN 150 MG CAPSULE [11292]

Facility

$1.91

Service Code	NDC 60687-575-11
Hospital Charge Code	1712082
Hospital Revenue Code	259
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.53
Rate for Payer: Cash Price	$0.86
Rate for Payer: Cigna of CA HMO/PPO	$1.53
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.43

RIFAMPIN 150 MG CAPSULE [11292]

Facility

$1.18

Service Code	NDC 61748-015-30
Hospital Charge Code	1712082
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.71
Rate for Payer: Aetna of CA Government/Medicare	$0.71
Rate for Payer: Cash Price	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

RIFAMPIN 150 MG CAPSULE [11292]

Facility

$1.91

Service Code	NDC 60687-575-21
Hospital Charge Code	1712082
Hospital Revenue Code	259
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.15
Rate for Payer: Aetna of CA Government/Medicare	$1.15
Rate for Payer: Cash Price	$0.86
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.43

RIFAMPIN 150 MG CAPSULE [11292]

Facility

$1.18

Service Code	NDC 61748-015-30
Hospital Charge Code	1712082
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.94
Rate for Payer: Cash Price	$0.53
Rate for Payer: Cigna of CA HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

RIFAMPIN 150 MG CAPSULE [11292]

Facility

$1.91

Service Code	NDC 60687-575-11
Hospital Charge Code	1712082
Hospital Revenue Code	259
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.15
Rate for Payer: Aetna of CA Government/Medicare	$1.15
Rate for Payer: Cash Price	$0.86
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.43

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$4.41

Service Code	NDC 68180-659-07
Hospital Charge Code	1710623
Hospital Revenue Code	259
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$3.31
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	$1.98
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 Beech St/Commercial/PHCS	$3.31

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$1.31

Service Code	NDC 60687-586-11
Hospital Charge Code	1710623
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.05
Rate for Payer: Cash Price	$0.59
Rate for Payer: Cigna of CA HMO/PPO	$1.05
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$1.31

Service Code	NDC 60687-586-01
Hospital Charge Code	1710623
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Cash Price	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$1.31

Service Code	NDC 60687-586-11
Hospital Charge Code	1710623
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Cash Price	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$4.41

Service Code	NDC 68180-659-07
Hospital Charge Code	1710623
Hospital Revenue Code	259
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$3.53
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$3.31

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$1.31

Service Code	NDC 60687-586-01
Hospital Charge Code	1710623
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.05
Rate for Payer: Cash Price	$0.59
Rate for Payer: Cigna of CA HMO/PPO	$1.05
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.98

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$4.41

Service Code	NDC 68180-659-06
Hospital Charge Code	1710623
Hospital Revenue Code	259
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$3.31
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	$1.98
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 Beech St/Commercial/PHCS	$3.31

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$1.51

Service Code	NDC 61748-018-01
Hospital Charge Code	1710623
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.91
Rate for Payer: Aetna of CA Government/Medicare	$0.91
Rate for Payer: Cash Price	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.13

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$1.51

Service Code	NDC 61748-018-30
Hospital Charge Code	1710623
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.21
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA HMO/PPO	$1.21
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.13

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$1.51

Service Code	NDC 61748-018-30
Hospital Charge Code	1710623
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.91
Rate for Payer: Aetna of CA Government/Medicare	$0.91
Rate for Payer: Cash Price	$0.68
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.13

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$1.51

Service Code	NDC 61748-018-01
Hospital Charge Code	1710623
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.21
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna of CA HMO/PPO	$1.21
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.13

RIFAMPIN 300 MG CAPSULE [11293]

Facility

$4.41

Service Code	NDC 68180-659-06
Hospital Charge Code	1710623
Hospital Revenue Code	259
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$3.53
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$3.31

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	$138.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$110.95
Rate for Payer: Aetna of CA Government/Medicare	$110.95
Rate for Payer: Cash Price	$83.21
Rate for Payer: Health Smart Auto/Commercial	$110.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$110.95
Rate for Payer: LLUH Dept of Risk Management WC	$101.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$138.69

Know your out-of-pocket cost for care.

All Charges