|
RISPERIDONE 1 MG TABLET [18313]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 68382-114-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
RISPERIDONE 1 MG TABLET [18313]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 68382-114-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
RISPERIDONE 1 MG TABLET [18313]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 43547-341-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
RISPERIDONE 2 MG DISINTEGRATING TABLET [35688]
|
Facility
|
OP
|
$7.97
|
|
|
Service Code
|
NDC 49884-401-91
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$6.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.78
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$5.98
|
|
|
RISPERIDONE 2 MG DISINTEGRATING TABLET [35688]
|
Facility
|
IP
|
$7.97
|
|
|
Service Code
|
NDC 49884-401-52
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$6.38 |
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$5.98
|
|
|
RISPERIDONE 2 MG DISINTEGRATING TABLET [35688]
|
Facility
|
OP
|
$4.01
|
|
|
Service Code
|
NDC 59746-030-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.41
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.41
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$3.01
|
|
|
RISPERIDONE 2 MG DISINTEGRATING TABLET [35688]
|
Facility
|
IP
|
$7.97
|
|
|
Service Code
|
NDC 49884-401-91
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$6.38 |
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$5.98
|
|
|
RISPERIDONE 2 MG DISINTEGRATING TABLET [35688]
|
Facility
|
OP
|
$7.97
|
|
|
Service Code
|
NDC 49884-401-52
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$6.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.78
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$5.98
|
|
|
RISPERIDONE 2 MG DISINTEGRATING TABLET [35688]
|
Facility
|
IP
|
$4.01
|
|
|
Service Code
|
NDC 59746-030-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$3.01
|
|
|
RISPERIDONE 3 MG TABLET [18312]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 68084-274-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
RISPERIDONE 3 MG TABLET [18312]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 68084-274-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
RISPERIDONE 3 MG TABLET [18312]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 68084-274-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
RISPERIDONE 3 MG TABLET [18312]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 68084-274-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
RISPERIDONE 4 MG TABLET [18310]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 68084-277-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
RISPERIDONE 4 MG TABLET [18310]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 68084-277-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
RISPERIDONE 4 MG TABLET [18310]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 68084-277-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
RISPERIDONE 4 MG TABLET [18310]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 68084-277-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
RITLECITINIB 50 MG CAPSULE [238783]
|
Facility
|
IP
|
$178.10
|
|
|
Service Code
|
NDC 0069-0334-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$97.95 |
| Max. Negotiated Rate |
$142.48 |
| Rate for Payer: Cash Price |
$97.95
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$142.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$106.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$97.95
|
| Rate for Payer: Multiplan Commercial |
$133.57
|
|
|
RITLECITINIB 50 MG CAPSULE [238783]
|
Facility
|
OP
|
$178.10
|
|
|
Service Code
|
NDC 0069-0334-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$97.95 |
| Max. Negotiated Rate |
$142.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$106.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$106.86
|
| Rate for Payer: Cash Price |
$97.95
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$142.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$106.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$106.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$97.95
|
| Rate for Payer: Multiplan Commercial |
$133.57
|
|
|
RITONAVIR 100 MG TABLET [100995]
|
Facility
|
IP
|
$6.40
|
|
|
Service Code
|
NDC 0054-0407-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$5.12 |
| Rate for Payer: Cash Price |
$3.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.52
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
|
|
RITONAVIR 100 MG TABLET [100995]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 65862-687-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.76
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
|
|
RITONAVIR 100 MG TABLET [100995]
|
Facility
|
OP
|
$6.40
|
|
|
Service Code
|
NDC 0054-0407-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$5.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.84
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.84
|
| Rate for Payer: Cash Price |
$3.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.52
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
|
|
RITONAVIR 100 MG TABLET [100995]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 31722-597-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.76
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
|
|
RITONAVIR 100 MG TABLET [100995]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 31722-597-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.92
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.76
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
|
|
RITONAVIR 100 MG TABLET [100995]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 65862-687-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.92
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.76
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
|
