|
RIVAROXABAN 2.5 MG TABLET [222768]
|
Facility
|
OP
|
$11.96
|
|
|
Service Code
|
NDC 50458-577-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.58 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.18
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.18
|
| Rate for Payer: Cash Price |
$6.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.58
|
| Rate for Payer: Multiplan Commercial |
$8.97
|
|
|
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH [82504]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 0378-9070-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.20
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH [82504]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 0378-9070-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH [82504]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 0378-9070-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.20
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH [82504]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 0378-9070-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
RIZATRIPTAN 10 MG TABLET [23377]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 57237-088-63
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
RIZATRIPTAN 10 MG TABLET [23377]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
NDC 65862-600-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
|
|
RIZATRIPTAN 10 MG TABLET [23377]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 57237-088-63
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.95 |
| 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 |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.95
|
| 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 Commercial |
$0.89
|
|
|
RIZATRIPTAN 10 MG TABLET [23377]
|
Facility
|
OP
|
$1.79
|
|
|
Service Code
|
NDC 0093-7472-19
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.07
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
|
|
RIZATRIPTAN 10 MG TABLET [23377]
|
Facility
|
IP
|
$1.79
|
|
|
Service Code
|
NDC 65862-600-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
|
|
RIZATRIPTAN 10 MG TABLET [23377]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
NDC 65862-600-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.08
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
|
|
RIZATRIPTAN 10 MG TABLET [23377]
|
Facility
|
OP
|
$1.79
|
|
|
Service Code
|
NDC 65862-600-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.07
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
|
|
RIZATRIPTAN 10 MG TABLET [23377]
|
Facility
|
IP
|
$1.79
|
|
|
Service Code
|
NDC 0093-7472-19
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
|
|
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95812]
|
Facility
|
IP
|
$0.77
|
|
|
Service Code
|
NDC 71839-141-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
|
|
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95812]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 63323-426-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.94
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.94
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
|
|
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95812]
|
Facility
|
IP
|
$0.77
|
|
|
Service Code
|
NDC 71839-141-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
|
|
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95812]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 67457-228-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.70
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.70
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.93
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
|
|
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95812]
|
Facility
|
OP
|
$0.77
|
|
|
Service Code
|
NDC 71839-141-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.46
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
|
|
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95812]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 63323-426-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.94
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.94
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
|
|
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95812]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 63323-426-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
|
|
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95812]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
NDC 67457-228-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.93
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
|
|
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95812]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 63323-426-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
|
|
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95812]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
NDC 67457-228-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.93
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
|
|
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95812]
|
Facility
|
IP
|
$0.96
|
|
|
Service Code
|
NDC 71288-700-06
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
|
|
ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION [95812]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 43066-007-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.30
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
