Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

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

Facility

OP

$34.56

Service Code	NDC 50474-802-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$19.01
Max. Negotiated Rate	$27.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.74
Rate for Payer: Aetna of CA Government/Medicare	$20.74
Rate for Payer: Cash Price	$19.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.65
Rate for Payer: Health Smart Auto/Commercial	$20.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.74
Rate for Payer: LLUH Dept of Risk Management WC	$19.01
Rate for Payer: Multiplan Commercial	$25.92

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

Facility

IP

$34.56

Service Code	NDC 50474-802-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$19.01
Max. Negotiated Rate	$27.65
Rate for Payer: Cash Price	$19.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.65
Rate for Payer: Health Smart Auto/Commercial	$20.74
Rate for Payer: LLUH Dept of Risk Management WC	$19.01
Rate for Payer: Multiplan Commercial	$25.92

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

Facility

IP

$34.56

Service Code	NDC 50474-804-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$19.01
Max. Negotiated Rate	$27.65
Rate for Payer: Cash Price	$19.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.65
Rate for Payer: Health Smart Auto/Commercial	$20.74
Rate for Payer: LLUH Dept of Risk Management WC	$19.01
Rate for Payer: Multiplan Commercial	$25.92

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

Facility

OP

$34.56

Service Code	NDC 50474-804-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$19.01
Max. Negotiated Rate	$27.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.74
Rate for Payer: Aetna of CA Government/Medicare	$20.74
Rate for Payer: Cash Price	$19.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.65
Rate for Payer: Health Smart Auto/Commercial	$20.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.74
Rate for Payer: LLUH Dept of Risk Management WC	$19.01
Rate for Payer: Multiplan Commercial	$25.92

RUFINAMIDE 200 MG TABLET [95691]

Facility

OP

$1.50

Service Code	NDC 68462-713-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.90
Rate for Payer: Aetna of CA Government/Medicare	$0.90
Rate for Payer: Cash Price	$0.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.20
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$1.12

RUFINAMIDE 200 MG TABLET [95691]

Facility

OP

$0.90

Service Code	NDC 42571-391-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

RUFINAMIDE 200 MG TABLET [95691]

Facility

IP

$3.68

Service Code	NDC 0054-0425-23
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$2.94
Rate for Payer: Cash Price	$2.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.94
Rate for Payer: Health Smart Auto/Commercial	$2.21
Rate for Payer: LLUH Dept of Risk Management WC	$2.02
Rate for Payer: Multiplan Commercial	$2.76

RUFINAMIDE 200 MG TABLET [95691]

Facility

IP

$0.90

Service Code	NDC 42571-391-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

RUFINAMIDE 200 MG TABLET [95691]

Facility

IP

$1.80

Service Code	NDC 31722-598-12
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

RUFINAMIDE 200 MG TABLET [95691]

Facility

OP

$3.68

Service Code	NDC 0054-0425-23
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$2.94
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	$2.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.94
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	$2.02
Rate for Payer: Multiplan Commercial	$2.76

RUFINAMIDE 200 MG TABLET [95691]

Facility

IP

$1.50

Service Code	NDC 68462-713-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Cash Price	$0.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.20
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$1.12

RUFINAMIDE 200 MG TABLET [95691]

Facility

OP

$1.80

Service Code	NDC 31722-598-12
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

RUFINAMIDE 400 MG TABLET [95692]

Facility

OP

$1.80

Service Code	NDC 42571-392-12
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

RUFINAMIDE 400 MG TABLET [95692]

Facility

OP

$7.37

Service Code	NDC 0054-0426-23
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$5.90
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	$4.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.90
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 Commercial	$5.53

RUFINAMIDE 400 MG TABLET [95692]

Facility

IP

$1.80

Service Code	NDC 42571-392-12
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

RUFINAMIDE 400 MG TABLET [95692]

Facility

IP

$7.37

Service Code	NDC 0054-0426-23
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$5.90
Rate for Payer: Cash Price	$4.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$5.53

RUFINAMIDE 40 MG/ML ORAL SUSPENSION [108804]

Facility

IP

$4.59

Service Code	NDC 62856-584-46
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$3.67
Rate for Payer: Cash Price	$2.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$3.44

RUFINAMIDE 40 MG/ML ORAL SUSPENSION [108804]

Facility

OP

$4.59

Service Code	NDC 62856-584-46
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$3.67
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	$2.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.67
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 Commercial	$3.44

RUXOLITINIB 10 MG TABLET [153887]

Facility

IP

$352.00

Service Code	NDC 50881-010-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$193.60
Max. Negotiated Rate	$281.60
Rate for Payer: Cash Price	$193.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$281.60
Rate for Payer: Health Smart Auto/Commercial	$211.20
Rate for Payer: LLUH Dept of Risk Management WC	$193.60
Rate for Payer: Multiplan Commercial	$264.00

RUXOLITINIB 10 MG TABLET [153887]

Facility

OP

$352.00

Service Code	NDC 50881-010-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$193.60
Max. Negotiated Rate	$281.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$211.20
Rate for Payer: Aetna of CA Government/Medicare	$211.20
Rate for Payer: Cash Price	$193.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$281.60
Rate for Payer: Health Smart Auto/Commercial	$211.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$211.20
Rate for Payer: LLUH Dept of Risk Management WC	$193.60
Rate for Payer: Multiplan Commercial	$264.00

RUXOLITINIB 15 MG TABLET [153888]

Facility

IP

$352.00

Service Code	NDC 50881-015-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$193.60
Max. Negotiated Rate	$281.60
Rate for Payer: Cash Price	$193.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$281.60
Rate for Payer: Health Smart Auto/Commercial	$211.20
Rate for Payer: LLUH Dept of Risk Management WC	$193.60
Rate for Payer: Multiplan Commercial	$264.00

RUXOLITINIB 15 MG TABLET [153888]

Facility

OP

$352.00

Service Code	NDC 50881-015-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$193.60
Max. Negotiated Rate	$281.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$211.20
Rate for Payer: Aetna of CA Government/Medicare	$211.20
Rate for Payer: Cash Price	$193.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$281.60
Rate for Payer: Health Smart Auto/Commercial	$211.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$211.20
Rate for Payer: LLUH Dept of Risk Management WC	$193.60
Rate for Payer: Multiplan Commercial	$264.00

RUXOLITINIB 20 MG TABLET [153889]

Facility

OP

$352.00

Service Code	NDC 50881-020-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$193.60
Max. Negotiated Rate	$281.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$211.20
Rate for Payer: Aetna of CA Government/Medicare	$211.20
Rate for Payer: Cash Price	$193.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$281.60
Rate for Payer: Health Smart Auto/Commercial	$211.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$211.20
Rate for Payer: LLUH Dept of Risk Management WC	$193.60
Rate for Payer: Multiplan Commercial	$264.00

RUXOLITINIB 20 MG TABLET [153889]

Facility

IP

$352.00

Service Code	NDC 50881-020-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$193.60
Max. Negotiated Rate	$281.60
Rate for Payer: Cash Price	$193.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$281.60
Rate for Payer: Health Smart Auto/Commercial	$211.20
Rate for Payer: LLUH Dept of Risk Management WC	$193.60
Rate for Payer: Multiplan Commercial	$264.00

RUXOLITINIB 25 MG TABLET [153890]

Facility

OP

$352.00

Service Code	NDC 50881-025-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$193.60
Max. Negotiated Rate	$281.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$211.20
Rate for Payer: Aetna of CA Government/Medicare	$211.20
Rate for Payer: Cash Price	$193.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$281.60
Rate for Payer: Health Smart Auto/Commercial	$211.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$211.20
Rate for Payer: LLUH Dept of Risk Management WC	$193.60
Rate for Payer: Multiplan Commercial	$264.00

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