|
RISPERIDONE 2 MG TABLET [18311]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 0904-6360-61
|
| Hospital Charge Code |
1712188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
RISPERIDONE 3 MG TABLET [18312]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 68084-274-11
|
| Hospital Charge Code |
1712189
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.46 |
| 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 |
$0.27
|
| 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 Beech St/Commercial/PHCS |
$0.46
|
|
|
RISPERIDONE 3 MG TABLET [18312]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 68084-274-11
|
| Hospital Charge Code |
1712189
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.46
|
|
|
RISPERIDONE 3 MG TABLET [18312]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 68084-274-01
|
| Hospital Charge Code |
1712189
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.46
|
|
|
RISPERIDONE 3 MG TABLET [18312]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 68084-274-01
|
| Hospital Charge Code |
1712189
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.46 |
| 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 |
$0.27
|
| 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 Beech St/Commercial/PHCS |
$0.46
|
|
|
RISPERIDONE 4 MG TABLET [18310]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 0904-6362-61
|
| Hospital Charge Code |
1712190
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
RISPERIDONE 4 MG TABLET [18310]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 68084-277-01
|
| Hospital Charge Code |
1712190
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.46 |
| 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 |
$0.27
|
| 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 Beech St/Commercial/PHCS |
$0.46
|
|
|
RISPERIDONE 4 MG TABLET [18310]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 68084-277-01
|
| Hospital Charge Code |
1712190
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.46
|
|
|
RISPERIDONE 4 MG TABLET [18310]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 0904-6362-61
|
| Hospital Charge Code |
1712190
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
RISPERIDONE 4 MG TABLET [18310]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 68084-277-11
|
| Hospital Charge Code |
1712190
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.46 |
| 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 |
$0.27
|
| 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 Beech St/Commercial/PHCS |
$0.46
|
|
|
RISPERIDONE 4 MG TABLET [18310]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 68084-277-11
|
| Hospital Charge Code |
1712190
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.46
|
|
|
RITLECITINIB 50 MG CAPSULE [238783]
|
Facility
|
OP
|
$161.54
|
|
|
Service Code
|
NDC 0069-0334-28
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$88.85 |
| Max. Negotiated Rate |
$121.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$96.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$96.92
|
| Rate for Payer: Cash Price |
$72.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$96.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$96.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$121.16
|
|
|
RITLECITINIB 50 MG CAPSULE [238783]
|
Facility
|
IP
|
$161.54
|
|
|
Service Code
|
NDC 0069-0334-28
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$88.85 |
| Max. Negotiated Rate |
$129.23 |
| Rate for Payer: Cash Price |
$72.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$129.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$96.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$121.16
|
|
|
RITONAVIR 100 MG TABLET [100995]
|
Facility
|
IP
|
$6.40
|
|
|
Service Code
|
NDC 0054-0407-13
|
| Hospital Charge Code |
1712621
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$5.12 |
| Rate for Payer: Cash Price |
$2.88
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$4.80
|
|
|
RITONAVIR 100 MG TABLET [100995]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 65862-687-30
|
| Hospital Charge Code |
1712621
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$2.40 |
| 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 |
$1.44
|
| 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 Beech St/Commercial/PHCS |
$2.40
|
|
|
RITONAVIR 100 MG TABLET [100995]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 31722-597-30
|
| Hospital Charge Code |
1712621
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$2.40
|
|
|
RITONAVIR 100 MG TABLET [100995]
|
Facility
|
OP
|
$6.40
|
|
|
Service Code
|
NDC 0054-0407-13
|
| Hospital Charge Code |
1712621
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$4.80 |
| 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 |
$2.88
|
| 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 Beech St/Commercial/PHCS |
$4.80
|
|
|
RITONAVIR 100 MG TABLET [100995]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 65862-687-30
|
| Hospital Charge Code |
1712621
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$2.40
|
|
|
RITONAVIR 100 MG TABLET [100995]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 31722-597-30
|
| Hospital Charge Code |
1712621
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$2.40 |
| 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 |
$1.44
|
| 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 Beech St/Commercial/PHCS |
$2.40
|
|
|
RITONAVIR 80 MG/ML ORAL SOLUTION [16440]
|
Facility
|
IP
|
$7.20
|
|
|
Service Code
|
NDC 0074-1940-63
|
| Hospital Charge Code |
1715199
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.40
|
|
|
RITONAVIR 80 MG/ML ORAL SOLUTION [16440]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
NDC 0074-1940-63
|
| Hospital Charge Code |
1715199
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.32
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.40
|
|
|
RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS [22149]
|
Facility
|
OP
|
$112.74
|
|
|
Service Code
|
CPT J9312
|
| Hospital Charge Code |
1755659
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.01 |
| Max. Negotiated Rate |
$84.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$67.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$67.64
|
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$67.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$67.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$84.56
|
|
|
RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS [22149]
|
Facility
|
OP
|
$112.74
|
|
|
Service Code
|
CPT J9312
|
| Hospital Charge Code |
1755782
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.01 |
| Max. Negotiated Rate |
$84.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$67.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$67.64
|
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$67.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$67.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$84.56
|
|
|
RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS [22149]
|
Facility
|
IP
|
$112.74
|
|
|
Service Code
|
CPT J9312
|
| Hospital Charge Code |
1755659
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.01 |
| Max. Negotiated Rate |
$90.19 |
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$90.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$67.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$84.56
|
|
|
RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS [22149]
|
Facility
|
IP
|
$112.74
|
|
|
Service Code
|
CPT J9312
|
| Hospital Charge Code |
1755782
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.01 |
| Max. Negotiated Rate |
$90.19 |
| Rate for Payer: Cash Price |
$50.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$90.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$67.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$84.56
|
|
