|
RIFAMPIN 300 MG CAPSULE [11293]
|
Facility
|
OP
|
$2.23
|
|
|
Service Code
|
NDC 60687-586-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.36
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.90
|
| Rate for Payer: Dignity Health Senior |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.38
|
| Rate for Payer: Heritage Provider Network Senior |
$1.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$1.67
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.89
|
| Rate for Payer: TriValley Medical Group Senior |
$0.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.90
|
|
|
RIFAMPIN 300 MG CAPSULE [11293]
|
Facility
|
OP
|
$4.41
|
|
|
Service Code
|
NDC 68180-659-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.75 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.31
|
| Rate for Payer: Blue Shield of California Commercial |
$2.69
|
| Rate for Payer: Blue Shield of California EPN |
$2.15
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.75
|
| Rate for Payer: Dignity Health Senior |
$3.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.73
|
| Rate for Payer: Heritage Provider Network Senior |
$2.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.09
|
| Rate for Payer: Multiplan Commercial |
$3.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.76
|
| Rate for Payer: TriValley Medical Group Senior |
$1.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.75
|
| Rate for Payer: Vantage Medical Group Senior |
$3.75
|
|
|
RIFAMPIN 300 MG CAPSULE [11293]
|
Facility
|
IP
|
$2.23
|
|
|
Service Code
|
NDC 60687-586-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.51
|
| Rate for Payer: Heritage Provider Network Senior |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.67
|
|
|
RIFAMPIN 300 MG CAPSULE [11293]
|
Facility
|
IP
|
$4.41
|
|
|
Service Code
|
NDC 68180-659-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.31 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.99
|
| Rate for Payer: Heritage Provider Network Senior |
$2.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$3.31
|
|
|
RIFAMPIN 300 MG CAPSULE [11293]
|
Facility
|
OP
|
$2.23
|
|
|
Service Code
|
NDC 60687-586-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.36
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.90
|
| Rate for Payer: Dignity Health Senior |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.38
|
| Rate for Payer: Heritage Provider Network Senior |
$1.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$1.67
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.89
|
| Rate for Payer: TriValley Medical Group Senior |
$0.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.90
|
|
|
RIFAMPIN 300 MG CAPSULE [11293]
|
Facility
|
IP
|
$4.41
|
|
|
Service Code
|
NDC 68180-659-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.31 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.99
|
| Rate for Payer: Heritage Provider Network Senior |
$2.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$3.31
|
|
|
RIFAMPIN 300 MG CAPSULE [11293]
|
Facility
|
OP
|
$4.41
|
|
|
Service Code
|
NDC 68180-659-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.75 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.31
|
| Rate for Payer: Blue Shield of California Commercial |
$2.69
|
| Rate for Payer: Blue Shield of California EPN |
$2.15
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.75
|
| Rate for Payer: Dignity Health Senior |
$3.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.73
|
| Rate for Payer: Heritage Provider Network Senior |
$2.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.09
|
| Rate for Payer: Multiplan Commercial |
$3.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.76
|
| Rate for Payer: TriValley Medical Group Senior |
$1.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.75
|
| Rate for Payer: Vantage Medical Group Senior |
$3.75
|
|
|
RIFAMPIN 600 MG INTRAVENOUS SOLUTION [11291]
|
Facility
|
OP
|
$184.92
|
|
|
Service Code
|
HCPCS J2804
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$157.18 |
| Rate for Payer: Adventist Health Commercial |
$36.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$98.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$127.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$157.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$101.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$138.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$112.80
|
| Rate for Payer: Blue Shield of California EPN |
$90.24
|
| Rate for Payer: Cash Price |
$101.71
|
| Rate for Payer: Cash Price |
$101.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$85.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$157.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$157.18
|
| Rate for Payer: Dignity Health Senior |
$157.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$118.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$85.62
|
| Rate for Payer: Heritage Provider Network Senior |
$85.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$88.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$129.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$129.44
|
| Rate for Payer: Multiplan Commercial |
$138.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$73.97
|
| Rate for Payer: TriValley Medical Group Senior |
$73.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$66.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$61.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$157.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$157.18
|
| Rate for Payer: Vantage Medical Group Senior |
$157.18
|
|
|
RIFAMPIN 600 MG INTRAVENOUS SOLUTION [11291]
|
Facility
|
IP
|
$184.92
|
|
|
Service Code
|
HCPCS J2804
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.47 |
| Max. Negotiated Rate |
$138.69 |
| Rate for Payer: Adventist Health Commercial |
$36.98
|
| Rate for Payer: Cash Price |
$101.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$85.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$99.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$85.62
|
| Rate for Payer: Heritage Provider Network Senior |
$85.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.23
|
| Rate for Payer: Multiplan Commercial |
$138.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$66.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$61.23
|
|
|
RIFAMPIN ORAL SUSPENSION COMPOUND 10 MG/ML [4080331]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 9994-0803-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
RIFAMPIN ORAL SUSPENSION COMPOUND 10 MG/ML [4080331]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 9994-0803-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
RIFAPENTINE 150 MG TABLET [23365]
|
Facility
|
OP
|
$5.96
|
|
|
Service Code
|
NDC 0088-2102-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$5.07 |
| Rate for Payer: Adventist Health Commercial |
$1.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.47
|
| Rate for Payer: Blue Shield of California Commercial |
$3.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.91
|
| Rate for Payer: Cash Price |
$3.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.07
|
| Rate for Payer: Dignity Health Senior |
$5.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.69
|
| Rate for Payer: Heritage Provider Network Senior |
$3.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.17
|
| Rate for Payer: Multiplan Commercial |
$4.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Senior |
$2.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.07
|
| Rate for Payer: Vantage Medical Group Senior |
$5.07
|
|
|
RIFAPENTINE 150 MG TABLET [23365]
|
Facility
|
IP
|
$5.96
|
|
|
Service Code
|
NDC 0088-2102-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Adventist Health Commercial |
$1.19
|
| Rate for Payer: Cash Price |
$3.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.03
|
| Rate for Payer: Heritage Provider Network Senior |
$4.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.49
|
| Rate for Payer: Multiplan Commercial |
$4.47
|
|
|
RIFAXIMIN 200 MG TABLET [39063]
|
Facility
|
IP
|
$13.47
|
|
|
Service Code
|
NDC 65649-301-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.44 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: Adventist Health Commercial |
$2.69
|
| Rate for Payer: Cash Price |
$7.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.12
|
| Rate for Payer: Heritage Provider Network Senior |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.37
|
| Rate for Payer: Multiplan Commercial |
$10.10
|
|
|
RIFAXIMIN 200 MG TABLET [39063]
|
Facility
|
OP
|
$13.47
|
|
|
Service Code
|
NDC 65649-301-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.44 |
| Max. Negotiated Rate |
$11.45 |
| Rate for Payer: Adventist Health Commercial |
$2.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.10
|
| Rate for Payer: Blue Shield of California Commercial |
$8.22
|
| Rate for Payer: Blue Shield of California EPN |
$6.57
|
| Rate for Payer: Cash Price |
$7.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.45
|
| Rate for Payer: Dignity Health Senior |
$11.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.34
|
| Rate for Payer: Heritage Provider Network Senior |
$8.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.43
|
| Rate for Payer: Multiplan Commercial |
$10.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.39
|
| Rate for Payer: TriValley Medical Group Senior |
$5.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.45
|
| Rate for Payer: Vantage Medical Group Senior |
$11.45
|
|
|
RIFAXIMIN 550 MG TABLET [104604]
|
Facility
|
IP
|
$69.26
|
|
|
Service Code
|
NDC 65649-303-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.54 |
| Max. Negotiated Rate |
$51.95 |
| Rate for Payer: Adventist Health Commercial |
$13.85
|
| Rate for Payer: Cash Price |
$38.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.89
|
| Rate for Payer: Heritage Provider Network Senior |
$46.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.32
|
| Rate for Payer: Multiplan Commercial |
$51.95
|
|
|
RIFAXIMIN 550 MG TABLET [104604]
|
Facility
|
OP
|
$69.26
|
|
|
Service Code
|
NDC 65649-303-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.54 |
| Max. Negotiated Rate |
$58.87 |
| Rate for Payer: Adventist Health Commercial |
$13.85
|
| Rate for Payer: Aetna of CA Gatekeeper |
$37.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$47.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$58.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$51.95
|
| Rate for Payer: Blue Shield of California Commercial |
$42.25
|
| Rate for Payer: Blue Shield of California EPN |
$33.80
|
| Rate for Payer: Cash Price |
$38.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$45.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$58.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$58.87
|
| Rate for Payer: Dignity Health Senior |
$58.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$42.87
|
| Rate for Payer: Heritage Provider Network Senior |
$42.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$33.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$48.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$48.48
|
| Rate for Payer: Multiplan Commercial |
$51.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$27.70
|
| Rate for Payer: TriValley Medical Group Senior |
$27.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$34.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$58.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$58.87
|
| Rate for Payer: Vantage Medical Group Senior |
$58.87
|
|
|
RIFAXIMIN 550 MG TABLET [104604]
|
Facility
|
IP
|
$69.26
|
|
|
Service Code
|
NDC 65649-303-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.54 |
| Max. Negotiated Rate |
$51.95 |
| Rate for Payer: Adventist Health Commercial |
$13.85
|
| Rate for Payer: Cash Price |
$38.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.89
|
| Rate for Payer: Heritage Provider Network Senior |
$46.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.32
|
| Rate for Payer: Multiplan Commercial |
$51.95
|
|
|
RIFAXIMIN 550 MG TABLET [104604]
|
Facility
|
OP
|
$69.26
|
|
|
Service Code
|
NDC 65649-303-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.54 |
| Max. Negotiated Rate |
$58.87 |
| Rate for Payer: Adventist Health Commercial |
$13.85
|
| Rate for Payer: Aetna of CA Gatekeeper |
$37.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$47.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$58.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$51.95
|
| Rate for Payer: Blue Shield of California Commercial |
$42.25
|
| Rate for Payer: Blue Shield of California EPN |
$33.80
|
| Rate for Payer: Cash Price |
$38.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$45.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$58.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$58.87
|
| Rate for Payer: Dignity Health Senior |
$58.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$42.87
|
| Rate for Payer: Heritage Provider Network Senior |
$42.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$33.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$48.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$48.48
|
| Rate for Payer: Multiplan Commercial |
$51.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$27.70
|
| Rate for Payer: TriValley Medical Group Senior |
$27.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$34.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$58.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$58.87
|
| Rate for Payer: Vantage Medical Group Senior |
$58.87
|
|
|
RIFAXIMIN ORAL SUSPENSION COMPOUND 20 MG/ML [4080332]
|
Facility
|
IP
|
$1.32
|
|
|
Service Code
|
NDC 9994-0803-32
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
|
|
RIFAXIMIN ORAL SUSPENSION COMPOUND 20 MG/ML [4080332]
|
Facility
|
OP
|
$1.32
|
|
|
Service Code
|
NDC 9994-0803-32
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.99
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.12
|
| Rate for Payer: Dignity Health Senior |
$1.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Senior |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Senior |
$0.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.12
|
| Rate for Payer: Vantage Medical Group Senior |
$1.12
|
|
|
RILPIVIRINE HCL 25 MG TABLET [109909]
|
Facility
|
OP
|
$59.33
|
|
|
Service Code
|
NDC 59676-278-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.74 |
| Max. Negotiated Rate |
$50.43 |
| Rate for Payer: Adventist Health Commercial |
$11.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$31.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$50.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$44.50
|
| Rate for Payer: Blue Shield of California Commercial |
$36.19
|
| Rate for Payer: Blue Shield of California EPN |
$28.95
|
| Rate for Payer: Cash Price |
$32.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.43
|
| Rate for Payer: Dignity Health Senior |
$50.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$36.73
|
| Rate for Payer: Heritage Provider Network Senior |
$36.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$28.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$41.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$41.53
|
| Rate for Payer: Multiplan Commercial |
$44.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$23.73
|
| Rate for Payer: TriValley Medical Group Senior |
$23.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$29.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$50.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.43
|
| Rate for Payer: Vantage Medical Group Senior |
$50.43
|
|
|
RILPIVIRINE HCL 25 MG TABLET [109909]
|
Facility
|
IP
|
$59.33
|
|
|
Service Code
|
NDC 59676-278-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.74 |
| Max. Negotiated Rate |
$44.50 |
| Rate for Payer: Adventist Health Commercial |
$11.87
|
| Rate for Payer: Cash Price |
$32.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.17
|
| Rate for Payer: Heritage Provider Network Senior |
$40.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.83
|
| Rate for Payer: Multiplan Commercial |
$44.50
|
|
|
RILUZOLE 50 MG TABLET [16124]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 67877-286-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
RILUZOLE 50 MG TABLET [16124]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 67877-286-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Senior |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
