|
RIFAMPIN 300 MG CAPSULE [11293]
|
Facility
IP
|
$1.51
|
|
|
Service Code
|
NDC 61748-018-01
|
| Hospital Charge Code |
1710623
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.13
|
|
|
RIFAMPIN 600 MG INTRAVENOUS SOLUTION [11291]
|
Facility
IP
|
$184.92
|
|
|
Service Code
|
NDC 67457-445-60
|
| Hospital Charge Code |
1753334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.47 |
| Max. Negotiated Rate |
$138.69 |
| Rate for Payer: Adventist Health Commercial |
$36.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$127.04
|
| Rate for Payer: Cash Price |
$83.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$99.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$125.19
|
| Rate for Payer: Heritage Provider Network Senior |
$125.19
|
| 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
|
|
|
RIFAMPIN 600 MG INTRAVENOUS SOLUTION [11291]
|
Facility
OP
|
$184.92
|
|
|
Service Code
|
NDC 67457-445-60
|
| Hospital Charge Code |
1753334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.47 |
| 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: AlphaCare Medical Group Commercial/Exchange |
$157.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$101.71
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$138.69
|
| Rate for Payer: Blue Shield of California Commercial |
$114.84
|
| Rate for Payer: Blue Shield of California EPN |
$108.55
|
| Rate for Payer: Cash Price |
$83.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$120.20
|
| 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 |
$114.47
|
| Rate for Payer: Heritage Provider Network Senior |
$114.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$89.13
|
| 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: Vantage Medical Group Medi-Cal |
$157.18
|
| Rate for Payer: Vantage Medical Group Senior |
$157.18
|
|
|
RIFAMPIN ORAL SUSPENSION COMPOUND 10 MG/ML [4080331]
|
Facility
OP
|
$0.05
|
|
|
Service Code
|
NDC 9994-0803-31
|
| Hospital Charge Code |
1715511
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| 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 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: Multiplan Commercial |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
RIFAMPIN ORAL SUSPENSION COMPOUND 10 MG/ML [4080331]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 9994-0803-31
|
| Hospital Charge Code |
1715511
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| 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 |
$0.04
|
|
|
RIFAPENTINE 150 MG TABLET [23365]
|
Facility
IP
|
$5.54
|
|
|
Service Code
|
NDC 0088-2102-01
|
| Hospital Charge Code |
ERX23365
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.16 |
| Rate for Payer: Adventist Health Commercial |
$1.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.81
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.75
|
| Rate for Payer: Heritage Provider Network Senior |
$3.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
|
|
RIFAPENTINE 150 MG TABLET [23365]
|
Facility
OP
|
$5.54
|
|
|
Service Code
|
NDC 0088-2102-01
|
| Hospital Charge Code |
ERX23365
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.71 |
| Rate for Payer: Adventist Health Commercial |
$1.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.16
|
| Rate for Payer: Blue Shield of California Commercial |
$3.44
|
| Rate for Payer: Blue Shield of California EPN |
$3.25
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.71
|
| Rate for Payer: Dignity Health Senior |
$4.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.43
|
| Rate for Payer: Heritage Provider Network Senior |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.71
|
| Rate for Payer: Vantage Medical Group Senior |
$4.71
|
|
|
RIFAXIMIN 200 MG TABLET [39063]
|
Facility
IP
|
$12.29
|
|
|
Service Code
|
NDC 65649-301-03
|
| Hospital Charge Code |
1710937
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$9.22 |
| Rate for Payer: Adventist Health Commercial |
$2.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.44
|
| Rate for Payer: Cash Price |
$5.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.32
|
| Rate for Payer: Heritage Provider Network Senior |
$8.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.07
|
| Rate for Payer: Multiplan Commercial |
$9.22
|
|
|
RIFAXIMIN 200 MG TABLET [39063]
|
Facility
OP
|
$12.29
|
|
|
Service Code
|
NDC 65649-301-03
|
| Hospital Charge Code |
1710937
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Adventist Health Commercial |
$2.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.22
|
| Rate for Payer: Blue Shield of California Commercial |
$7.63
|
| Rate for Payer: Blue Shield of California EPN |
$7.21
|
| Rate for Payer: Cash Price |
$5.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.45
|
| Rate for Payer: Dignity Health Senior |
$10.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.61
|
| Rate for Payer: Heritage Provider Network Senior |
$7.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.07
|
| Rate for Payer: Multiplan Commercial |
$9.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.45
|
| Rate for Payer: Vantage Medical Group Senior |
$10.45
|
|
|
RIFAXIMIN 550 MG TABLET [104604]
|
Facility
IP
|
$63.20
|
|
|
Service Code
|
NDC 65649-303-03
|
| Hospital Charge Code |
1712455
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.44 |
| Max. Negotiated Rate |
$47.40 |
| Rate for Payer: Adventist Health Commercial |
$12.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.42
|
| Rate for Payer: Cash Price |
$28.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$42.79
|
| Rate for Payer: Heritage Provider Network Senior |
$42.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.80
|
| Rate for Payer: Multiplan Commercial |
$47.40
|
|
|
RIFAXIMIN 550 MG TABLET [104604]
|
Facility
IP
|
$63.20
|
|
|
Service Code
|
NDC 65649-303-02
|
| Hospital Charge Code |
1712455
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.44 |
| Max. Negotiated Rate |
$47.40 |
| Rate for Payer: Adventist Health Commercial |
$12.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.42
|
| Rate for Payer: Cash Price |
$28.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$42.79
|
| Rate for Payer: Heritage Provider Network Senior |
$42.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.80
|
| Rate for Payer: Multiplan Commercial |
$47.40
|
|
|
RIFAXIMIN 550 MG TABLET [104604]
|
Facility
OP
|
$63.20
|
|
|
Service Code
|
NDC 65649-303-03
|
| Hospital Charge Code |
1712455
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.44 |
| Max. Negotiated Rate |
$53.72 |
| Rate for Payer: Adventist Health Commercial |
$12.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$33.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$53.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$34.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$47.40
|
| Rate for Payer: Blue Shield of California Commercial |
$39.25
|
| Rate for Payer: Blue Shield of California EPN |
$37.10
|
| Rate for Payer: Cash Price |
$28.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$41.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$53.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.72
|
| Rate for Payer: Dignity Health Senior |
$53.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$39.12
|
| Rate for Payer: Heritage Provider Network Senior |
$39.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$30.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.80
|
| Rate for Payer: Multiplan Commercial |
$47.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.72
|
| Rate for Payer: Vantage Medical Group Senior |
$53.72
|
|
|
RIFAXIMIN 550 MG TABLET [104604]
|
Facility
OP
|
$63.20
|
|
|
Service Code
|
NDC 65649-303-02
|
| Hospital Charge Code |
1712455
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.44 |
| Max. Negotiated Rate |
$53.72 |
| Rate for Payer: Adventist Health Commercial |
$12.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$33.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$53.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$34.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$47.40
|
| Rate for Payer: Blue Shield of California Commercial |
$39.25
|
| Rate for Payer: Blue Shield of California EPN |
$37.10
|
| Rate for Payer: Cash Price |
$28.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$41.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$53.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.72
|
| Rate for Payer: Dignity Health Senior |
$53.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$39.12
|
| Rate for Payer: Heritage Provider Network Senior |
$39.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$30.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.80
|
| Rate for Payer: Multiplan Commercial |
$47.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.72
|
| Rate for Payer: Vantage Medical Group Senior |
$53.72
|
|
|
RIFAXIMIN ORAL SUSPENSION COMPOUND 20 MG/ML [4080332]
|
Facility
IP
|
$1.33
|
|
|
Service Code
|
NDC 9994-0803-32
|
| Hospital Charge Code |
1715270
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.91
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Senior |
$0.90
|
| 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 |
$1.00
|
|
|
RIFAXIMIN ORAL SUSPENSION COMPOUND 20 MG/ML [4080332]
|
Facility
OP
|
$1.33
|
|
|
Service Code
|
NDC 9994-0803-32
|
| Hospital Charge Code |
1715270
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.13
|
| Rate for Payer: Dignity Health Senior |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| 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 |
$0.64
|
| 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 |
$1.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.13
|
| Rate for Payer: Vantage Medical Group Senior |
$1.13
|
|
|
RILPIVIRINE HCL 25 MG TABLET [109909]
|
Facility
OP
|
$54.01
|
|
|
Service Code
|
NDC 59676-278-01
|
| Hospital Charge Code |
1712619
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.78 |
| Max. Negotiated Rate |
$45.91 |
| Rate for Payer: Adventist Health Commercial |
$10.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$28.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$45.91
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$29.71
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$40.51
|
| Rate for Payer: Blue Shield of California Commercial |
$33.54
|
| Rate for Payer: Blue Shield of California EPN |
$31.70
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$35.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$45.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$45.91
|
| Rate for Payer: Dignity Health Senior |
$45.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.43
|
| Rate for Payer: Heritage Provider Network Senior |
$33.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$26.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.50
|
| Rate for Payer: Multiplan Commercial |
$40.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$45.91
|
| Rate for Payer: Vantage Medical Group Senior |
$45.91
|
|
|
RILPIVIRINE HCL 25 MG TABLET [109909]
|
Facility
IP
|
$54.01
|
|
|
Service Code
|
NDC 59676-278-01
|
| Hospital Charge Code |
1712619
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.78 |
| Max. Negotiated Rate |
$40.51 |
| Rate for Payer: Adventist Health Commercial |
$10.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.10
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$36.56
|
| Rate for Payer: Heritage Provider Network Senior |
$36.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.50
|
| Rate for Payer: Multiplan Commercial |
$40.51
|
|
|
RILUZOLE 50 MG TABLET [16124]
|
Facility
OP
|
$1.58
|
|
|
Service Code
|
NDC 68462-381-60
|
| Hospital Charge Code |
1712269
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.93
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.34
|
| Rate for Payer: Dignity Health Senior |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.98
|
| Rate for Payer: Heritage Provider Network Senior |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: Vantage Medical Group Senior |
$1.34
|
|
|
RILUZOLE 50 MG TABLET [16124]
|
Facility
OP
|
$1.58
|
|
|
Service Code
|
NDC 62756-538-86
|
| Hospital Charge Code |
1712269
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.93
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.34
|
| Rate for Payer: Dignity Health Senior |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.98
|
| Rate for Payer: Heritage Provider Network Senior |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: Vantage Medical Group Senior |
$1.34
|
|
|
RILUZOLE 50 MG TABLET [16124]
|
Facility
IP
|
$1.58
|
|
|
Service Code
|
NDC 62756-538-86
|
| Hospital Charge Code |
1712269
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.09
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.07
|
| Rate for Payer: Heritage Provider Network Senior |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
|
|
RILUZOLE 50 MG TABLET [16124]
|
Facility
OP
|
$0.80
|
|
|
Service Code
|
NDC 67877-286-60
|
| Hospital Charge Code |
1712269
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| 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 |
$0.39
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
RILUZOLE 50 MG TABLET [16124]
|
Facility
IP
|
$1.58
|
|
|
Service Code
|
NDC 68462-381-60
|
| Hospital Charge Code |
1712269
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.09
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.07
|
| Rate for Payer: Heritage Provider Network Senior |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
|
|
RILUZOLE 50 MG TABLET [16124]
|
Facility
IP
|
$0.80
|
|
|
Service Code
|
NDC 67877-286-60
|
| Hospital Charge Code |
1712269
|
|
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: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Cash Price |
$0.36
|
| 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
|
|
|
RIMABOTULINUMTOXINB 2,500 UNIT/0.5 ML INTRAMUSCULAR SOLUTION [108078]
|
Facility
IP
|
$747.14
|
|
|
Service Code
|
CPT J0587
|
| Hospital Charge Code |
NDG108078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$135.23 |
| Max. Negotiated Rate |
$560.36 |
| Rate for Payer: Adventist Health Commercial |
$149.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$513.29
|
| Rate for Payer: Cash Price |
$336.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$343.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$403.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$505.81
|
| Rate for Payer: Heritage Provider Network Senior |
$505.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$135.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$186.78
|
| Rate for Payer: Multiplan Commercial |
$560.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$272.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$249.62
|
|
|
RIMABOTULINUMTOXINB 2,500 UNIT/0.5 ML INTRAMUSCULAR SOLUTION [108078]
|
Facility
OP
|
$747.14
|
|
|
Service Code
|
CPT J0587
|
| Hospital Charge Code |
NDG108078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.39 |
| Max. Negotiated Rate |
$560.36 |
| Rate for Payer: Adventist Health Commercial |
$149.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$32.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$513.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$16.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.42
|
| Rate for Payer: Blue Shield of California Commercial |
$12.39
|
| Rate for Payer: Blue Shield of California EPN |
$12.39
|
| Rate for Payer: Cash Price |
$336.21
|
| Rate for Payer: Cash Price |
$336.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$343.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.33
|
| Rate for Payer: Dignity Health Senior |
$14.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$478.17
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$345.93
|
| Rate for Payer: Heritage Provider Network Senior |
$345.93
|
| Rate for Payer: Humana Medicare |
$13.03
|
| Rate for Payer: IEHP Medi-Cal |
$27.28
|
| Rate for Payer: IEHP Medicare Advantage |
$13.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$135.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$186.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.41
|
| Rate for Payer: Multiplan Commercial |
$560.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.33
|
| Rate for Payer: TriValley Medical Group Senior |
$13.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$272.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$249.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.33
|
| Rate for Payer: Vantage Medical Group Senior |
$13.03
|
|
