|
ROSUVASTATIN 10 MG TABLET [35134]
|
Facility
IP
|
$11.06
|
|
|
Service Code
|
NDC 0310-0751-90
|
| Hospital Charge Code |
1712304
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$8.30 |
| Rate for Payer: Adventist Health Commercial |
$2.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.60
|
| Rate for Payer: Cash Price |
$4.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.49
|
| Rate for Payer: Heritage Provider Network Senior |
$7.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$8.30
|
|
|
ROSUVASTATIN 10 MG TABLET [35134]
|
Facility
OP
|
$11.06
|
|
|
Service Code
|
NDC 0310-0751-90
|
| Hospital Charge Code |
1712304
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$9.40 |
| Rate for Payer: Adventist Health Commercial |
$2.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.30
|
| Rate for Payer: Blue Shield of California Commercial |
$6.87
|
| Rate for Payer: Blue Shield of California EPN |
$6.49
|
| Rate for Payer: Cash Price |
$4.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.40
|
| Rate for Payer: Dignity Health Senior |
$9.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.85
|
| Rate for Payer: Heritage Provider Network Senior |
$6.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$8.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.40
|
| Rate for Payer: Vantage Medical Group Senior |
$9.40
|
|
|
ROSUVASTATIN 20 MG TABLET [35135]
|
Facility
IP
|
$11.06
|
|
|
Service Code
|
NDC 0310-0752-90
|
| Hospital Charge Code |
1712305
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$8.30 |
| Rate for Payer: Adventist Health Commercial |
$2.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.60
|
| Rate for Payer: Cash Price |
$4.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.49
|
| Rate for Payer: Heritage Provider Network Senior |
$7.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$8.30
|
|
|
ROSUVASTATIN 20 MG TABLET [35135]
|
Facility
OP
|
$11.06
|
|
|
Service Code
|
NDC 0310-0752-90
|
| Hospital Charge Code |
1712305
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$9.40 |
| Rate for Payer: Adventist Health Commercial |
$2.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.30
|
| Rate for Payer: Blue Shield of California Commercial |
$6.87
|
| Rate for Payer: Blue Shield of California EPN |
$6.49
|
| Rate for Payer: Cash Price |
$4.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.40
|
| Rate for Payer: Dignity Health Senior |
$9.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.85
|
| Rate for Payer: Heritage Provider Network Senior |
$6.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$8.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.40
|
| Rate for Payer: Vantage Medical Group Senior |
$9.40
|
|
|
ROSUVASTATIN 40 MG TABLET [35136]
|
Facility
IP
|
$17.90
|
|
|
Service Code
|
NDC 71205-078-30
|
| Hospital Charge Code |
1712306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$13.42 |
| Rate for Payer: Adventist Health Commercial |
$3.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.30
|
| Rate for Payer: Cash Price |
$8.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.12
|
| Rate for Payer: Heritage Provider Network Senior |
$12.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.48
|
| Rate for Payer: Multiplan Commercial |
$13.42
|
|
|
ROSUVASTATIN 40 MG TABLET [35136]
|
Facility
OP
|
$17.90
|
|
|
Service Code
|
NDC 71205-078-30
|
| Hospital Charge Code |
1712306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$15.22 |
| Rate for Payer: Adventist Health Commercial |
$3.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$15.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.42
|
| Rate for Payer: Blue Shield of California Commercial |
$11.12
|
| Rate for Payer: Blue Shield of California EPN |
$10.51
|
| Rate for Payer: Cash Price |
$8.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.22
|
| Rate for Payer: Dignity Health Senior |
$15.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.08
|
| Rate for Payer: Heritage Provider Network Senior |
$11.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.48
|
| Rate for Payer: Multiplan Commercial |
$13.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.22
|
| Rate for Payer: Vantage Medical Group Senior |
$15.22
|
|
|
ROSUVASTATIN 40 MG TABLET [35136]
|
Facility
OP
|
$0.23
|
|
|
Service Code
|
NDC 68462-264-30
|
| Hospital Charge Code |
1712306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
ROSUVASTATIN 40 MG TABLET [35136]
|
Facility
IP
|
$0.23
|
|
|
Service Code
|
NDC 68462-264-30
|
| Hospital Charge Code |
1712306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION [70476]
|
Facility
IP
|
$55.46
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
1716082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.04 |
| Max. Negotiated Rate |
$41.60 |
| Rate for Payer: Adventist Health Commercial |
$11.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.10
|
| Rate for Payer: Cash Price |
$24.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.55
|
| Rate for Payer: Heritage Provider Network Senior |
$37.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.86
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.53
|
|
|
ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION [70476]
|
Facility
OP
|
$55.46
|
|
|
Service Code
|
CPT 90680
|
| Hospital Charge Code |
1716082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.04 |
| Max. Negotiated Rate |
$237.76 |
| Rate for Payer: Adventist Health Commercial |
$11.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$237.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$47.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$30.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$41.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$143.40
|
| Rate for Payer: Blue Shield of California Commercial |
$92.18
|
| Rate for Payer: Blue Shield of California EPN |
$92.18
|
| Rate for Payer: Cash Price |
$24.96
|
| Rate for Payer: Cash Price |
$24.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.14
|
| Rate for Payer: Dignity Health Senior |
$47.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.68
|
| Rate for Payer: Heritage Provider Network Senior |
$25.68
|
| Rate for Payer: IEHP Medi-Cal |
$155.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$26.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.86
|
| Rate for Payer: Multiplan Commercial |
$41.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.14
|
| Rate for Payer: Vantage Medical Group Senior |
$47.14
|
|
|
ROTIGOTINE 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH [82100]
|
Facility
IP
|
$32.26
|
|
|
Service Code
|
NDC 50474-802-03
|
| Hospital Charge Code |
ERX82100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.84 |
| Max. Negotiated Rate |
$24.20 |
| Rate for Payer: Adventist Health Commercial |
$6.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.16
|
| Rate for Payer: Cash Price |
$14.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.84
|
| Rate for Payer: Heritage Provider Network Senior |
$21.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.06
|
| Rate for Payer: Multiplan Commercial |
$24.20
|
|
|
ROTIGOTINE 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH [82100]
|
Facility
OP
|
$32.26
|
|
|
Service Code
|
NDC 50474-802-03
|
| Hospital Charge Code |
ERX82100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.84 |
| Max. Negotiated Rate |
$27.42 |
| Rate for Payer: Adventist Health Commercial |
$6.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$24.20
|
| Rate for Payer: Blue Shield of California Commercial |
$20.03
|
| Rate for Payer: Blue Shield of California EPN |
$18.94
|
| Rate for Payer: Cash Price |
$14.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.42
|
| Rate for Payer: Dignity Health Senior |
$27.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.97
|
| Rate for Payer: Heritage Provider Network Senior |
$19.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.06
|
| Rate for Payer: Multiplan Commercial |
$24.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.42
|
| Rate for Payer: Vantage Medical Group Senior |
$27.42
|
|
|
ROTIGOTINE 4 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH [82101]
|
Facility
OP
|
$32.26
|
|
|
Service Code
|
NDC 50474-804-03
|
| Hospital Charge Code |
ERX82101
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.84 |
| Max. Negotiated Rate |
$27.42 |
| Rate for Payer: Adventist Health Commercial |
$6.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$24.20
|
| Rate for Payer: Blue Shield of California Commercial |
$20.03
|
| Rate for Payer: Blue Shield of California EPN |
$18.94
|
| Rate for Payer: Cash Price |
$14.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.42
|
| Rate for Payer: Dignity Health Senior |
$27.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.97
|
| Rate for Payer: Heritage Provider Network Senior |
$19.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.06
|
| Rate for Payer: Multiplan Commercial |
$24.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.42
|
| Rate for Payer: Vantage Medical Group Senior |
$27.42
|
|
|
ROTIGOTINE 4 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH [82101]
|
Facility
IP
|
$32.26
|
|
|
Service Code
|
NDC 50474-804-03
|
| Hospital Charge Code |
ERX82101
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.84 |
| Max. Negotiated Rate |
$24.20 |
| Rate for Payer: Adventist Health Commercial |
$6.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.16
|
| Rate for Payer: Cash Price |
$14.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.84
|
| Rate for Payer: Heritage Provider Network Senior |
$21.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.06
|
| Rate for Payer: Multiplan Commercial |
$24.20
|
|
|
RUFINAMIDE 200 MG TABLET [95691]
|
Facility
OP
|
$3.69
|
|
|
Service Code
|
NDC 0054-0425-23
|
| Hospital Charge Code |
1712406
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$3.14 |
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.77
|
| Rate for Payer: Blue Shield of California Commercial |
$2.29
|
| Rate for Payer: Blue Shield of California EPN |
$2.17
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.14
|
| Rate for Payer: Dignity Health Senior |
$3.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.28
|
| Rate for Payer: Heritage Provider Network Senior |
$2.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$2.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.14
|
| Rate for Payer: Vantage Medical Group Senior |
$3.14
|
|
|
RUFINAMIDE 200 MG TABLET [95691]
|
Facility
IP
|
$3.69
|
|
|
Service Code
|
NDC 0054-0425-23
|
| Hospital Charge Code |
1712406
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.77 |
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.54
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$2.77
|
|
|
RUFINAMIDE 200 MG TABLET [95691]
|
Facility
IP
|
$3.69
|
|
|
Service Code
|
NDC 68462-713-08
|
| Hospital Charge Code |
1712406
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.77 |
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.54
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$2.77
|
|
|
RUFINAMIDE 200 MG TABLET [95691]
|
Facility
OP
|
$3.69
|
|
|
Service Code
|
NDC 68462-713-08
|
| Hospital Charge Code |
1712406
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$3.14 |
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.77
|
| Rate for Payer: Blue Shield of California Commercial |
$2.29
|
| Rate for Payer: Blue Shield of California EPN |
$2.17
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.14
|
| Rate for Payer: Dignity Health Senior |
$3.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.28
|
| Rate for Payer: Heritage Provider Network Senior |
$2.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$2.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.14
|
| Rate for Payer: Vantage Medical Group Senior |
$3.14
|
|
|
RUFINAMIDE 400 MG TABLET [95692]
|
Facility
IP
|
$7.37
|
|
|
Service Code
|
NDC 0054-0426-23
|
| Hospital Charge Code |
1712407
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$5.53 |
| Rate for Payer: Adventist Health Commercial |
$1.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.06
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.99
|
| Rate for Payer: Heritage Provider Network Senior |
$4.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$5.53
|
|
|
RUFINAMIDE 400 MG TABLET [95692]
|
Facility
OP
|
$7.37
|
|
|
Service Code
|
NDC 0054-0426-23
|
| Hospital Charge Code |
1712407
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$6.26 |
| Rate for Payer: Adventist Health Commercial |
$1.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.53
|
| Rate for Payer: Blue Shield of California Commercial |
$4.58
|
| Rate for Payer: Blue Shield of California EPN |
$4.33
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.26
|
| Rate for Payer: Dignity Health Senior |
$6.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.56
|
| Rate for Payer: Heritage Provider Network Senior |
$4.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$5.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.26
|
| Rate for Payer: Vantage Medical Group Senior |
$6.26
|
|
|
RUFINAMIDE 40 MG/ML ORAL SUSPENSION [108804]
|
Facility
IP
|
$4.59
|
|
|
Service Code
|
NDC 62856-584-46
|
| Hospital Charge Code |
1715258
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Adventist Health Commercial |
$0.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.15
|
| Rate for Payer: Cash Price |
$2.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.11
|
| Rate for Payer: Heritage Provider Network Senior |
$3.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.15
|
| 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 |
1715258
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Adventist Health Commercial |
$0.92
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.44
|
| Rate for Payer: Blue Shield of California Commercial |
$2.85
|
| Rate for Payer: Blue Shield of California EPN |
$2.69
|
| Rate for Payer: Cash Price |
$2.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.90
|
| Rate for Payer: Dignity Health Senior |
$3.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Senior |
$2.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.15
|
| Rate for Payer: Multiplan Commercial |
$3.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.90
|
| Rate for Payer: Vantage Medical Group Senior |
$3.90
|
|
|
RUXOLITINIB 10 MG TABLET [153887]
|
Facility
IP
|
$333.72
|
|
|
Service Code
|
NDC 50881-010-60
|
| Hospital Charge Code |
ERX153887
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$60.40 |
| Max. Negotiated Rate |
$250.29 |
| Rate for Payer: Adventist Health Commercial |
$66.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.27
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$180.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$225.93
|
| Rate for Payer: Heritage Provider Network Senior |
$225.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.43
|
| Rate for Payer: Multiplan Commercial |
$250.29
|
|
|
RUXOLITINIB 10 MG TABLET [153887]
|
Facility
OP
|
$333.72
|
|
|
Service Code
|
NDC 50881-010-60
|
| Hospital Charge Code |
ERX153887
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$60.40 |
| Max. Negotiated Rate |
$283.66 |
| Rate for Payer: Adventist Health Commercial |
$66.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$178.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$283.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$183.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$250.29
|
| Rate for Payer: Blue Shield of California Commercial |
$207.24
|
| Rate for Payer: Blue Shield of California EPN |
$195.89
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$216.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$283.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$283.66
|
| Rate for Payer: Dignity Health Senior |
$283.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$213.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$206.57
|
| Rate for Payer: Heritage Provider Network Senior |
$206.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$160.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.43
|
| Rate for Payer: Multiplan Commercial |
$250.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$283.66
|
| Rate for Payer: Vantage Medical Group Senior |
$283.66
|
|
|
RUXOLITINIB 15 MG TABLET [153888]
|
Facility
OP
|
$333.72
|
|
|
Service Code
|
NDC 50881-015-60
|
| Hospital Charge Code |
ERX153888
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$60.40 |
| Max. Negotiated Rate |
$283.66 |
| Rate for Payer: Adventist Health Commercial |
$66.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$178.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$283.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$183.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$250.29
|
| Rate for Payer: Blue Shield of California Commercial |
$207.24
|
| Rate for Payer: Blue Shield of California EPN |
$195.89
|
| Rate for Payer: Cash Price |
$150.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$216.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$283.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$283.66
|
| Rate for Payer: Dignity Health Senior |
$283.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$213.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$206.57
|
| Rate for Payer: Heritage Provider Network Senior |
$206.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$160.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.43
|
| Rate for Payer: Multiplan Commercial |
$250.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$283.66
|
| Rate for Payer: Vantage Medical Group Senior |
$283.66
|
|
