Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PRALATREXATE 20 MG/ML (1 ML) INTRAVENOUS SOLUTION [99982]

Facility

$8,145.02

Service Code	CPT J9307
Hospital Charge Code	1722057
Hospital Revenue Code	636
Min. Negotiated Rate	$4,479.76
Max. Negotiated Rate	$6,516.02
Rate for Payer: Cash Price	$3,665.26
Rate for Payer: Cigna of CA HMO/PPO	$6,516.02
Rate for Payer: Health Smart Auto/Commercial	$4,887.01
Rate for Payer: LLUH Dept of Risk Management WC	$4,479.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6,108.76

PRALATREXATE 20 MG/ML (1 ML) INTRAVENOUS SOLUTION [99982]

Facility

$8,145.02

Service Code	CPT J9307
Hospital Charge Code	1722057
Hospital Revenue Code	636
Min. Negotiated Rate	$4,479.76
Max. Negotiated Rate	$6,108.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4,887.01
Rate for Payer: Aetna of CA Government/Medicare	$4,887.01
Rate for Payer: Cash Price	$3,665.26
Rate for Payer: Health Smart Auto/Commercial	$4,887.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4,887.01
Rate for Payer: LLUH Dept of Risk Management WC	$4,479.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6,108.76

PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION [6462]

Facility

$104.04

Service Code	CPT J2730
Hospital Charge Code	1720666
Hospital Revenue Code	636
Min. Negotiated Rate	$57.22
Max. Negotiated Rate	$78.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$62.42
Rate for Payer: Aetna of CA Government/Medicare	$62.42
Rate for Payer: Cash Price	$46.82
Rate for Payer: Health Smart Auto/Commercial	$62.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$62.42
Rate for Payer: LLUH Dept of Risk Management WC	$57.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$78.03

PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION [6462]

Facility

$104.04

Service Code	CPT J2730
Hospital Charge Code	1720666
Hospital Revenue Code	636
Min. Negotiated Rate	$57.22
Max. Negotiated Rate	$83.23
Rate for Payer: Cash Price	$46.82
Rate for Payer: Cigna of CA HMO/PPO	$83.23
Rate for Payer: Health Smart Auto/Commercial	$62.42
Rate for Payer: LLUH Dept of Risk Management WC	$57.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$78.03

PRALSETINIB 100 MG CAPSULE [229123]

Facility

$212.28

Service Code	NDC 50242-210-60
Hospital Charge Code	ERX229123
Hospital Revenue Code	259
Min. Negotiated Rate	$116.75
Max. Negotiated Rate	$169.82
Rate for Payer: Cash Price	$95.53
Rate for Payer: Cigna of CA HMO/PPO	$169.82
Rate for Payer: Health Smart Auto/Commercial	$127.37
Rate for Payer: LLUH Dept of Risk Management WC	$116.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$159.21

PRALSETINIB 100 MG CAPSULE [229123]

Facility

$212.28

Service Code	NDC 50242-210-90
Hospital Charge Code	ERX229123
Hospital Revenue Code	259
Min. Negotiated Rate	$116.75
Max. Negotiated Rate	$169.82
Rate for Payer: Cash Price	$95.53
Rate for Payer: Cigna of CA HMO/PPO	$169.82
Rate for Payer: Health Smart Auto/Commercial	$127.37
Rate for Payer: LLUH Dept of Risk Management WC	$116.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$159.21

PRALSETINIB 100 MG CAPSULE [229123]

Facility

$212.28

Service Code	NDC 50242-210-90
Hospital Charge Code	ERX229123
Hospital Revenue Code	259
Min. Negotiated Rate	$116.75
Max. Negotiated Rate	$159.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$127.37
Rate for Payer: Aetna of CA Government/Medicare	$127.37
Rate for Payer: Cash Price	$95.53
Rate for Payer: Health Smart Auto/Commercial	$127.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$127.37
Rate for Payer: LLUH Dept of Risk Management WC	$116.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$159.21

PRALSETINIB 100 MG CAPSULE [229123]

Facility

$212.28

Service Code	NDC 50242-210-60
Hospital Charge Code	ERX229123
Hospital Revenue Code	259
Min. Negotiated Rate	$116.75
Max. Negotiated Rate	$159.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$127.37
Rate for Payer: Aetna of CA Government/Medicare	$127.37
Rate for Payer: Cash Price	$95.53
Rate for Payer: Health Smart Auto/Commercial	$127.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$127.37
Rate for Payer: LLUH Dept of Risk Management WC	$116.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$159.21

PRAMIPEXOLE 0.125 MG TABLET [21287]

Facility

$0.13

Service Code	NDC 68462-330-90
Hospital Charge Code	1711961
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

PRAMIPEXOLE 0.125 MG TABLET [21287]

Facility

$0.18

Service Code	NDC 13668-091-90
Hospital Charge Code	1711961
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

PRAMIPEXOLE 0.125 MG TABLET [21287]

Facility

$0.13

Service Code	NDC 68462-330-90
Hospital Charge Code	1711961
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

PRAMIPEXOLE 0.125 MG TABLET [21287]

Facility

$0.18

Service Code	NDC 13668-091-90
Hospital Charge Code	1711961
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

PRAMIPEXOLE 0.25 MG TABLET [21290]

Facility

$0.18

Service Code	NDC 13668-092-90
Hospital Charge Code	1710889
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

PRAMIPEXOLE 0.25 MG TABLET [21290]

Facility

$0.18

Service Code	NDC 13668-092-90
Hospital Charge Code	1710889
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

PRAMIPEXOLE 0.5 MG TABLET [22719]

Facility

$0.18

Service Code	NDC 13668-093-90
Hospital Charge Code	1712457
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

PRAMIPEXOLE 0.5 MG TABLET [22719]

Facility

$1.00

Service Code	NDC 60687-581-21
Hospital Charge Code	1712457
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.60
Rate for Payer: Aetna of CA Government/Medicare	$0.60
Rate for Payer: Cash Price	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.75

PRAMIPEXOLE 0.5 MG TABLET [22719]

Facility

$1.00

Service Code	NDC 60687-581-11
Hospital Charge Code	1712457
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cigna of CA HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.75

PRAMIPEXOLE 0.5 MG TABLET [22719]

Facility

$1.00

Service Code	NDC 60687-581-11
Hospital Charge Code	1712457
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.60
Rate for Payer: Aetna of CA Government/Medicare	$0.60
Rate for Payer: Cash Price	$0.45
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.75

PRAMIPEXOLE 0.5 MG TABLET [22719]

Facility

$0.18

Service Code	NDC 13668-093-90
Hospital Charge Code	1712457
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

PRAMIPEXOLE 0.5 MG TABLET [22719]

Facility

$1.00

Service Code	NDC 60687-581-21
Hospital Charge Code	1712457
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cigna of CA HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.75

PRAMIPEXOLE 1 MG TABLET [21288]

Facility

$8.85

Service Code	NDC 0597-0190-61
Hospital Charge Code	1711769
Hospital Revenue Code	259
Min. Negotiated Rate	$4.87
Max. Negotiated Rate	$7.08
Rate for Payer: Cash Price	$3.98
Rate for Payer: Cigna of CA HMO/PPO	$7.08
Rate for Payer: Health Smart Auto/Commercial	$5.31
Rate for Payer: LLUH Dept of Risk Management WC	$4.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.64

PRAMIPEXOLE 1 MG TABLET [21288]

Facility

$0.13

Service Code	NDC 68462-333-90
Hospital Charge Code	1711769
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

PRAMIPEXOLE 1 MG TABLET [21288]

Facility

$0.18

Service Code	NDC 13668-094-90
Hospital Charge Code	1711769
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

PRAMIPEXOLE 1 MG TABLET [21288]

Facility

$0.13

Service Code	NDC 68462-333-90
Hospital Charge Code	1711769
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

PRAMIPEXOLE 1 MG TABLET [21288]

Facility

$0.18

Service Code	NDC 13668-094-90
Hospital Charge Code	1711769
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

Know your out-of-pocket cost for care.

All Charges