|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
OP
|
$0.65
|
|
|
Service Code
|
NDC 6025800615
|
| Hospital Charge Code |
1713105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.39
|
| Rate for Payer: Blue Distinction Transplant |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.55
|
| Rate for Payer: Dignity Health Media |
$0.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.55
|
| Rate for Payer: Global Benefits Group Commercial |
$0.39
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.33
|
| Rate for Payer: United Healthcare All Other HMO |
$0.33
|
| Rate for Payer: United Healthcare HMO Rider |
$0.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: Vantage Medical Group Senior |
$0.55
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
OP
|
$0.65
|
|
|
Service Code
|
NDC 6025800601
|
| Hospital Charge Code |
1713105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.39
|
| Rate for Payer: Blue Distinction Transplant |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.55
|
| Rate for Payer: Dignity Health Media |
$0.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.55
|
| Rate for Payer: Global Benefits Group Commercial |
$0.39
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.33
|
| Rate for Payer: United Healthcare All Other HMO |
$0.33
|
| Rate for Payer: United Healthcare HMO Rider |
$0.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: Vantage Medical Group Senior |
$0.55
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 7135101099
|
| Hospital Charge Code |
1713105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
IP
|
$0.65
|
|
|
Service Code
|
NDC 6025800601
|
| Hospital Charge Code |
1713105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.55
|
| Rate for Payer: Global Benefits Group Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.55
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 7135101001
|
| Hospital Charge Code |
1713105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 7135101001
|
| Hospital Charge Code |
1713105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Distinction Transplant |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Media |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 7135101099
|
| Hospital Charge Code |
1713105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Distinction Transplant |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Media |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
POVIDONE-IODINE 10 % TOPICAL OINTMENT [6455]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 0536-1271-80
|
| Hospital Charge Code |
NDG6455
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
POVIDONE-IODINE 10 % TOPICAL OINTMENT [6455]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0536-1271-80
|
| Hospital Charge Code |
NDG6455
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Distinction Transplant |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Media |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION [6458]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0395-2325-16
|
| Hospital Charge Code |
1743092
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION [6458]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0395-2325-16
|
| Hospital Charge Code |
1743092
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Media |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
POVIDONE-IODINE 5 % EYE SOLUTION [19791]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 0065-0411-30
|
| Hospital Charge Code |
1740329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.38
|
| Rate for Payer: Blue Distinction Transplant |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Media |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO |
$0.32
|
| Rate for Payer: United Healthcare HMO Rider |
$0.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
POVIDONE-IODINE 5 % EYE SOLUTION [19791]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 0065-0411-30
|
| Hospital Charge Code |
1740329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
|
|
PRALATREXATE 20 MG/ML (1 ML) INTRAVENOUS SOLUTION [99982]
|
Facility
|
IP
|
$8,145.02
|
|
|
Service Code
|
CPT J9307
|
| Hospital Charge Code |
1722057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,954.80 |
| Max. Negotiated Rate |
$6,923.27 |
| Rate for Payer: Blue Shield of California Commercial |
$5,799.25
|
| Rate for Payer: Blue Shield of California EPN |
$4,170.25
|
| Rate for Payer: Cash Price |
$3,665.26
|
| Rate for Payer: Cigna of CA HMO |
$5,701.51
|
| Rate for Payer: Cigna of CA PPO |
$5,701.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,258.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,258.01
|
| Rate for Payer: Galaxy Health WC |
$6,923.27
|
| Rate for Payer: Global Benefits Group Commercial |
$4,887.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,432.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,103.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,954.80
|
| Rate for Payer: Multiplan Commercial |
$6,516.02
|
| Rate for Payer: Networks By Design Commercial |
$4,072.51
|
| Rate for Payer: Prime Health Services Commercial |
$6,923.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,075.56
|
| Rate for Payer: United Healthcare All Other HMO |
$3,003.88
|
| Rate for Payer: United Healthcare HMO Rider |
$2,938.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,687.86
|
|
|
PRALATREXATE 20 MG/ML (1 ML) INTRAVENOUS SOLUTION [99982]
|
Facility
|
OP
|
$8,145.02
|
|
|
Service Code
|
CPT J9307
|
| Hospital Charge Code |
1722057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$289.14 |
| Max. Negotiated Rate |
$6,923.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,818.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$361.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$318.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$318.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$333.08
|
| Rate for Payer: Blue Distinction Transplant |
$4,887.01
|
| Rate for Payer: Blue Shield of California Commercial |
$6,002.88
|
| Rate for Payer: Blue Shield of California EPN |
$352.83
|
| Rate for Payer: Cash Price |
$3,665.26
|
| Rate for Payer: Cash Price |
$3,665.26
|
| Rate for Payer: Cigna of CA HMO |
$5,701.51
|
| Rate for Payer: Cigna of CA PPO |
$5,701.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$433.71
|
| Rate for Payer: Dignity Health Media |
$289.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$318.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$390.34
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$289.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$289.14
|
| Rate for Payer: Galaxy Health WC |
$6,923.27
|
| Rate for Payer: Global Benefits Group Commercial |
$4,887.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6,108.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$474.19
|
| Rate for Payer: Heritage Provider Network Transplant |
$474.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$468.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$468.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$289.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,432.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$557.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$289.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,954.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$364.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$387.45
|
| Rate for Payer: Multiplan Commercial |
$6,516.02
|
| Rate for Payer: Networks By Design Commercial |
$4,072.51
|
| Rate for Payer: Prime Health Services Commercial |
$6,923.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4,887.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4,887.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,072.51
|
| Rate for Payer: United Healthcare All Other HMO |
$4,072.51
|
| Rate for Payer: United Healthcare HMO Rider |
$4,072.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,072.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$433.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$318.06
|
| Rate for Payer: Vantage Medical Group Senior |
$289.14
|
|
|
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION [6462]
|
Facility
|
OP
|
$104.04
|
|
|
Service Code
|
CPT J2730
|
| Hospital Charge Code |
1720666
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.97 |
| Max. Negotiated Rate |
$537.72 |
| Rate for Payer: Aetna of CA HMO/PPO |
$537.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$88.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$57.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$57.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$192.58
|
| Rate for Payer: Blue Distinction Transplant |
$62.42
|
| Rate for Payer: Blue Shield of California Commercial |
$76.68
|
| Rate for Payer: Blue Shield of California EPN |
$104.04
|
| Rate for Payer: Cash Price |
$46.82
|
| Rate for Payer: Cash Price |
$46.82
|
| Rate for Payer: Cigna of CA HMO |
$72.83
|
| Rate for Payer: Cigna of CA PPO |
$72.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$88.43
|
| Rate for Payer: Dignity Health Media |
$88.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$88.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$41.62
|
| Rate for Payer: Galaxy Health WC |
$88.43
|
| Rate for Payer: Global Benefits Group Commercial |
$62.42
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$78.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$69.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.97
|
| Rate for Payer: Multiplan Commercial |
$83.23
|
| Rate for Payer: Networks By Design Commercial |
$52.02
|
| Rate for Payer: Prime Health Services Commercial |
$88.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$62.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$62.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.02
|
| Rate for Payer: United Healthcare All Other HMO |
$52.02
|
| Rate for Payer: United Healthcare HMO Rider |
$52.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$88.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$88.43
|
| Rate for Payer: Vantage Medical Group Senior |
$88.43
|
|
|
PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION [6462]
|
Facility
|
IP
|
$104.04
|
|
|
Service Code
|
CPT J2730
|
| Hospital Charge Code |
1720666
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.97 |
| Max. Negotiated Rate |
$88.43 |
| Rate for Payer: Blue Shield of California Commercial |
$74.08
|
| Rate for Payer: Blue Shield of California EPN |
$53.27
|
| Rate for Payer: Cash Price |
$46.82
|
| Rate for Payer: Cigna of CA HMO |
$72.83
|
| Rate for Payer: Cigna of CA PPO |
$72.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$41.62
|
| Rate for Payer: Galaxy Health WC |
$88.43
|
| Rate for Payer: Global Benefits Group Commercial |
$62.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$69.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.97
|
| Rate for Payer: Multiplan Commercial |
$83.23
|
| Rate for Payer: Networks By Design Commercial |
$52.02
|
| Rate for Payer: Prime Health Services Commercial |
$88.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$39.29
|
| Rate for Payer: United Healthcare All Other HMO |
$38.37
|
| Rate for Payer: United Healthcare HMO Rider |
$37.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$34.33
|
|
|
PRALSETINIB 100 MG CAPSULE [229123]
|
Facility
|
OP
|
$212.28
|
|
|
Service Code
|
NDC 50242-210-60
|
| Hospital Charge Code |
ERX229123
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.95 |
| Max. Negotiated Rate |
$180.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$139.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$180.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$116.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$116.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$126.48
|
| Rate for Payer: Blue Distinction Transplant |
$127.37
|
| Rate for Payer: Blue Shield of California Commercial |
$156.45
|
| Rate for Payer: Blue Shield of California EPN |
$123.97
|
| Rate for Payer: Cash Price |
$95.53
|
| Rate for Payer: Cigna of CA HMO |
$148.60
|
| Rate for Payer: Cigna of CA PPO |
$148.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$180.44
|
| Rate for Payer: Dignity Health Media |
$180.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$180.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.91
|
| Rate for Payer: EPIC Health Plan Transplant |
$84.91
|
| Rate for Payer: Galaxy Health WC |
$180.44
|
| Rate for Payer: Global Benefits Group Commercial |
$127.37
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$159.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.95
|
| Rate for Payer: Multiplan Commercial |
$169.82
|
| Rate for Payer: Networks By Design Commercial |
$137.98
|
| Rate for Payer: Prime Health Services Commercial |
$180.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$127.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$127.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$106.14
|
| Rate for Payer: United Healthcare All Other HMO |
$106.14
|
| Rate for Payer: United Healthcare HMO Rider |
$106.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$106.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$180.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$180.44
|
| Rate for Payer: Vantage Medical Group Senior |
$180.44
|
|
|
PRALSETINIB 100 MG CAPSULE [229123]
|
Facility
|
IP
|
$212.28
|
|
|
Service Code
|
NDC 50242-210-90
|
| Hospital Charge Code |
ERX229123
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.95 |
| Max. Negotiated Rate |
$180.44 |
| Rate for Payer: Blue Shield of California Commercial |
$151.14
|
| Rate for Payer: Blue Shield of California EPN |
$108.69
|
| Rate for Payer: Cash Price |
$95.53
|
| Rate for Payer: Cigna of CA HMO |
$148.60
|
| Rate for Payer: Cigna of CA PPO |
$148.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.91
|
| Rate for Payer: Galaxy Health WC |
$180.44
|
| Rate for Payer: Global Benefits Group Commercial |
$127.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.95
|
| Rate for Payer: Multiplan Commercial |
$169.82
|
| Rate for Payer: Networks By Design Commercial |
$137.98
|
| Rate for Payer: Prime Health Services Commercial |
$180.44
|
|
|
PRALSETINIB 100 MG CAPSULE [229123]
|
Facility
|
IP
|
$212.28
|
|
|
Service Code
|
NDC 50242-210-60
|
| Hospital Charge Code |
ERX229123
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.95 |
| Max. Negotiated Rate |
$180.44 |
| Rate for Payer: Blue Shield of California Commercial |
$151.14
|
| Rate for Payer: Blue Shield of California EPN |
$108.69
|
| Rate for Payer: Cash Price |
$95.53
|
| Rate for Payer: Cigna of CA HMO |
$148.60
|
| Rate for Payer: Cigna of CA PPO |
$148.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.91
|
| Rate for Payer: Galaxy Health WC |
$180.44
|
| Rate for Payer: Global Benefits Group Commercial |
$127.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.95
|
| Rate for Payer: Multiplan Commercial |
$169.82
|
| Rate for Payer: Networks By Design Commercial |
$137.98
|
| Rate for Payer: Prime Health Services Commercial |
$180.44
|
|
|
PRALSETINIB 100 MG CAPSULE [229123]
|
Facility
|
OP
|
$212.28
|
|
|
Service Code
|
NDC 50242-210-90
|
| Hospital Charge Code |
ERX229123
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.95 |
| Max. Negotiated Rate |
$180.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$139.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$180.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$116.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$116.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$126.48
|
| Rate for Payer: Blue Distinction Transplant |
$127.37
|
| Rate for Payer: Blue Shield of California Commercial |
$156.45
|
| Rate for Payer: Blue Shield of California EPN |
$123.97
|
| Rate for Payer: Cash Price |
$95.53
|
| Rate for Payer: Cigna of CA HMO |
$148.60
|
| Rate for Payer: Cigna of CA PPO |
$148.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$180.44
|
| Rate for Payer: Dignity Health Media |
$180.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$180.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.91
|
| Rate for Payer: EPIC Health Plan Transplant |
$84.91
|
| Rate for Payer: Galaxy Health WC |
$180.44
|
| Rate for Payer: Global Benefits Group Commercial |
$127.37
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$159.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.95
|
| Rate for Payer: Multiplan Commercial |
$169.82
|
| Rate for Payer: Networks By Design Commercial |
$137.98
|
| Rate for Payer: Prime Health Services Commercial |
$180.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$127.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$127.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$106.14
|
| Rate for Payer: United Healthcare All Other HMO |
$106.14
|
| Rate for Payer: United Healthcare HMO Rider |
$106.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$106.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$180.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$180.44
|
| Rate for Payer: Vantage Medical Group Senior |
$180.44
|
|
|
PRAMIPEXOLE 0.125 MG TABLET [21287]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 13668-091-90
|
| Hospital Charge Code |
1711961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
PRAMIPEXOLE 0.125 MG TABLET [21287]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 68462-330-90
|
| Hospital Charge Code |
1711961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Distinction Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Media |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
PRAMIPEXOLE 0.125 MG TABLET [21287]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 68462-330-90
|
| Hospital Charge Code |
1711961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
|
|
PRAMIPEXOLE 0.125 MG TABLET [21287]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 13668-091-90
|
| Hospital Charge Code |
1711961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Distinction Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Media |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
