|
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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$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: Health Management Network EPO/PPO |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| 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 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 |
$0.13 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Central Health Plan Commercial |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
|
|
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 |
$0.13 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.38
|
| Rate for Payer: BCBS Transplant Transplant |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Central Health Plan Commercial |
$0.51
|
| 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: 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 Management Network EPO/PPO |
$0.58
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.48
|
| Rate for Payer: IEHP medi-cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
| Rate for Payer: Riverside University Health MISP |
$0.26
|
| 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 Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
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 |
$7,330.52 |
| Rate for Payer: Adventist Health Medi-Cal |
$289.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,791.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$361.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$318.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$318.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$309.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$338.62
|
| Rate for Payer: BCBS Transplant Transplant |
$4,887.01
|
| Rate for Payer: Blue Shield of California Commercial |
$388.11
|
| Rate for Payer: Blue Shield of California EPN |
$352.83
|
| Rate for Payer: Caremore Medicare Advantage |
$289.14
|
| Rate for Payer: Cash Price |
$3,665.26
|
| Rate for Payer: Cash Price |
$3,665.26
|
| Rate for Payer: Central Health Plan Commercial |
$6,516.02
|
| 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: 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 Management Network EPO/PPO |
$7,330.52
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6,108.76
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$474.19
|
| Rate for Payer: IEHP medi-cal |
$477.08
|
| Rate for Payer: IEHP Medicare Advantage |
$289.14
|
| Rate for Payer: Innovage PACE Commercial |
$433.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,432.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$289.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,629.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$387.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$387.45
|
| Rate for Payer: Multiplan Commercial |
$6,108.76
|
| Rate for Payer: Networks By Design Commercial |
$4,072.51
|
| Rate for Payer: Prime Health Services Commercial |
$6,923.27
|
| Rate for Payer: Prime Health Services Medicare |
$306.49
|
| Rate for Payer: Riverside University Health MISP |
$318.06
|
| 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
|
|
|
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 |
$1,629.00 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$6,108.76
|
| Rate for Payer: Blue Shield of California EPN |
$4,349.44
|
| Rate for Payer: Cash Price |
$3,665.26
|
| Rate for Payer: Cash Price |
$3,665.26
|
| Rate for Payer: Central Health Plan Commercial |
$6,516.02
|
| 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: Health Management Network EPO/PPO |
$7,330.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,432.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,629.00
|
| Rate for Payer: Multiplan Commercial |
$6,108.76
|
| Rate for Payer: Networks By Design Commercial |
$4,072.51
|
| Rate for Payer: Prime Health Services Commercial |
$6,923.27
|
|
|
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 |
$20.81 |
| Max. Negotiated Rate |
$529.82 |
| Rate for Payer: Aetna of CA HMO/PPO |
$529.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$88.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$57.22
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$57.22
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$178.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$195.78
|
| Rate for Payer: BCBS Transplant Transplant |
$62.42
|
| Rate for Payer: Blue Shield of California Commercial |
$114.44
|
| 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: Central Health Plan Commercial |
$83.23
|
| 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: 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 Management Network EPO/PPO |
$93.64
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$78.03
|
| Rate for Payer: IEHP medi-cal |
$36.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$69.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.81
|
| Rate for Payer: Multiplan Commercial |
$78.03
|
| Rate for Payer: Networks By Design Commercial |
$52.02
|
| Rate for Payer: Prime Health Services Commercial |
$88.43
|
| Rate for Payer: Riverside University Health MISP |
$41.62
|
| 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 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 |
$20.81 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$78.03
|
| Rate for Payer: Blue Shield of California EPN |
$55.56
|
| Rate for Payer: Cash Price |
$46.82
|
| Rate for Payer: Cash Price |
$46.82
|
| Rate for Payer: Central Health Plan Commercial |
$83.23
|
| 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: Health Management Network EPO/PPO |
$93.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$69.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.81
|
| Rate for Payer: Multiplan Commercial |
$78.03
|
| Rate for Payer: Networks By Design Commercial |
$52.02
|
| Rate for Payer: Prime Health Services Commercial |
$88.43
|
|
|
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 |
$42.46 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$159.21
|
| Rate for Payer: Blue Shield of California EPN |
$113.36
|
| Rate for Payer: Cash Price |
$95.53
|
| Rate for Payer: Cash Price |
$95.53
|
| Rate for Payer: Central Health Plan Commercial |
$169.82
|
| 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: Health Management Network EPO/PPO |
$191.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.46
|
| Rate for Payer: Multiplan Commercial |
$159.21
|
| 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 50242-210-60
|
| Hospital Charge Code |
ERX229123
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.46 |
| Max. Negotiated Rate |
$191.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$128.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$180.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$116.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$116.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$102.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$125.42
|
| Rate for Payer: BCBS Transplant Transplant |
$127.37
|
| Rate for Payer: Blue Shield of California Commercial |
$133.52
|
| Rate for Payer: Blue Shield of California EPN |
$103.80
|
| Rate for Payer: Cash Price |
$95.53
|
| Rate for Payer: Central Health Plan Commercial |
$169.82
|
| 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: 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 Management Network EPO/PPO |
$191.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$159.21
|
| Rate for Payer: IEHP medi-cal |
$74.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.46
|
| Rate for Payer: Multiplan Commercial |
$159.21
|
| Rate for Payer: Networks By Design Commercial |
$137.98
|
| Rate for Payer: Prime Health Services Commercial |
$180.44
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$127.37
|
| Rate for Payer: Riverside University Health MISP |
$84.91
|
| 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 Medi-Cal |
$180.44
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$42.46 |
| Max. Negotiated Rate |
$191.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$128.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$180.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$116.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$116.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$102.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$125.42
|
| Rate for Payer: BCBS Transplant Transplant |
$127.37
|
| Rate for Payer: Blue Shield of California Commercial |
$133.52
|
| Rate for Payer: Blue Shield of California EPN |
$103.80
|
| Rate for Payer: Cash Price |
$95.53
|
| Rate for Payer: Central Health Plan Commercial |
$169.82
|
| 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: 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 Management Network EPO/PPO |
$191.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$159.21
|
| Rate for Payer: IEHP medi-cal |
$74.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.46
|
| Rate for Payer: Multiplan Commercial |
$159.21
|
| Rate for Payer: Networks By Design Commercial |
$137.98
|
| Rate for Payer: Prime Health Services Commercial |
$180.44
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$127.37
|
| Rate for Payer: Riverside University Health MISP |
$84.91
|
| 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 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 50242-210-60
|
| Hospital Charge Code |
ERX229123
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.46 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$159.21
|
| Rate for Payer: Blue Shield of California EPN |
$113.36
|
| Rate for Payer: Cash Price |
$95.53
|
| Rate for Payer: Cash Price |
$95.53
|
| Rate for Payer: Central Health Plan Commercial |
$169.82
|
| 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: Health Management Network EPO/PPO |
$191.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$141.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.46
|
| Rate for Payer: Multiplan Commercial |
$159.21
|
| Rate for Payer: Networks By Design Commercial |
$137.98
|
| Rate for Payer: Prime Health Services Commercial |
$180.44
|
|
|
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 |
$0.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: BCBS Transplant Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| 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: 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 Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.14
|
| Rate for Payer: IEHP medi-cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: Riverside University Health MISP |
$0.07
|
| 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 Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| 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: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| 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 |
$0.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: BCBS Transplant Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| 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: 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 Management Network EPO/PPO |
$0.12
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.10
|
| Rate for Payer: IEHP medi-cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: Riverside University Health MISP |
$0.05
|
| 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 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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| 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: Health Management Network EPO/PPO |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| 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 0.25 MG TABLET [21290]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 13668-092-90
|
| Hospital Charge Code |
1710889
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| 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: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| 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 0.25 MG TABLET [21290]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 13668-092-90
|
| Hospital Charge Code |
1710889
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: BCBS Transplant Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| 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: 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 Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.14
|
| Rate for Payer: IEHP medi-cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: Riverside University Health MISP |
$0.07
|
| 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 Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
PRAMIPEXOLE 0.5 MG TABLET [22719]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 13668-093-90
|
| Hospital Charge Code |
1712457
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: BCBS Transplant Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| 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: 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 Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.14
|
| Rate for Payer: IEHP medi-cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: Riverside University Health MISP |
$0.07
|
| 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 Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
PRAMIPEXOLE 0.5 MG TABLET [22719]
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687-581-11
|
| Hospital Charge Code |
1712457
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Central Health Plan Commercial |
$0.80
|
| Rate for Payer: Cigna of CA HMO |
$0.70
|
| Rate for Payer: Cigna of CA PPO |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Galaxy Health WC |
$0.85
|
| Rate for Payer: Global Benefits Group Commercial |
$0.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Networks By Design Commercial |
$0.65
|
| Rate for Payer: Prime Health Services Commercial |
$0.85
|
|
|
PRAMIPEXOLE 0.5 MG TABLET [22719]
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687-581-11
|
| Hospital Charge Code |
1712457
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.55
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.59
|
| Rate for Payer: BCBS Transplant Transplant |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Central Health Plan Commercial |
$0.80
|
| Rate for Payer: Cigna of CA HMO |
$0.70
|
| Rate for Payer: Cigna of CA PPO |
$0.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.40
|
| Rate for Payer: Galaxy Health WC |
$0.85
|
| Rate for Payer: Global Benefits Group Commercial |
$0.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.90
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.75
|
| Rate for Payer: IEHP medi-cal |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Networks By Design Commercial |
$0.65
|
| Rate for Payer: Prime Health Services Commercial |
$0.85
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.60
|
| Rate for Payer: Riverside University Health MISP |
$0.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO |
$0.50
|
| Rate for Payer: United Healthcare HMO Rider |
$0.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.85
|
| Rate for Payer: Vantage Medical Group Senior |
$0.85
|
|
|
PRAMIPEXOLE 0.5 MG TABLET [22719]
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687-581-21
|
| Hospital Charge Code |
1712457
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Central Health Plan Commercial |
$0.80
|
| Rate for Payer: Cigna of CA HMO |
$0.70
|
| Rate for Payer: Cigna of CA PPO |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Galaxy Health WC |
$0.85
|
| Rate for Payer: Global Benefits Group Commercial |
$0.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Networks By Design Commercial |
$0.65
|
| Rate for Payer: Prime Health Services Commercial |
$0.85
|
|
|
PRAMIPEXOLE 0.5 MG TABLET [22719]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 13668-093-90
|
| Hospital Charge Code |
1712457
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| 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: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| 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 0.5 MG TABLET [22719]
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687-581-21
|
| Hospital Charge Code |
1712457
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.55
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.59
|
| Rate for Payer: BCBS Transplant Transplant |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Central Health Plan Commercial |
$0.80
|
| Rate for Payer: Cigna of CA HMO |
$0.70
|
| Rate for Payer: Cigna of CA PPO |
$0.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.40
|
| Rate for Payer: Galaxy Health WC |
$0.85
|
| Rate for Payer: Global Benefits Group Commercial |
$0.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.90
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.75
|
| Rate for Payer: IEHP medi-cal |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Networks By Design Commercial |
$0.65
|
| Rate for Payer: Prime Health Services Commercial |
$0.85
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.60
|
| Rate for Payer: Riverside University Health MISP |
$0.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO |
$0.50
|
| Rate for Payer: United Healthcare HMO Rider |
$0.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.85
|
| Rate for Payer: Vantage Medical Group Senior |
$0.85
|
|
|
PRAMIPEXOLE 1 MG TABLET [21288]
|
Facility
IP
|
$8.85
|
|
|
Service Code
|
NDC 0597-0190-61
|
| Hospital Charge Code |
1711769
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$6.64
|
| Rate for Payer: Blue Shield of California EPN |
$4.73
|
| Rate for Payer: Cash Price |
$3.98
|
| Rate for Payer: Cash Price |
$3.98
|
| Rate for Payer: Central Health Plan Commercial |
$7.08
|
| Rate for Payer: Cigna of CA HMO |
$6.20
|
| Rate for Payer: Cigna of CA PPO |
$6.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.54
|
| Rate for Payer: Galaxy Health WC |
$7.52
|
| Rate for Payer: Global Benefits Group Commercial |
$5.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.77
|
| Rate for Payer: Multiplan Commercial |
$6.64
|
| Rate for Payer: Networks By Design Commercial |
$5.75
|
| Rate for Payer: Prime Health Services Commercial |
$7.52
|
|
|
PRAMIPEXOLE 1 MG TABLET [21288]
|
Facility
OP
|
$8.85
|
|
|
Service Code
|
NDC 0597-0190-61
|
| Hospital Charge Code |
1711769
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$7.96 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.23
|
| Rate for Payer: BCBS Transplant Transplant |
$5.31
|
| Rate for Payer: Blue Shield of California Commercial |
$5.57
|
| Rate for Payer: Blue Shield of California EPN |
$4.33
|
| Rate for Payer: Cash Price |
$3.98
|
| Rate for Payer: Central Health Plan Commercial |
$7.08
|
| Rate for Payer: Cigna of CA HMO |
$6.20
|
| Rate for Payer: Cigna of CA PPO |
$6.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.54
|
| Rate for Payer: Galaxy Health WC |
$7.52
|
| Rate for Payer: Global Benefits Group Commercial |
$5.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.96
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.64
|
| Rate for Payer: IEHP medi-cal |
$3.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.77
|
| Rate for Payer: Multiplan Commercial |
$6.64
|
| Rate for Payer: Networks By Design Commercial |
$5.75
|
| Rate for Payer: Prime Health Services Commercial |
$7.52
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$5.31
|
| Rate for Payer: Riverside University Health MISP |
$3.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.42
|
| Rate for Payer: United Healthcare All Other HMO |
$4.42
|
| Rate for Payer: United Healthcare HMO Rider |
$4.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.52
|
| Rate for Payer: Vantage Medical Group Senior |
$7.52
|
|
