|
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 |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| 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 |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| 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 |
$6,108.76 |
| Rate for Payer: Adventist Health Commercial |
$1,629.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$710.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,595.63
|
| 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 HMO/PPO |
$333.96
|
| Rate for Payer: Blue Shield of California Commercial |
$341.05
|
| Rate for Payer: Blue Shield of California EPN |
$341.05
|
| Rate for Payer: Cash Price |
$3,665.26
|
| Rate for Payer: Cash Price |
$3,665.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,746.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$433.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$318.06
|
| Rate for Payer: Dignity Health Senior |
$318.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,212.81
|
| Rate for Payer: EPIC Health Plan Medicare |
$289.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,771.14
|
| Rate for Payer: Heritage Provider Network Senior |
$3,771.14
|
| Rate for Payer: Humana Medicare |
$289.14
|
| Rate for Payer: IEHP Medi-Cal |
$458.02
|
| Rate for Payer: IEHP Medicare Advantage |
$289.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$549.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,474.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$341.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,036.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$364.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$364.32
|
| Rate for Payer: Multiplan Commercial |
$6,108.76
|
| Rate for Payer: TriValley Medical Group Commercial |
$318.06
|
| Rate for Payer: TriValley Medical Group Senior |
$289.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,969.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,721.25
|
| 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 |
$1,474.25 |
| Max. Negotiated Rate |
$6,108.76 |
| Rate for Payer: Adventist Health Commercial |
$1,629.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,595.63
|
| Rate for Payer: Cash Price |
$3,665.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,746.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,398.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,514.18
|
| Rate for Payer: Heritage Provider Network Senior |
$5,514.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,474.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,036.26
|
| Rate for Payer: Multiplan Commercial |
$6,108.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,969.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,721.25
|
|
|
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 |
$18.83 |
| Max. Negotiated Rate |
$78.03 |
| Rate for Payer: Adventist Health Commercial |
$20.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$71.48
|
| Rate for Payer: Cash Price |
$46.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$47.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$70.44
|
| Rate for Payer: Heritage Provider Network Senior |
$70.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.01
|
| Rate for Payer: Multiplan Commercial |
$78.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$34.76
|
|
|
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 |
$18.83 |
| Max. Negotiated Rate |
$210.03 |
| Rate for Payer: Adventist Health Commercial |
$20.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$210.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$71.48
|
| 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 |
$78.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$193.09
|
| Rate for Payer: Blue Shield of California Commercial |
$88.43
|
| Rate for Payer: Blue Shield of California EPN |
$88.43
|
| Rate for Payer: Cash Price |
$46.82
|
| Rate for Payer: Cash Price |
$46.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$47.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$88.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$88.43
|
| Rate for Payer: Dignity Health Senior |
$88.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.17
|
| Rate for Payer: Heritage Provider Network Senior |
$48.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$50.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.01
|
| Rate for Payer: Multiplan Commercial |
$78.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$34.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$88.43
|
| Rate for Payer: Vantage Medical Group Senior |
$88.43
|
|
|
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 |
$38.42 |
| Max. Negotiated Rate |
$180.44 |
| Rate for Payer: Adventist Health Commercial |
$42.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$113.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$145.84
|
| 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 |
$159.21
|
| Rate for Payer: Blue Shield of California Commercial |
$131.83
|
| Rate for Payer: Blue Shield of California EPN |
$124.61
|
| Rate for Payer: Cash Price |
$95.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$137.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$180.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$180.44
|
| Rate for Payer: Dignity Health Senior |
$180.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$131.40
|
| Rate for Payer: Heritage Provider Network Senior |
$131.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$102.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.07
|
| Rate for Payer: Multiplan Commercial |
$159.21
|
| 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 |
$38.42 |
| Max. Negotiated Rate |
$159.21 |
| Rate for Payer: Adventist Health Commercial |
$42.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$145.84
|
| Rate for Payer: Cash Price |
$95.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$114.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$143.71
|
| Rate for Payer: Heritage Provider Network Senior |
$143.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.07
|
| Rate for Payer: Multiplan Commercial |
$159.21
|
|
|
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 |
$38.42 |
| Max. Negotiated Rate |
$180.44 |
| Rate for Payer: Adventist Health Commercial |
$42.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$113.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$145.84
|
| 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 |
$159.21
|
| Rate for Payer: Blue Shield of California Commercial |
$131.83
|
| Rate for Payer: Blue Shield of California EPN |
$124.61
|
| Rate for Payer: Cash Price |
$95.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$137.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$180.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$180.44
|
| Rate for Payer: Dignity Health Senior |
$180.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$131.40
|
| Rate for Payer: Heritage Provider Network Senior |
$131.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$102.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.07
|
| Rate for Payer: Multiplan Commercial |
$159.21
|
| 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 |
$38.42 |
| Max. Negotiated Rate |
$159.21 |
| Rate for Payer: Adventist Health Commercial |
$42.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$145.84
|
| Rate for Payer: Cash Price |
$95.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$114.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$143.71
|
| Rate for Payer: Heritage Provider Network Senior |
$143.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$38.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.07
|
| Rate for Payer: Multiplan Commercial |
$159.21
|
|
|
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 |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
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 |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| 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 |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| 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 |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
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 |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| 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 |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Senior |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
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 |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| 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 |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| 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
|
$0.18
|
|
|
Service Code
|
NDC 13668-093-90
|
| Hospital Charge Code |
1712457
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
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 |
$0.18 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.69
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Senior |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
|
|
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 |
$0.18 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.69
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Senior |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
|
|
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 |
$0.18 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.69
|
| 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 |
$0.75
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.85
|
| Rate for Payer: Dignity Health Senior |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| 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
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687-581-21
|
| Hospital Charge Code |
1712457
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.69
|
| 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 |
$0.75
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.85
|
| Rate for Payer: Dignity Health Senior |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| 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
OP
|
$0.18
|
|
|
Service Code
|
NDC 13668-093-90
|
| Hospital Charge Code |
1712457
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| 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 |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
PRAMIPEXOLE 1 MG TABLET [21288]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 13668-094-90
|
| Hospital Charge Code |
1711769
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| 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 |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
PRAMIPEXOLE 1 MG TABLET [21288]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 13668-094-90
|
| Hospital Charge Code |
1711769
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
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 |
$1.60 |
| Max. Negotiated Rate |
$7.52 |
| Rate for Payer: Adventist Health Commercial |
$1.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.08
|
| 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 |
$6.64
|
| Rate for Payer: Blue Shield of California Commercial |
$5.50
|
| Rate for Payer: Blue Shield of California EPN |
$5.19
|
| Rate for Payer: Cash Price |
$3.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.52
|
| Rate for Payer: Dignity Health Senior |
$7.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.48
|
| Rate for Payer: Heritage Provider Network Senior |
$5.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$6.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.52
|
| Rate for Payer: Vantage Medical Group Senior |
$7.52
|
|
|
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 |
$1.60 |
| Max. Negotiated Rate |
$6.64 |
| Rate for Payer: Adventist Health Commercial |
$1.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.08
|
| Rate for Payer: Cash Price |
$3.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.99
|
| Rate for Payer: Heritage Provider Network Senior |
$5.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$6.64
|
|
