|
PERMETHRIN 5 % TOPICAL CREAM [10917]
|
Facility
|
IP
|
$1.98
|
|
|
Service Code
|
NDC 45802-269-37
|
| Hospital Charge Code |
1743612
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.58 |
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.48
|
|
|
PERMETHRIN 5 % TOPICAL CREAM [10917]
|
Facility
|
IP
|
$1.98
|
|
|
Service Code
|
NDC 0472-0242-60
|
| Hospital Charge Code |
1743612
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.58 |
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.48
|
|
|
PERMETHRIN 5 % TOPICAL CREAM [10917]
|
Facility
|
OP
|
$1.98
|
|
|
Service Code
|
NDC 0472-0242-60
|
| Hospital Charge Code |
1743612
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.19
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.48
|
|
|
PERMETHRIN 5 % TOPICAL CREAM [10917]
|
Facility
|
OP
|
$1.98
|
|
|
Service Code
|
NDC 45802-269-37
|
| Hospital Charge Code |
1743612
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.19
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.48
|
|
|
PERMETHRIN 5 % TOPICAL CREAM [10917]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 21922-021-07
|
| Hospital Charge Code |
1743612
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.45
|
|
|
PERMETHRIN 5 % TOPICAL CREAM [10917]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 21922-021-07
|
| Hospital Charge Code |
1743612
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.45
|
|
|
PERPHENAZINE 2 MG TABLET [6157]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 64980-290-01
|
| Hospital Charge Code |
1711077
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.25
|
|
|
PERPHENAZINE 2 MG TABLET [6157]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 64980-290-01
|
| Hospital Charge Code |
1711077
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.25
|
|
|
PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN [228328]
|
Facility
|
IP
|
$1,016.56
|
|
|
Service Code
|
CPT J9316
|
| Hospital Charge Code |
NDG228328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$559.11 |
| Max. Negotiated Rate |
$813.25 |
| Rate for Payer: Cash Price |
$457.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$813.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$609.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$559.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$762.42
|
|
|
PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN [228328]
|
Facility
|
OP
|
$1,016.56
|
|
|
Service Code
|
CPT J9316
|
| Hospital Charge Code |
NDG228328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$559.11 |
| Max. Negotiated Rate |
$762.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$609.94
|
| Rate for Payer: Aetna of CA Government/Medicare |
$609.94
|
| Rate for Payer: Cash Price |
$457.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$609.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$609.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$559.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$762.42
|
|
|
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [196616]
|
Facility
|
OP
|
$543.14
|
|
|
Service Code
|
CPT J9306
|
| Hospital Charge Code |
NDG196616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$298.73 |
| Max. Negotiated Rate |
$407.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$325.88
|
| Rate for Payer: Aetna of CA Government/Medicare |
$325.88
|
| Rate for Payer: Cash Price |
$244.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$325.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$325.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$298.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$407.36
|
|
|
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [196616]
|
Facility
|
IP
|
$543.14
|
|
|
Service Code
|
CPT J9306
|
| Hospital Charge Code |
NDG196616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$298.73 |
| Max. Negotiated Rate |
$434.51 |
| Rate for Payer: Cash Price |
$244.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$434.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$325.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$298.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$407.36
|
|
|
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN [228329]
|
Facility
|
OP
|
$1,016.52
|
|
|
Service Code
|
CPT J9316
|
| Hospital Charge Code |
NDG228329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$559.09 |
| Max. Negotiated Rate |
$762.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$609.91
|
| Rate for Payer: Aetna of CA Government/Medicare |
$609.91
|
| Rate for Payer: Cash Price |
$457.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$609.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$609.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$559.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$762.39
|
|
|
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN [228329]
|
Facility
|
IP
|
$1,016.52
|
|
|
Service Code
|
CPT J9316
|
| Hospital Charge Code |
NDG228329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$559.09 |
| Max. Negotiated Rate |
$813.22 |
| Rate for Payer: Cash Price |
$457.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$813.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$609.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$559.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$762.39
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 65162-681-10
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 42192-801-01
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.77
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 42192-801-01
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.77
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 69367-162-04
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.77
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 51293-810-01
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 69367-162-04
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.77
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 65162-681-10
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.23
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 51293-810-01
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.23
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
|
IP
|
$1.98
|
|
|
Service Code
|
NDC 42937-702-10
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.58 |
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.48
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 51293-612-01
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 51293-612-01
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
