|
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 |
$4.87 |
| Max. Negotiated Rate |
$6.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.31
|
| Rate for Payer: Cash Price |
$3.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.87
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.64
|
|
|
PRASUGREL 10 MG TABLET [98373]
|
Facility
|
OP
|
$0.99
|
|
|
Service Code
|
NDC 60505-4643-3
|
| Hospital Charge Code |
1712410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.74
|
|
|
PRASUGREL 10 MG TABLET [98373]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 51407-445-30
|
| Hospital Charge Code |
1712410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.23
|
|
|
PRASUGREL 10 MG TABLET [98373]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 51407-445-30
|
| Hospital Charge Code |
1712410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.23
|
|
|
PRASUGREL 10 MG TABLET [98373]
|
Facility
|
OP
|
$0.99
|
|
|
Service Code
|
NDC 16729-273-10
|
| Hospital Charge Code |
1712410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.74
|
|
|
PRASUGREL 10 MG TABLET [98373]
|
Facility
|
IP
|
$0.99
|
|
|
Service Code
|
NDC 16729-273-10
|
| Hospital Charge Code |
1712410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.74
|
|
|
PRASUGREL 10 MG TABLET [98373]
|
Facility
|
IP
|
$0.99
|
|
|
Service Code
|
NDC 60505-4643-3
|
| Hospital Charge Code |
1712410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.74
|
|
|
PRASUGREL 5 MG TABLET [98372]
|
Facility
|
IP
|
$18.36
|
|
|
Service Code
|
NDC 0002-5121-01
|
| Hospital Charge Code |
1712411
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$14.69 |
| Rate for Payer: Cash Price |
$8.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.77
|
|
|
PRASUGREL 5 MG TABLET [98372]
|
Facility
|
OP
|
$18.36
|
|
|
Service Code
|
NDC 0002-5121-01
|
| Hospital Charge Code |
1712411
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$13.77 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.02
|
| Rate for Payer: Cash Price |
$8.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.77
|
|
|
PRAVASTATIN 10 MG TABLET [11110]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 60687-169-11
|
| Hospital Charge Code |
1711538
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.34
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.42
|
|
|
PRAVASTATIN 10 MG TABLET [11110]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 68462-195-90
|
| Hospital Charge Code |
1711538
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.23
|
|
|
PRAVASTATIN 10 MG TABLET [11110]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 60687-169-01
|
| Hospital Charge Code |
1711538
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.34
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.42
|
|
|
PRAVASTATIN 10 MG TABLET [11110]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 60687-169-01
|
| Hospital Charge Code |
1711538
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.42
|
|
|
PRAVASTATIN 10 MG TABLET [11110]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 60687-169-11
|
| Hospital Charge Code |
1711538
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.42
|
|
|
PRAVASTATIN 10 MG TABLET [11110]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 60505-0168-9
|
| Hospital Charge Code |
1711538
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.23
|
|
|
PRAVASTATIN 10 MG TABLET [11110]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 60505-0168-9
|
| Hospital Charge Code |
1711538
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.23
|
|
|
PRAVASTATIN 10 MG TABLET [11110]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 68462-195-90
|
| Hospital Charge Code |
1711538
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.23
|
|
|
PRAVASTATIN 20 MG TABLET [11111]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 60505-0169-9
|
| Hospital Charge Code |
1711539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.23
|
|
|
PRAVASTATIN 20 MG TABLET [11111]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 60687-178-11
|
| Hospital Charge Code |
1711539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.50
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.63
|
|
|
PRAVASTATIN 20 MG TABLET [11111]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 60505-0169-9
|
| Hospital Charge Code |
1711539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.23
|
|
|
PRAVASTATIN 20 MG TABLET [11111]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 68462-196-90
|
| Hospital Charge Code |
1711539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.23
|
|
|
PRAVASTATIN 20 MG TABLET [11111]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 0904-5892-61
|
| Hospital Charge Code |
1711539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.51
|
|
|
PRAVASTATIN 20 MG TABLET [11111]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 68462-196-90
|
| Hospital Charge Code |
1711539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.23
|
|
|
PRAVASTATIN 20 MG TABLET [11111]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 60687-178-01
|
| Hospital Charge Code |
1711539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.50
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.63
|
|
|
PRAVASTATIN 20 MG TABLET [11111]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 60687-178-01
|
| Hospital Charge Code |
1711539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.63
|
|
