|
PREDNISONE 5 MG/ML ORAL CONCENTRATE [110852]
|
Facility
|
IP
|
$5.20
|
|
|
Service Code
|
CPT J7512
|
| Hospital Charge Code |
1715989
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$4.16 |
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.90
|
|
|
PREDNISONE 5 MG TABLET [6497]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
CPT J7512
|
| Hospital Charge Code |
1710062
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.15
|
|
|
PREDNISONE 5 MG TABLET [6497]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
CPT J7512
|
| Hospital Charge Code |
1710062
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.12
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.14
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
PREGABALIN 100 MG CAPSULE [42165]
|
Facility
|
OP
|
$1.01
|
|
|
Service Code
|
NDC 0904-7001-61
|
| Hospital Charge Code |
1730157
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.76 |
| 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 |
$0.45
|
| 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 |
$0.76
|
|
|
PREGABALIN 100 MG CAPSULE [42165]
|
Facility
|
IP
|
$1.62
|
|
|
Service Code
|
NDC 60687-506-11
|
| Hospital Charge Code |
1730157
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
PREGABALIN 100 MG CAPSULE [42165]
|
Facility
|
IP
|
$1.62
|
|
|
Service Code
|
NDC 60687-506-01
|
| Hospital Charge Code |
1730157
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
PREGABALIN 100 MG CAPSULE [42165]
|
Facility
|
OP
|
$1.62
|
|
|
Service Code
|
NDC 60687-506-01
|
| Hospital Charge Code |
1730157
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
PREGABALIN 100 MG CAPSULE [42165]
|
Facility
|
IP
|
$1.01
|
|
|
Service Code
|
NDC 0904-7001-61
|
| Hospital Charge Code |
1730157
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.81
|
| 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 |
$0.76
|
|
|
PREGABALIN 100 MG CAPSULE [42165]
|
Facility
|
OP
|
$1.62
|
|
|
Service Code
|
NDC 60687-506-11
|
| Hospital Charge Code |
1730157
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
PREGABALIN 25 MG CAPSULE [42162]
|
Facility
|
OP
|
$1.62
|
|
|
Service Code
|
NDC 60687-473-11
|
| Hospital Charge Code |
1730154
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
PREGABALIN 25 MG CAPSULE [42162]
|
Facility
|
OP
|
$1.62
|
|
|
Service Code
|
NDC 60687-473-01
|
| Hospital Charge Code |
1730154
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
PREGABALIN 25 MG CAPSULE [42162]
|
Facility
|
IP
|
$1.62
|
|
|
Service Code
|
NDC 60687-473-11
|
| Hospital Charge Code |
1730154
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
PREGABALIN 25 MG CAPSULE [42162]
|
Facility
|
IP
|
$1.62
|
|
|
Service Code
|
NDC 60687-473-01
|
| Hospital Charge Code |
1730154
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
PREGABALIN 50 MG CAPSULE [42163]
|
Facility
|
OP
|
$1.62
|
|
|
Service Code
|
NDC 60687-484-01
|
| Hospital Charge Code |
1730155
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
PREGABALIN 50 MG CAPSULE [42163]
|
Facility
|
IP
|
$1.62
|
|
|
Service Code
|
NDC 60687-484-01
|
| Hospital Charge Code |
1730155
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
PREGABALIN 50 MG CAPSULE [42163]
|
Facility
|
OP
|
$1.62
|
|
|
Service Code
|
NDC 60687-484-11
|
| Hospital Charge Code |
1730155
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
PREGABALIN 50 MG CAPSULE [42163]
|
Facility
|
IP
|
$1.62
|
|
|
Service Code
|
NDC 60687-484-11
|
| Hospital Charge Code |
1730155
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
PREGABALIN 75 MG CAPSULE [42164]
|
Facility
|
IP
|
$1.62
|
|
|
Service Code
|
NDC 60687-495-01
|
| Hospital Charge Code |
1730156
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
PREGABALIN 75 MG CAPSULE [42164]
|
Facility
|
OP
|
$1.62
|
|
|
Service Code
|
NDC 60687-495-01
|
| Hospital Charge Code |
1730156
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
PREGABALIN 75 MG CAPSULE [42164]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 69097-679-05
|
| Hospital Charge Code |
1730156
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
PREGABALIN 75 MG CAPSULE [42164]
|
Facility
|
IP
|
$1.62
|
|
|
Service Code
|
NDC 60687-495-11
|
| Hospital Charge Code |
1730156
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
PREGABALIN 75 MG CAPSULE [42164]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 69097-679-05
|
| Hospital Charge Code |
1730156
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
PREGABALIN 75 MG CAPSULE [42164]
|
Facility
|
OP
|
$1.62
|
|
|
Service Code
|
NDC 60687-495-11
|
| Hospital Charge Code |
1730156
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.22
|
|
|
PRENATAL NO.118-FERROUS FUMARATE 29 MG-FOLIC ACID 1 MG CHEWABLE TABLET [203818]
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
NDC 1392511701
|
| Hospital Charge Code |
ERX203818
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.53
|
|
|
PRENATAL NO.118-FERROUS FUMARATE 29 MG-FOLIC ACID 1 MG CHEWABLE TABLET [203818]
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
NDC 1392511701
|
| Hospital Charge Code |
ERX203818
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.53
|
|
