|
PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$2.18
|
|
|
Service Code
|
NDC 60687072511
|
| Hospital Charge Code |
26224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Aetna Commercial |
$1.85
|
| Rate for Payer: Aetna Medicare |
$1.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.42
|
| Rate for Payer: BCBS Complete |
$0.87
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Cofinity Commercial |
$1.53
|
| Rate for Payer: Cofinity Commercial |
$1.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.74
|
| Rate for Payer: Healthscope Commercial |
$1.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.85
|
| Rate for Payer: PHP Commercial |
$1.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.42
|
| Rate for Payer: Priority Health SBD |
$1.37
|
|
|
PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$215.65
|
|
|
Service Code
|
NDC 68084064301
|
| Hospital Charge Code |
26224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.26 |
| Max. Negotiated Rate |
$194.08 |
| Rate for Payer: Aetna Commercial |
$183.30
|
| Rate for Payer: Aetna Medicare |
$107.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$140.17
|
| Rate for Payer: BCBS Complete |
$86.26
|
| Rate for Payer: Cash Price |
$172.52
|
| Rate for Payer: Cofinity Commercial |
$150.96
|
| Rate for Payer: Cofinity Commercial |
$185.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$150.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$172.52
|
| Rate for Payer: Healthscope Commercial |
$194.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$183.30
|
| Rate for Payer: PHP Commercial |
$183.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.17
|
| Rate for Payer: Priority Health SBD |
$135.86
|
|
|
PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$217.55
|
|
|
Service Code
|
NDC 60687072501
|
| Hospital Charge Code |
26224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.06 |
| Max. Negotiated Rate |
$195.80 |
| Rate for Payer: Aetna Commercial |
$184.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$141.41
|
| Rate for Payer: Cash Price |
$174.04
|
| Rate for Payer: Cofinity Commercial |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$187.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$152.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.04
|
| Rate for Payer: Healthscope Commercial |
$195.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.92
|
| Rate for Payer: PHP Commercial |
$184.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.41
|
| Rate for Payer: Priority Health SBD |
$137.06
|
|
|
PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$217.55
|
|
|
Service Code
|
NDC 60687072501
|
| Hospital Charge Code |
26224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.02 |
| Max. Negotiated Rate |
$195.80 |
| Rate for Payer: Aetna Commercial |
$184.92
|
| Rate for Payer: Aetna Medicare |
$108.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$141.41
|
| Rate for Payer: BCBS Complete |
$87.02
|
| Rate for Payer: Cash Price |
$174.04
|
| Rate for Payer: Cofinity Commercial |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$187.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$152.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.04
|
| Rate for Payer: Healthscope Commercial |
$195.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.92
|
| Rate for Payer: PHP Commercial |
$184.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.41
|
| Rate for Payer: Priority Health SBD |
$137.06
|
|
|
PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$2.16
|
|
|
Service Code
|
NDC 68084064311
|
| Hospital Charge Code |
26224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Aetna Commercial |
$1.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.40
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cofinity Commercial |
$1.51
|
| Rate for Payer: Cofinity Commercial |
$1.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.73
|
| Rate for Payer: Healthscope Commercial |
$1.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.84
|
| Rate for Payer: PHP Commercial |
$1.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.40
|
| Rate for Payer: Priority Health SBD |
$1.36
|
|
|
PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$197.60
|
|
|
Service Code
|
NDC 60687058501
|
| Hospital Charge Code |
26224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.49 |
| Max. Negotiated Rate |
$177.84 |
| Rate for Payer: Aetna Commercial |
$167.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.44
|
| Rate for Payer: Cash Price |
$158.08
|
| Rate for Payer: Cofinity Commercial |
$138.32
|
| Rate for Payer: Cofinity Commercial |
$169.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$138.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$158.08
|
| Rate for Payer: Healthscope Commercial |
$177.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.96
|
| Rate for Payer: PHP Commercial |
$167.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.44
|
| Rate for Payer: Priority Health SBD |
$124.49
|
|
|
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
26226
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$18.90 |
| Rate for Payer: Aetna Commercial |
$17.85
|
| Rate for Payer: Aetna Commercial |
$17.60
|
| Rate for Payer: Aetna Commercial |
$22.40
|
| Rate for Payer: Aetna Commercial |
$14.35
|
| Rate for Payer: Aetna Commercial |
$14.06
|
| Rate for Payer: Aetna Commercial |
$19.10
|
| Rate for Payer: Aetna Commercial |
$18.18
|
| Rate for Payer: Aetna Medicare |
$10.70
|
| Rate for Payer: Aetna Medicare |
$10.35
|
| Rate for Payer: Aetna Medicare |
$8.27
|
| Rate for Payer: Aetna Medicare |
$10.50
|
| Rate for Payer: Aetna Medicare |
$8.44
|
| Rate for Payer: Aetna Medicare |
$13.18
|
| Rate for Payer: Aetna Medicare |
$11.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.13
|
| Rate for Payer: BCBS Complete |
$6.75
|
| Rate for Payer: BCBS Complete |
$6.62
|
| Rate for Payer: BCBS Complete |
$8.56
|
| Rate for Payer: BCBS Complete |
$8.99
|
| Rate for Payer: BCBS Complete |
$10.54
|
| Rate for Payer: BCBS Complete |
$8.28
|
| Rate for Payer: BCBS Complete |
$8.40
|
| Rate for Payer: BCBS Trust/PPO |
$14.39
|
| Rate for Payer: BCBS Trust/PPO |
$14.39
|
| Rate for Payer: BCBS Trust/PPO |
$14.39
|
| Rate for Payer: BCBS Trust/PPO |
$14.39
|
| Rate for Payer: BCBS Trust/PPO |
$14.39
|
| Rate for Payer: BCBS Trust/PPO |
$14.39
|
| Rate for Payer: BCBS Trust/PPO |
$14.39
|
| Rate for Payer: BCN Commercial |
$14.39
|
| Rate for Payer: BCN Commercial |
$14.39
|
| Rate for Payer: BCN Commercial |
$14.39
|
| Rate for Payer: BCN Commercial |
$14.39
|
| Rate for Payer: BCN Commercial |
$14.39
|
| Rate for Payer: BCN Commercial |
$14.39
|
| Rate for Payer: BCN Commercial |
$14.39
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cash Price |
$13.23
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$13.23
|
| Rate for Payer: Cash Price |
$17.11
|
| Rate for Payer: Cash Price |
$17.11
|
| Rate for Payer: Cash Price |
$17.98
|
| Rate for Payer: Cash Price |
$17.98
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cofinity Commercial |
$18.06
|
| Rate for Payer: Cofinity Commercial |
$11.58
|
| Rate for Payer: Cofinity Commercial |
$14.22
|
| Rate for Payer: Cofinity Commercial |
$11.82
|
| Rate for Payer: Cofinity Commercial |
$14.52
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Cofinity Commercial |
$14.70
|
| Rate for Payer: Cofinity Commercial |
$22.66
|
| Rate for Payer: Cofinity Commercial |
$18.44
|
| Rate for Payer: Cofinity Commercial |
$14.97
|
| Rate for Payer: Cofinity Commercial |
$18.40
|
| Rate for Payer: Cofinity Commercial |
$19.32
|
| Rate for Payer: Cofinity Commercial |
$15.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.50
|
| Rate for Payer: Healthscope Commercial |
$19.25
|
| Rate for Payer: Healthscope Commercial |
$18.63
|
| Rate for Payer: Healthscope Commercial |
$18.90
|
| Rate for Payer: Healthscope Commercial |
$23.72
|
| Rate for Payer: Healthscope Commercial |
$15.19
|
| Rate for Payer: Healthscope Commercial |
$20.22
|
| Rate for Payer: Healthscope Commercial |
$14.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.60
|
| Rate for Payer: PHP Commercial |
$17.85
|
| Rate for Payer: PHP Commercial |
$14.35
|
| Rate for Payer: PHP Commercial |
$19.10
|
| Rate for Payer: PHP Commercial |
$22.40
|
| Rate for Payer: PHP Commercial |
$18.18
|
| Rate for Payer: PHP Commercial |
$17.60
|
| Rate for Payer: PHP Commercial |
$14.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.75
|
| Rate for Payer: Priority Health SBD |
$13.48
|
| Rate for Payer: Priority Health SBD |
$14.16
|
| Rate for Payer: Priority Health SBD |
$13.23
|
| Rate for Payer: Priority Health SBD |
$13.04
|
| Rate for Payer: Priority Health SBD |
$10.42
|
| Rate for Payer: Priority Health SBD |
$10.63
|
| Rate for Payer: Priority Health SBD |
$16.60
|
|
|
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$19.27
|
|
|
Service Code
|
HCPCS J2471
|
| Hospital Charge Code |
26226
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$17.34 |
| Rate for Payer: Aetna Commercial |
$16.38
|
| Rate for Payer: Aetna Commercial |
$22.41
|
| Rate for Payer: Aetna Medicare |
$13.18
|
| Rate for Payer: Aetna Medicare |
$9.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.14
|
| Rate for Payer: BCBS Complete |
$10.55
|
| Rate for Payer: BCBS Complete |
$7.71
|
| Rate for Payer: BCBS Trust/PPO |
$13.14
|
| Rate for Payer: BCBS Trust/PPO |
$13.14
|
| Rate for Payer: BCN Commercial |
$13.14
|
| Rate for Payer: BCN Commercial |
$13.14
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cash Price |
$15.42
|
| Rate for Payer: Cash Price |
$15.42
|
| Rate for Payer: Cofinity Commercial |
$13.49
|
| Rate for Payer: Cofinity Commercial |
$22.68
|
| Rate for Payer: Cofinity Commercial |
$18.46
|
| Rate for Payer: Cofinity Commercial |
$16.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.10
|
| Rate for Payer: Healthscope Commercial |
$17.34
|
| Rate for Payer: Healthscope Commercial |
$23.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.38
|
| Rate for Payer: PHP Commercial |
$22.41
|
| Rate for Payer: PHP Commercial |
$16.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.14
|
| Rate for Payer: Priority Health SBD |
$16.61
|
| Rate for Payer: Priority Health SBD |
$12.14
|
|
|
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$19.27
|
|
|
Service Code
|
HCPCS J2471
|
| Hospital Charge Code |
26226
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.14 |
| Max. Negotiated Rate |
$17.34 |
| Rate for Payer: Aetna Commercial |
$16.38
|
| Rate for Payer: Aetna Commercial |
$22.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.14
|
| Rate for Payer: Cash Price |
$15.42
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cofinity Commercial |
$13.49
|
| Rate for Payer: Cofinity Commercial |
$18.46
|
| Rate for Payer: Cofinity Commercial |
$22.68
|
| Rate for Payer: Cofinity Commercial |
$16.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.10
|
| Rate for Payer: Healthscope Commercial |
$17.34
|
| Rate for Payer: Healthscope Commercial |
$23.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.41
|
| Rate for Payer: PHP Commercial |
$16.38
|
| Rate for Payer: PHP Commercial |
$22.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.53
|
| Rate for Payer: Priority Health SBD |
$16.61
|
| Rate for Payer: Priority Health SBD |
$12.14
|
|
|
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$22.47
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
26226
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.16 |
| Max. Negotiated Rate |
$20.22 |
| Rate for Payer: Aetna Commercial |
$19.10
|
| Rate for Payer: Aetna Commercial |
$14.35
|
| Rate for Payer: Aetna Commercial |
$17.85
|
| Rate for Payer: Aetna Commercial |
$18.18
|
| Rate for Payer: Aetna Commercial |
$14.06
|
| Rate for Payer: Aetna Commercial |
$17.60
|
| Rate for Payer: Aetna Commercial |
$22.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.90
|
| Rate for Payer: Cash Price |
$17.98
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cash Price |
$13.23
|
| Rate for Payer: Cash Price |
$17.11
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cofinity Commercial |
$18.44
|
| Rate for Payer: Cofinity Commercial |
$19.32
|
| Rate for Payer: Cofinity Commercial |
$11.58
|
| Rate for Payer: Cofinity Commercial |
$14.22
|
| Rate for Payer: Cofinity Commercial |
$11.82
|
| Rate for Payer: Cofinity Commercial |
$14.52
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Cofinity Commercial |
$14.70
|
| Rate for Payer: Cofinity Commercial |
$18.06
|
| Rate for Payer: Cofinity Commercial |
$14.97
|
| Rate for Payer: Cofinity Commercial |
$18.40
|
| Rate for Payer: Cofinity Commercial |
$15.73
|
| Rate for Payer: Cofinity Commercial |
$22.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.98
|
| Rate for Payer: Healthscope Commercial |
$15.19
|
| Rate for Payer: Healthscope Commercial |
$19.25
|
| Rate for Payer: Healthscope Commercial |
$18.63
|
| Rate for Payer: Healthscope Commercial |
$18.90
|
| Rate for Payer: Healthscope Commercial |
$14.89
|
| Rate for Payer: Healthscope Commercial |
$20.22
|
| Rate for Payer: Healthscope Commercial |
$23.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.40
|
| Rate for Payer: PHP Commercial |
$19.10
|
| Rate for Payer: PHP Commercial |
$17.60
|
| Rate for Payer: PHP Commercial |
$14.06
|
| Rate for Payer: PHP Commercial |
$18.18
|
| Rate for Payer: PHP Commercial |
$17.85
|
| Rate for Payer: PHP Commercial |
$14.35
|
| Rate for Payer: PHP Commercial |
$22.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.97
|
| Rate for Payer: Priority Health SBD |
$13.48
|
| Rate for Payer: Priority Health SBD |
$10.63
|
| Rate for Payer: Priority Health SBD |
$16.60
|
| Rate for Payer: Priority Health SBD |
$10.42
|
| Rate for Payer: Priority Health SBD |
$13.04
|
| Rate for Payer: Priority Health SBD |
$13.23
|
| Rate for Payer: Priority Health SBD |
$14.16
|
|
|
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION FOR DRIP
|
Facility
|
IP
|
$22.47
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
301183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.16 |
| Max. Negotiated Rate |
$20.22 |
| Rate for Payer: Aetna Commercial |
$19.10
|
| Rate for Payer: Aetna Commercial |
$18.18
|
| Rate for Payer: Aetna Commercial |
$22.40
|
| Rate for Payer: Aetna Commercial |
$17.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.13
|
| Rate for Payer: Cash Price |
$17.98
|
| Rate for Payer: Cash Price |
$17.11
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$22.66
|
| Rate for Payer: Cofinity Commercial |
$18.44
|
| Rate for Payer: Cofinity Commercial |
$14.97
|
| Rate for Payer: Cofinity Commercial |
$18.40
|
| Rate for Payer: Cofinity Commercial |
$19.32
|
| Rate for Payer: Cofinity Commercial |
$15.73
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.08
|
| Rate for Payer: Healthscope Commercial |
$19.25
|
| Rate for Payer: Healthscope Commercial |
$18.63
|
| Rate for Payer: Healthscope Commercial |
$23.72
|
| Rate for Payer: Healthscope Commercial |
$20.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.60
|
| Rate for Payer: PHP Commercial |
$17.60
|
| Rate for Payer: PHP Commercial |
$19.10
|
| Rate for Payer: PHP Commercial |
$18.18
|
| Rate for Payer: PHP Commercial |
$22.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.13
|
| Rate for Payer: Priority Health SBD |
$13.04
|
| Rate for Payer: Priority Health SBD |
$14.16
|
| Rate for Payer: Priority Health SBD |
$13.48
|
| Rate for Payer: Priority Health SBD |
$16.60
|
|
|
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION FOR DRIP
|
Facility
|
OP
|
$26.35
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
301183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.54 |
| Max. Negotiated Rate |
$23.72 |
| Rate for Payer: Aetna Commercial |
$22.40
|
| Rate for Payer: Aetna Commercial |
$17.60
|
| Rate for Payer: Aetna Commercial |
$19.10
|
| Rate for Payer: Aetna Commercial |
$18.18
|
| Rate for Payer: Aetna Medicare |
$11.24
|
| Rate for Payer: Aetna Medicare |
$10.35
|
| Rate for Payer: Aetna Medicare |
$13.18
|
| Rate for Payer: Aetna Medicare |
$10.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.90
|
| Rate for Payer: BCBS Complete |
$8.99
|
| Rate for Payer: BCBS Complete |
$10.54
|
| Rate for Payer: BCBS Complete |
$8.56
|
| Rate for Payer: BCBS Complete |
$8.28
|
| Rate for Payer: BCBS Trust/PPO |
$14.39
|
| Rate for Payer: BCBS Trust/PPO |
$14.39
|
| Rate for Payer: BCBS Trust/PPO |
$14.39
|
| Rate for Payer: BCBS Trust/PPO |
$14.39
|
| Rate for Payer: BCN Commercial |
$14.39
|
| Rate for Payer: BCN Commercial |
$14.39
|
| Rate for Payer: BCN Commercial |
$14.39
|
| Rate for Payer: BCN Commercial |
$14.39
|
| Rate for Payer: Cash Price |
$17.11
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cash Price |
$17.98
|
| Rate for Payer: Cash Price |
$17.11
|
| Rate for Payer: Cash Price |
$17.98
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cofinity Commercial |
$14.97
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Cofinity Commercial |
$18.40
|
| Rate for Payer: Cofinity Commercial |
$15.73
|
| Rate for Payer: Cofinity Commercial |
$19.32
|
| Rate for Payer: Cofinity Commercial |
$18.44
|
| Rate for Payer: Cofinity Commercial |
$22.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.11
|
| Rate for Payer: Healthscope Commercial |
$19.25
|
| Rate for Payer: Healthscope Commercial |
$23.72
|
| Rate for Payer: Healthscope Commercial |
$20.22
|
| Rate for Payer: Healthscope Commercial |
$18.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.40
|
| Rate for Payer: PHP Commercial |
$22.40
|
| Rate for Payer: PHP Commercial |
$18.18
|
| Rate for Payer: PHP Commercial |
$19.10
|
| Rate for Payer: PHP Commercial |
$17.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.90
|
| Rate for Payer: Priority Health SBD |
$16.60
|
| Rate for Payer: Priority Health SBD |
$13.48
|
| Rate for Payer: Priority Health SBD |
$13.04
|
| Rate for Payer: Priority Health SBD |
$14.16
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$319.60
|
|
|
Service Code
|
NDC 68084081309
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.84 |
| Max. Negotiated Rate |
$287.64 |
| Rate for Payer: Aetna Commercial |
$271.66
|
| Rate for Payer: Aetna Medicare |
$159.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.74
|
| Rate for Payer: BCBS Complete |
$127.84
|
| Rate for Payer: Cash Price |
$255.68
|
| Rate for Payer: Cofinity Commercial |
$223.72
|
| Rate for Payer: Cofinity Commercial |
$274.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$223.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$255.68
|
| Rate for Payer: Healthscope Commercial |
$287.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$271.66
|
| Rate for Payer: PHP Commercial |
$271.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.74
|
| Rate for Payer: Priority Health SBD |
$201.35
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$2.22
|
|
|
Service Code
|
NDC 51079005101
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Aetna Commercial |
$1.89
|
| Rate for Payer: Aetna Medicare |
$1.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.44
|
| Rate for Payer: BCBS Complete |
$0.89
|
| Rate for Payer: Cash Price |
$1.78
|
| Rate for Payer: Cofinity Commercial |
$1.55
|
| Rate for Payer: Cofinity Commercial |
$1.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.78
|
| Rate for Payer: Healthscope Commercial |
$2.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.89
|
| Rate for Payer: PHP Commercial |
$1.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.44
|
| Rate for Payer: Priority Health SBD |
$1.40
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$220.40
|
|
|
Service Code
|
NDC 35573042880
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.16 |
| Max. Negotiated Rate |
$198.36 |
| Rate for Payer: Aetna Commercial |
$187.34
|
| Rate for Payer: Aetna Medicare |
$110.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.26
|
| Rate for Payer: BCBS Complete |
$88.16
|
| Rate for Payer: Cash Price |
$176.32
|
| Rate for Payer: Cofinity Commercial |
$154.28
|
| Rate for Payer: Cofinity Commercial |
$189.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$154.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$176.32
|
| Rate for Payer: Healthscope Commercial |
$198.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$187.34
|
| Rate for Payer: PHP Commercial |
$187.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$143.26
|
| Rate for Payer: Priority Health SBD |
$138.85
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$319.60
|
|
|
Service Code
|
NDC 68084081309
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$201.35 |
| Max. Negotiated Rate |
$287.64 |
| Rate for Payer: Aetna Commercial |
$271.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.74
|
| Rate for Payer: Cash Price |
$255.68
|
| Rate for Payer: Cofinity Commercial |
$223.72
|
| Rate for Payer: Cofinity Commercial |
$274.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$223.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$255.68
|
| Rate for Payer: Healthscope Commercial |
$287.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$271.66
|
| Rate for Payer: PHP Commercial |
$271.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.74
|
| Rate for Payer: Priority Health SBD |
$201.35
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$220.40
|
|
|
Service Code
|
NDC 35573042880
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.85 |
| Max. Negotiated Rate |
$198.36 |
| Rate for Payer: Aetna Commercial |
$187.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.26
|
| Rate for Payer: Cash Price |
$176.32
|
| Rate for Payer: Cofinity Commercial |
$154.28
|
| Rate for Payer: Cofinity Commercial |
$189.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$154.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$176.32
|
| Rate for Payer: Healthscope Commercial |
$198.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$187.34
|
| Rate for Payer: PHP Commercial |
$187.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$143.26
|
| Rate for Payer: Priority Health SBD |
$138.85
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 68084081311
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$3.60 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.60
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cofinity Commercial |
$2.80
|
| Rate for Payer: Cofinity Commercial |
$3.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.20
|
| Rate for Payer: Healthscope Commercial |
$3.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.40
|
| Rate for Payer: PHP Commercial |
$3.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.60
|
| Rate for Payer: Priority Health SBD |
$2.52
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$1,081.00
|
|
|
Service Code
|
NDC 65862056099
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$432.40 |
| Max. Negotiated Rate |
$972.90 |
| Rate for Payer: Aetna Commercial |
$918.85
|
| Rate for Payer: Aetna Medicare |
$540.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$702.65
|
| Rate for Payer: BCBS Complete |
$432.40
|
| Rate for Payer: Cash Price |
$864.80
|
| Rate for Payer: Cofinity Commercial |
$756.70
|
| Rate for Payer: Cofinity Commercial |
$929.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$756.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$864.80
|
| Rate for Payer: Healthscope Commercial |
$972.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$918.85
|
| Rate for Payer: PHP Commercial |
$918.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$702.65
|
| Rate for Payer: Priority Health SBD |
$681.03
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$2.21
|
|
|
Service Code
|
NDC 35573042851
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Aetna Commercial |
$1.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.44
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cofinity Commercial |
$1.55
|
| Rate for Payer: Cofinity Commercial |
$1.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.77
|
| Rate for Payer: Healthscope Commercial |
$1.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.88
|
| Rate for Payer: PHP Commercial |
$1.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.44
|
| Rate for Payer: Priority Health SBD |
$1.39
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$3.74
|
|
|
Service Code
|
NDC 60687073611
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna Commercial |
$3.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.43
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.18
|
| Rate for Payer: PHP Commercial |
$3.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.43
|
| Rate for Payer: Priority Health SBD |
$2.36
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$3.74
|
|
|
Service Code
|
NDC 60687073611
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna Commercial |
$3.18
|
| Rate for Payer: Aetna Medicare |
$1.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.43
|
| Rate for Payer: BCBS Complete |
$1.50
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.18
|
| Rate for Payer: PHP Commercial |
$3.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.43
|
| Rate for Payer: Priority Health SBD |
$2.36
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$169.20
|
|
|
Service Code
|
NDC 60687073665
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.60 |
| Max. Negotiated Rate |
$152.28 |
| Rate for Payer: Aetna Commercial |
$143.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.98
|
| Rate for Payer: Cash Price |
$135.36
|
| Rate for Payer: Cofinity Commercial |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$145.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$118.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.36
|
| Rate for Payer: Healthscope Commercial |
$152.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.82
|
| Rate for Payer: PHP Commercial |
$143.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.98
|
| Rate for Payer: Priority Health SBD |
$106.60
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$4,482.85
|
|
|
Service Code
|
NDC 00008084181
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,824.20 |
| Max. Negotiated Rate |
$4,034.56 |
| Rate for Payer: Aetna Commercial |
$3,810.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,913.85
|
| Rate for Payer: Cash Price |
$3,586.28
|
| Rate for Payer: Cofinity Commercial |
$3,138.00
|
| Rate for Payer: Cofinity Commercial |
$3,855.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,138.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,586.28
|
| Rate for Payer: Healthscope Commercial |
$4,034.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,810.42
|
| Rate for Payer: PHP Commercial |
$3,810.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,913.85
|
| Rate for Payer: Priority Health SBD |
$2,824.20
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$180.41
|
|
|
Service Code
|
NDC 55111033390
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.16 |
| Max. Negotiated Rate |
$162.37 |
| Rate for Payer: Aetna Commercial |
$153.35
|
| Rate for Payer: Aetna Medicare |
$90.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$117.27
|
| Rate for Payer: BCBS Complete |
$72.16
|
| Rate for Payer: Cash Price |
$144.33
|
| Rate for Payer: Cofinity Commercial |
$126.29
|
| Rate for Payer: Cofinity Commercial |
$155.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$126.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$144.33
|
| Rate for Payer: Healthscope Commercial |
$162.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$153.35
|
| Rate for Payer: PHP Commercial |
$153.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$117.27
|
| Rate for Payer: Priority Health SBD |
$113.66
|
|
