|
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$19.27
|
|
|
Service Code
|
HCPCS J2471
|
| Hospital Charge Code |
26226
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.30 |
| Max. Negotiated Rate |
$19.27 |
| Rate for Payer: Aetna Commercial |
$17.34
|
| Rate for Payer: Aetna Medicare |
$9.64
|
| Rate for Payer: ASR ASR |
$18.69
|
| Rate for Payer: ASR Commercial |
$18.69
|
| Rate for Payer: BCBS Complete |
$7.71
|
| Rate for Payer: BCBS Trust/PPO |
$15.78
|
| Rate for Payer: BCN Commercial |
$14.94
|
| Rate for Payer: Cash Price |
$15.42
|
| Rate for Payer: Cash Price |
$15.42
|
| Rate for Payer: Cofinity Commercial |
$18.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.42
|
| Rate for Payer: Healthscope Commercial |
$19.27
|
| Rate for Payer: Healthscope Whirlpool |
$18.69
|
| Rate for Payer: Mclaren Commercial |
$17.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.38
|
| Rate for Payer: Nomi Health Commercial |
$15.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.53
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6.63
|
| Rate for Payer: Priority Health Narrow Network |
$5.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.96
|
|
|
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$19.27
|
|
|
Service Code
|
HCPCS J2471
|
| Hospital Charge Code |
26226
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$19.27 |
| Rate for Payer: Aetna Commercial |
$17.34
|
| Rate for Payer: ASR ASR |
$18.69
|
| Rate for Payer: ASR Commercial |
$18.69
|
| Rate for Payer: BCBS Trust/PPO |
$15.70
|
| Rate for Payer: BCN Commercial |
$14.94
|
| Rate for Payer: Cash Price |
$15.42
|
| Rate for Payer: Cofinity Commercial |
$18.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.42
|
| Rate for Payer: Healthscope Commercial |
$19.27
|
| Rate for Payer: Healthscope Whirlpool |
$18.69
|
| Rate for Payer: Mclaren Commercial |
$17.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.38
|
| Rate for Payer: Nomi Health Commercial |
$15.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.96
|
|
|
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION FOR DRIP
|
Facility
|
OP
|
$19.64
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
301183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$19.64 |
| Rate for Payer: Aetna Commercial |
$17.68
|
| Rate for Payer: Aetna Medicare |
$9.82
|
| Rate for Payer: ASR ASR |
$19.05
|
| Rate for Payer: ASR Commercial |
$19.05
|
| Rate for Payer: BCBS Complete |
$7.86
|
| Rate for Payer: BCBS Trust/PPO |
$16.08
|
| Rate for Payer: BCN Commercial |
$15.23
|
| Rate for Payer: Cash Price |
$15.71
|
| Rate for Payer: Cash Price |
$15.71
|
| Rate for Payer: Cofinity Commercial |
$18.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.71
|
| Rate for Payer: Healthscope Commercial |
$19.64
|
| Rate for Payer: Healthscope Whirlpool |
$19.05
|
| Rate for Payer: Mclaren Commercial |
$17.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.69
|
| Rate for Payer: Nomi Health Commercial |
$16.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.64
|
| Rate for Payer: Priority Health Narrow Network |
$3.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.28
|
|
|
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION FOR DRIP
|
Facility
|
IP
|
$19.64
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
301183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$19.64 |
| Rate for Payer: Aetna Commercial |
$17.68
|
| Rate for Payer: ASR ASR |
$19.05
|
| Rate for Payer: ASR Commercial |
$19.05
|
| Rate for Payer: BCBS Trust/PPO |
$16.00
|
| Rate for Payer: BCN Commercial |
$15.23
|
| Rate for Payer: Cash Price |
$15.71
|
| Rate for Payer: Cofinity Commercial |
$18.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.71
|
| Rate for Payer: Healthscope Commercial |
$19.64
|
| Rate for Payer: Healthscope Whirlpool |
$19.05
|
| Rate for Payer: Mclaren Commercial |
$17.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.69
|
| Rate for Payer: Nomi Health Commercial |
$16.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.28
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$446.50
|
|
|
Service Code
|
NDC 66993006880
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$290.22 |
| Max. Negotiated Rate |
$446.50 |
| Rate for Payer: Aetna Commercial |
$401.85
|
| Rate for Payer: ASR ASR |
$433.10
|
| Rate for Payer: ASR Commercial |
$433.10
|
| Rate for Payer: BCBS Trust/PPO |
$363.85
|
| Rate for Payer: BCN Commercial |
$346.17
|
| Rate for Payer: Cash Price |
$357.20
|
| Rate for Payer: Cofinity Commercial |
$419.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$357.20
|
| Rate for Payer: Healthscope Commercial |
$446.50
|
| Rate for Payer: Healthscope Whirlpool |
$433.10
|
| Rate for Payer: Mclaren Commercial |
$401.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$379.52
|
| Rate for Payer: Nomi Health Commercial |
$366.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$290.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$392.92
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$270.72
|
|
|
Service Code
|
NDC 00904687045
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.29 |
| Max. Negotiated Rate |
$270.72 |
| Rate for Payer: Aetna Commercial |
$243.65
|
| Rate for Payer: Aetna Medicare |
$135.36
|
| Rate for Payer: ASR ASR |
$262.60
|
| Rate for Payer: ASR Commercial |
$262.60
|
| Rate for Payer: BCBS Complete |
$108.29
|
| Rate for Payer: BCBS Trust/PPO |
$221.69
|
| Rate for Payer: BCN Commercial |
$209.89
|
| Rate for Payer: Cash Price |
$216.58
|
| Rate for Payer: Cofinity Commercial |
$254.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.58
|
| Rate for Payer: Healthscope Commercial |
$270.72
|
| Rate for Payer: Healthscope Whirlpool |
$262.60
|
| Rate for Payer: Mclaren Commercial |
$243.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.11
|
| Rate for Payer: Nomi Health Commercial |
$221.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$237.20
|
| Rate for Payer: Priority Health Narrow Network |
$189.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$238.23
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$3.08
|
|
|
Service Code
|
NDC 50268063911
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$3.08 |
| Rate for Payer: Aetna Commercial |
$2.77
|
| Rate for Payer: ASR ASR |
$2.99
|
| Rate for Payer: ASR Commercial |
$2.99
|
| Rate for Payer: BCBS Trust/PPO |
$2.51
|
| Rate for Payer: BCN Commercial |
$2.39
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cofinity Commercial |
$2.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.46
|
| Rate for Payer: Healthscope Commercial |
$3.08
|
| Rate for Payer: Healthscope Whirlpool |
$2.99
|
| Rate for Payer: Mclaren Commercial |
$2.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.62
|
| Rate for Payer: Nomi Health Commercial |
$2.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.71
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$4.46
|
|
|
Service Code
|
NDC 66993006851
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna Commercial |
$4.01
|
| Rate for Payer: Aetna Medicare |
$2.23
|
| Rate for Payer: ASR ASR |
$4.33
|
| Rate for Payer: ASR Commercial |
$4.33
|
| Rate for Payer: BCBS Complete |
$1.78
|
| Rate for Payer: BCBS Trust/PPO |
$3.65
|
| Rate for Payer: BCN Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$3.57
|
| Rate for Payer: Cofinity Commercial |
$4.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.57
|
| Rate for Payer: Healthscope Commercial |
$4.46
|
| Rate for Payer: Healthscope Whirlpool |
$4.33
|
| Rate for Payer: Mclaren Commercial |
$4.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.79
|
| Rate for Payer: Nomi Health Commercial |
$3.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.91
|
| Rate for Payer: Priority Health Narrow Network |
$3.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.92
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$153.93
|
|
|
Service Code
|
NDC 50268063915
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.57 |
| Max. Negotiated Rate |
$153.93 |
| Rate for Payer: Aetna Commercial |
$138.54
|
| Rate for Payer: Aetna Medicare |
$76.96
|
| Rate for Payer: ASR ASR |
$149.31
|
| Rate for Payer: ASR Commercial |
$149.31
|
| Rate for Payer: BCBS Complete |
$61.57
|
| Rate for Payer: BCBS Trust/PPO |
$126.05
|
| Rate for Payer: BCN Commercial |
$119.34
|
| Rate for Payer: Cash Price |
$123.14
|
| Rate for Payer: Cofinity Commercial |
$144.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$123.14
|
| Rate for Payer: Healthscope Commercial |
$153.93
|
| Rate for Payer: Healthscope Whirlpool |
$149.31
|
| Rate for Payer: Mclaren Commercial |
$138.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.84
|
| Rate for Payer: Nomi Health Commercial |
$126.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.05
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$134.87
|
| Rate for Payer: Priority Health Narrow Network |
$107.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$135.46
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$446.50
|
|
|
Service Code
|
NDC 66993006880
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.60 |
| Max. Negotiated Rate |
$446.50 |
| Rate for Payer: Aetna Commercial |
$401.85
|
| Rate for Payer: Aetna Medicare |
$223.25
|
| Rate for Payer: ASR ASR |
$433.10
|
| Rate for Payer: ASR Commercial |
$433.10
|
| Rate for Payer: BCBS Complete |
$178.60
|
| Rate for Payer: BCBS Trust/PPO |
$365.64
|
| Rate for Payer: BCN Commercial |
$346.17
|
| Rate for Payer: Cash Price |
$357.20
|
| Rate for Payer: Cofinity Commercial |
$419.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$357.20
|
| Rate for Payer: Healthscope Commercial |
$446.50
|
| Rate for Payer: Healthscope Whirlpool |
$433.10
|
| Rate for Payer: Mclaren Commercial |
$401.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$379.52
|
| Rate for Payer: Nomi Health Commercial |
$366.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$290.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$391.22
|
| Rate for Payer: Priority Health Narrow Network |
$313.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$392.92
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$3.08
|
|
|
Service Code
|
NDC 50268063911
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$3.08 |
| Rate for Payer: Aetna Commercial |
$2.77
|
| Rate for Payer: Aetna Medicare |
$1.54
|
| Rate for Payer: ASR ASR |
$2.99
|
| Rate for Payer: ASR Commercial |
$2.99
|
| Rate for Payer: BCBS Complete |
$1.23
|
| Rate for Payer: BCBS Trust/PPO |
$2.52
|
| Rate for Payer: BCN Commercial |
$2.39
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cofinity Commercial |
$2.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.46
|
| Rate for Payer: Healthscope Commercial |
$3.08
|
| Rate for Payer: Healthscope Whirlpool |
$2.99
|
| Rate for Payer: Mclaren Commercial |
$2.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.62
|
| Rate for Payer: Nomi Health Commercial |
$2.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.70
|
| Rate for Payer: Priority Health Narrow Network |
$2.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.71
|
|
|
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 |
$2,913.85 |
| Max. Negotiated Rate |
$4,482.85 |
| Rate for Payer: Aetna Commercial |
$4,034.56
|
| Rate for Payer: ASR ASR |
$4,348.36
|
| Rate for Payer: ASR Commercial |
$4,348.36
|
| Rate for Payer: BCBS Trust/PPO |
$3,653.07
|
| Rate for Payer: BCN Commercial |
$3,475.55
|
| Rate for Payer: Cash Price |
$3,586.28
|
| Rate for Payer: Cofinity Commercial |
$4,213.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,586.28
|
| Rate for Payer: Healthscope Commercial |
$4,482.85
|
| Rate for Payer: Healthscope Whirlpool |
$4,348.36
|
| Rate for Payer: Mclaren Commercial |
$4,034.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,810.42
|
| Rate for Payer: Nomi Health Commercial |
$3,675.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,913.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,944.91
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$4,482.85
|
|
|
Service Code
|
NDC 00008084181
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,793.14 |
| Max. Negotiated Rate |
$4,482.85 |
| Rate for Payer: Aetna Commercial |
$4,034.56
|
| Rate for Payer: Aetna Medicare |
$2,241.42
|
| Rate for Payer: ASR ASR |
$4,348.36
|
| Rate for Payer: ASR Commercial |
$4,348.36
|
| Rate for Payer: BCBS Complete |
$1,793.14
|
| Rate for Payer: BCBS Trust/PPO |
$3,671.01
|
| Rate for Payer: BCN Commercial |
$3,475.55
|
| Rate for Payer: Cash Price |
$3,586.28
|
| Rate for Payer: Cofinity Commercial |
$4,213.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,586.28
|
| Rate for Payer: Healthscope Commercial |
$4,482.85
|
| Rate for Payer: Healthscope Whirlpool |
$4,348.36
|
| Rate for Payer: Mclaren Commercial |
$4,034.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,810.42
|
| Rate for Payer: Nomi Health Commercial |
$3,675.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,913.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3,927.87
|
| Rate for Payer: Priority Health Narrow Network |
$3,142.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,944.91
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$153.93
|
|
|
Service Code
|
NDC 50268063915
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.05 |
| Max. Negotiated Rate |
$153.93 |
| Rate for Payer: Aetna Commercial |
$138.54
|
| Rate for Payer: ASR ASR |
$149.31
|
| Rate for Payer: ASR Commercial |
$149.31
|
| Rate for Payer: BCBS Trust/PPO |
$125.44
|
| Rate for Payer: BCN Commercial |
$119.34
|
| Rate for Payer: Cash Price |
$123.14
|
| Rate for Payer: Cofinity Commercial |
$144.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$123.14
|
| Rate for Payer: Healthscope Commercial |
$153.93
|
| Rate for Payer: Healthscope Whirlpool |
$149.31
|
| Rate for Payer: Mclaren Commercial |
$138.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.84
|
| Rate for Payer: Nomi Health Commercial |
$126.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$135.46
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$222.30
|
|
|
Service Code
|
NDC 63739056410
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.50 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Aetna Commercial |
$200.07
|
| Rate for Payer: ASR ASR |
$215.63
|
| Rate for Payer: ASR Commercial |
$215.63
|
| Rate for Payer: BCBS Trust/PPO |
$181.15
|
| Rate for Payer: BCN Commercial |
$172.35
|
| Rate for Payer: Cash Price |
$177.84
|
| Rate for Payer: Cofinity Commercial |
$208.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.84
|
| Rate for Payer: Healthscope Commercial |
$222.30
|
| Rate for Payer: Healthscope Whirlpool |
$215.63
|
| Rate for Payer: Mclaren Commercial |
$200.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$188.96
|
| Rate for Payer: Nomi Health Commercial |
$182.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$195.62
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$200.45
|
|
|
Service Code
|
NDC 00904647461
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.18 |
| Max. Negotiated Rate |
$200.45 |
| Rate for Payer: Aetna Commercial |
$180.40
|
| Rate for Payer: Aetna Medicare |
$100.22
|
| Rate for Payer: ASR ASR |
$194.44
|
| Rate for Payer: ASR Commercial |
$194.44
|
| Rate for Payer: BCBS Complete |
$80.18
|
| Rate for Payer: BCBS Trust/PPO |
$164.15
|
| Rate for Payer: BCN Commercial |
$155.41
|
| Rate for Payer: Cash Price |
$160.36
|
| Rate for Payer: Cofinity Commercial |
$188.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.36
|
| Rate for Payer: Healthscope Commercial |
$200.45
|
| Rate for Payer: Healthscope Whirlpool |
$194.44
|
| Rate for Payer: Mclaren Commercial |
$180.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.38
|
| Rate for Payer: Nomi Health Commercial |
$164.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$175.63
|
| Rate for Payer: Priority Health Narrow Network |
$140.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$176.40
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$2.21
|
|
|
Service Code
|
NDC 51079005101
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna Commercial |
$1.99
|
| Rate for Payer: Aetna Medicare |
$1.10
|
| Rate for Payer: ASR ASR |
$2.14
|
| Rate for Payer: ASR Commercial |
$2.14
|
| Rate for Payer: BCBS Complete |
$0.88
|
| Rate for Payer: BCBS Trust/PPO |
$1.81
|
| Rate for Payer: BCN Commercial |
$1.71
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cofinity Commercial |
$2.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.77
|
| Rate for Payer: Healthscope Commercial |
$2.21
|
| Rate for Payer: Healthscope Whirlpool |
$2.14
|
| Rate for Payer: Mclaren Commercial |
$1.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.88
|
| Rate for Payer: Nomi Health Commercial |
$1.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.94
|
| Rate for Payer: Priority Health Narrow Network |
$1.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.94
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$200.45
|
|
|
Service Code
|
NDC 00904647461
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.29 |
| Max. Negotiated Rate |
$200.45 |
| Rate for Payer: Aetna Commercial |
$180.40
|
| Rate for Payer: ASR ASR |
$194.44
|
| Rate for Payer: ASR Commercial |
$194.44
|
| Rate for Payer: BCBS Trust/PPO |
$163.35
|
| Rate for Payer: BCN Commercial |
$155.41
|
| Rate for Payer: Cash Price |
$160.36
|
| Rate for Payer: Cofinity Commercial |
$188.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.36
|
| Rate for Payer: Healthscope Commercial |
$200.45
|
| Rate for Payer: Healthscope Whirlpool |
$194.44
|
| Rate for Payer: Mclaren Commercial |
$180.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.38
|
| Rate for Payer: Nomi Health Commercial |
$164.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$176.40
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$270.72
|
|
|
Service Code
|
NDC 00904687045
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$175.97 |
| Max. Negotiated Rate |
$270.72 |
| Rate for Payer: Aetna Commercial |
$243.65
|
| Rate for Payer: ASR ASR |
$262.60
|
| Rate for Payer: ASR Commercial |
$262.60
|
| Rate for Payer: BCBS Trust/PPO |
$220.61
|
| Rate for Payer: BCN Commercial |
$209.89
|
| Rate for Payer: Cash Price |
$216.58
|
| Rate for Payer: Cofinity Commercial |
$254.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.58
|
| Rate for Payer: Healthscope Commercial |
$270.72
|
| Rate for Payer: Healthscope Whirlpool |
$262.60
|
| Rate for Payer: Mclaren Commercial |
$243.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.11
|
| Rate for Payer: Nomi Health Commercial |
$221.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$238.23
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$2.21
|
|
|
Service Code
|
NDC 51079005101
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna Commercial |
$1.99
|
| Rate for Payer: ASR ASR |
$2.14
|
| Rate for Payer: ASR Commercial |
$2.14
|
| Rate for Payer: BCBS Trust/PPO |
$1.80
|
| Rate for Payer: BCN Commercial |
$1.71
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cofinity Commercial |
$2.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.77
|
| Rate for Payer: Healthscope Commercial |
$2.21
|
| Rate for Payer: Healthscope Whirlpool |
$2.14
|
| Rate for Payer: Mclaren Commercial |
$1.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.88
|
| Rate for Payer: Nomi Health Commercial |
$1.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.94
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$222.30
|
|
|
Service Code
|
NDC 63739056410
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.92 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Aetna Commercial |
$200.07
|
| Rate for Payer: Aetna Medicare |
$111.15
|
| Rate for Payer: ASR ASR |
$215.63
|
| Rate for Payer: ASR Commercial |
$215.63
|
| Rate for Payer: BCBS Complete |
$88.92
|
| Rate for Payer: BCBS Trust/PPO |
$182.04
|
| Rate for Payer: BCN Commercial |
$172.35
|
| Rate for Payer: Cash Price |
$177.84
|
| Rate for Payer: Cofinity Commercial |
$208.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.84
|
| Rate for Payer: Healthscope Commercial |
$222.30
|
| Rate for Payer: Healthscope Whirlpool |
$215.63
|
| Rate for Payer: Mclaren Commercial |
$200.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$188.96
|
| Rate for Payer: Nomi Health Commercial |
$182.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$194.78
|
| Rate for Payer: Priority Health Narrow Network |
$155.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$195.62
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$4.46
|
|
|
Service Code
|
NDC 66993006851
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna Commercial |
$4.01
|
| Rate for Payer: ASR ASR |
$4.33
|
| Rate for Payer: ASR Commercial |
$4.33
|
| Rate for Payer: BCBS Trust/PPO |
$3.63
|
| Rate for Payer: BCN Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$3.57
|
| Rate for Payer: Cofinity Commercial |
$4.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.57
|
| Rate for Payer: Healthscope Commercial |
$4.46
|
| Rate for Payer: Healthscope Whirlpool |
$4.33
|
| Rate for Payer: Mclaren Commercial |
$4.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.79
|
| Rate for Payer: Nomi Health Commercial |
$3.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.92
|
|
|
PAROXETINE 10 MG TABLET
|
Facility
|
OP
|
$470.25
|
|
|
Service Code
|
NDC 68084004401
|
| Hospital Charge Code |
16632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.10 |
| Max. Negotiated Rate |
$470.25 |
| Rate for Payer: Aetna Commercial |
$423.22
|
| Rate for Payer: Aetna Medicare |
$235.12
|
| Rate for Payer: ASR ASR |
$456.14
|
| Rate for Payer: ASR Commercial |
$456.14
|
| Rate for Payer: BCBS Complete |
$188.10
|
| Rate for Payer: BCBS Trust/PPO |
$385.09
|
| Rate for Payer: BCN Commercial |
$364.58
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cofinity Commercial |
$442.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.20
|
| Rate for Payer: Healthscope Commercial |
$470.25
|
| Rate for Payer: Healthscope Whirlpool |
$456.14
|
| Rate for Payer: Mclaren Commercial |
$423.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.71
|
| Rate for Payer: Nomi Health Commercial |
$385.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$412.03
|
| Rate for Payer: Priority Health Narrow Network |
$329.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$413.82
|
|
|
PAROXETINE 10 MG TABLET
|
Facility
|
OP
|
$470.25
|
|
|
Service Code
|
NDC 68084004411
|
| Hospital Charge Code |
16632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.10 |
| Max. Negotiated Rate |
$470.25 |
| Rate for Payer: Aetna Commercial |
$423.22
|
| Rate for Payer: Aetna Medicare |
$235.12
|
| Rate for Payer: ASR ASR |
$456.14
|
| Rate for Payer: ASR Commercial |
$456.14
|
| Rate for Payer: BCBS Complete |
$188.10
|
| Rate for Payer: BCBS Trust/PPO |
$385.09
|
| Rate for Payer: BCN Commercial |
$364.58
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cofinity Commercial |
$442.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.20
|
| Rate for Payer: Healthscope Commercial |
$470.25
|
| Rate for Payer: Healthscope Whirlpool |
$456.14
|
| Rate for Payer: Mclaren Commercial |
$423.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.71
|
| Rate for Payer: Nomi Health Commercial |
$385.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$412.03
|
| Rate for Payer: Priority Health Narrow Network |
$329.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$413.82
|
|
|
PAROXETINE 10 MG TABLET
|
Facility
|
IP
|
$74.73
|
|
|
Service Code
|
NDC 00378700193
|
| Hospital Charge Code |
16632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.57 |
| Max. Negotiated Rate |
$74.73 |
| Rate for Payer: Aetna Commercial |
$67.26
|
| Rate for Payer: ASR ASR |
$72.49
|
| Rate for Payer: ASR Commercial |
$72.49
|
| Rate for Payer: BCBS Trust/PPO |
$60.90
|
| Rate for Payer: BCN Commercial |
$57.94
|
| Rate for Payer: Cash Price |
$59.78
|
| Rate for Payer: Cofinity Commercial |
$70.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.78
|
| Rate for Payer: Healthscope Commercial |
$74.73
|
| Rate for Payer: Healthscope Whirlpool |
$72.49
|
| Rate for Payer: Mclaren Commercial |
$67.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.52
|
| Rate for Payer: Nomi Health Commercial |
$61.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$65.76
|
|
