|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 6068773665
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 6586256099
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 6068773611
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 6068773601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 6586256099
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 6586256090
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 6068773665
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$16.99
|
|
|
Service Code
|
NDC 6275607160
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Blue Shield of California Commercial |
$13.07
|
| Rate for Payer: Blue Shield of California Commercial |
$8.61
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cigna of CA HMO |
$11.89
|
| Rate for Payer: Cigna of CA PPO |
$11.89
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.80
|
| Rate for Payer: EPIC Health Plan Senior |
$6.80
|
| Rate for Payer: Galaxy Health WC |
$14.44
|
| Rate for Payer: Global Benefits Group Commercial |
$10.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.08
|
| Rate for Payer: Multiplan Commercial |
$13.59
|
| Rate for Payer: Networks By Design Commercial |
$11.04
|
| Rate for Payer: Prime Health Services Commercial |
$14.44
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$17.81
|
|
|
Service Code
|
NDC 0008084402
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$15.14 |
| Rate for Payer: Adventist Health Commercial |
$3.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.43
|
| Rate for Payer: Cash Price |
$8.01
|
| Rate for Payer: Cigna of CA HMO |
$12.47
|
| Rate for Payer: Cigna of CA PPO |
$12.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.12
|
| Rate for Payer: EPIC Health Plan Senior |
$7.12
|
| Rate for Payer: Galaxy Health WC |
$15.14
|
| Rate for Payer: Global Benefits Group Commercial |
$10.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.47
|
| Rate for Payer: Multiplan Commercial |
$14.25
|
| Rate for Payer: Networks By Design Commercial |
$11.58
|
| Rate for Payer: Prime Health Services Commercial |
$15.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.90
|
| Rate for Payer: United Healthcare All Other HMO |
$8.90
|
| Rate for Payer: United Healthcare HMO Rider |
$8.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.14
|
| Rate for Payer: Vantage Medical Group Senior |
$15.14
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$16.99
|
|
|
Service Code
|
NDC 6068776799
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Blue Shield of California Commercial |
$13.07
|
| Rate for Payer: Blue Shield of California Commercial |
$8.61
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cigna of CA HMO |
$11.89
|
| Rate for Payer: Cigna of CA PPO |
$11.89
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.80
|
| Rate for Payer: EPIC Health Plan Senior |
$6.80
|
| Rate for Payer: Galaxy Health WC |
$14.44
|
| Rate for Payer: Global Benefits Group Commercial |
$10.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.08
|
| Rate for Payer: Multiplan Commercial |
$13.59
|
| Rate for Payer: Networks By Design Commercial |
$11.04
|
| Rate for Payer: Prime Health Services Commercial |
$14.44
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$16.99
|
|
|
Service Code
|
NDC 6068776727
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Blue Shield of California Commercial |
$13.07
|
| Rate for Payer: Blue Shield of California Commercial |
$8.61
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cigna of CA HMO |
$11.89
|
| Rate for Payer: Cigna of CA PPO |
$11.89
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.80
|
| Rate for Payer: EPIC Health Plan Senior |
$6.80
|
| Rate for Payer: Galaxy Health WC |
$14.44
|
| Rate for Payer: Global Benefits Group Commercial |
$10.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.08
|
| Rate for Payer: Multiplan Commercial |
$13.59
|
| Rate for Payer: Networks By Design Commercial |
$11.04
|
| Rate for Payer: Prime Health Services Commercial |
$14.44
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$17.81
|
|
|
Service Code
|
NDC 0008084401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$15.14 |
| Rate for Payer: Adventist Health Commercial |
$3.56
|
| Rate for Payer: Blue Shield of California Commercial |
$13.70
|
| Rate for Payer: Blue Shield of California Commercial |
$9.03
|
| Rate for Payer: Cash Price |
$8.01
|
| Rate for Payer: Cigna of CA HMO |
$12.47
|
| Rate for Payer: Cigna of CA PPO |
$12.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.12
|
| Rate for Payer: EPIC Health Plan Senior |
$7.12
|
| Rate for Payer: Galaxy Health WC |
$15.14
|
| Rate for Payer: Global Benefits Group Commercial |
$10.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.27
|
| Rate for Payer: Multiplan Commercial |
$14.25
|
| Rate for Payer: Networks By Design Commercial |
$11.58
|
| Rate for Payer: Prime Health Services Commercial |
$15.14
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$7.98
|
|
|
Service Code
|
NDC 2724125638
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$6.78 |
| Rate for Payer: Adventist Health Commercial |
$1.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.12
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Cigna of CA HMO |
$5.59
|
| Rate for Payer: Cigna of CA PPO |
$5.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.78
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.19
|
| Rate for Payer: EPIC Health Plan Senior |
$3.19
|
| Rate for Payer: Galaxy Health WC |
$6.78
|
| Rate for Payer: Global Benefits Group Commercial |
$4.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.59
|
| Rate for Payer: Multiplan Commercial |
$6.38
|
| Rate for Payer: Networks By Design Commercial |
$5.19
|
| Rate for Payer: Prime Health Services Commercial |
$6.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.99
|
| Rate for Payer: United Healthcare All Other HMO |
$3.99
|
| Rate for Payer: United Healthcare HMO Rider |
$3.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.78
|
| Rate for Payer: Vantage Medical Group Senior |
$6.78
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$7.98
|
|
|
Service Code
|
NDC 2724125611
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$6.78 |
| Rate for Payer: Adventist Health Commercial |
$1.60
|
| Rate for Payer: Blue Shield of California Commercial |
$4.05
|
| Rate for Payer: Blue Shield of California Commercial |
$6.14
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Cigna of CA HMO |
$5.59
|
| Rate for Payer: Cigna of CA PPO |
$5.59
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.19
|
| Rate for Payer: EPIC Health Plan Senior |
$3.19
|
| Rate for Payer: Galaxy Health WC |
$6.78
|
| Rate for Payer: Global Benefits Group Commercial |
$4.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.92
|
| Rate for Payer: Multiplan Commercial |
$6.38
|
| Rate for Payer: Networks By Design Commercial |
$5.19
|
| Rate for Payer: Prime Health Services Commercial |
$6.78
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$16.99
|
|
|
Service Code
|
NDC 6068776799
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.90
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cigna of CA HMO |
$11.89
|
| Rate for Payer: Cigna of CA PPO |
$11.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.44
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.44
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.80
|
| Rate for Payer: EPIC Health Plan Senior |
$6.80
|
| Rate for Payer: Galaxy Health WC |
$14.44
|
| Rate for Payer: Global Benefits Group Commercial |
$10.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.89
|
| Rate for Payer: Multiplan Commercial |
$13.59
|
| Rate for Payer: Networks By Design Commercial |
$11.04
|
| Rate for Payer: Prime Health Services Commercial |
$14.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.49
|
| Rate for Payer: United Healthcare All Other HMO |
$8.49
|
| Rate for Payer: United Healthcare HMO Rider |
$8.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.44
|
| Rate for Payer: Vantage Medical Group Senior |
$14.44
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$7.98
|
|
|
Service Code
|
NDC 2724125638
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$6.78 |
| Rate for Payer: Adventist Health Commercial |
$1.60
|
| Rate for Payer: Blue Shield of California Commercial |
$4.05
|
| Rate for Payer: Blue Shield of California Commercial |
$6.14
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Cigna of CA HMO |
$5.59
|
| Rate for Payer: Cigna of CA PPO |
$5.59
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.19
|
| Rate for Payer: EPIC Health Plan Senior |
$3.19
|
| Rate for Payer: Galaxy Health WC |
$6.78
|
| Rate for Payer: Global Benefits Group Commercial |
$4.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.92
|
| Rate for Payer: Multiplan Commercial |
$6.38
|
| Rate for Payer: Networks By Design Commercial |
$5.19
|
| Rate for Payer: Prime Health Services Commercial |
$6.78
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$16.99
|
|
|
Service Code
|
NDC 6068776727
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.90
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cigna of CA HMO |
$11.89
|
| Rate for Payer: Cigna of CA PPO |
$11.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.44
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.44
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.80
|
| Rate for Payer: EPIC Health Plan Senior |
$6.80
|
| Rate for Payer: Galaxy Health WC |
$14.44
|
| Rate for Payer: Global Benefits Group Commercial |
$10.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.89
|
| Rate for Payer: Multiplan Commercial |
$13.59
|
| Rate for Payer: Networks By Design Commercial |
$11.04
|
| Rate for Payer: Prime Health Services Commercial |
$14.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.49
|
| Rate for Payer: United Healthcare All Other HMO |
$8.49
|
| Rate for Payer: United Healthcare HMO Rider |
$8.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.44
|
| Rate for Payer: Vantage Medical Group Senior |
$14.44
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$17.81
|
|
|
Service Code
|
NDC 0008084401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$15.14 |
| Rate for Payer: Adventist Health Commercial |
$3.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.43
|
| Rate for Payer: Cash Price |
$8.01
|
| Rate for Payer: Cigna of CA HMO |
$12.47
|
| Rate for Payer: Cigna of CA PPO |
$12.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.12
|
| Rate for Payer: EPIC Health Plan Senior |
$7.12
|
| Rate for Payer: Galaxy Health WC |
$15.14
|
| Rate for Payer: Global Benefits Group Commercial |
$10.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.47
|
| Rate for Payer: Multiplan Commercial |
$14.25
|
| Rate for Payer: Networks By Design Commercial |
$11.58
|
| Rate for Payer: Prime Health Services Commercial |
$15.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.90
|
| Rate for Payer: United Healthcare All Other HMO |
$8.90
|
| Rate for Payer: United Healthcare HMO Rider |
$8.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.14
|
| Rate for Payer: Vantage Medical Group Senior |
$15.14
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$16.99
|
|
|
Service Code
|
NDC 6275607160
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.90
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cigna of CA HMO |
$11.89
|
| Rate for Payer: Cigna of CA PPO |
$11.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.44
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.44
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.80
|
| Rate for Payer: EPIC Health Plan Senior |
$6.80
|
| Rate for Payer: Galaxy Health WC |
$14.44
|
| Rate for Payer: Global Benefits Group Commercial |
$10.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.89
|
| Rate for Payer: Multiplan Commercial |
$13.59
|
| Rate for Payer: Networks By Design Commercial |
$11.04
|
| Rate for Payer: Prime Health Services Commercial |
$14.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.49
|
| Rate for Payer: United Healthcare All Other HMO |
$8.49
|
| Rate for Payer: United Healthcare HMO Rider |
$8.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.44
|
| Rate for Payer: Vantage Medical Group Senior |
$14.44
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$16.99
|
|
|
Service Code
|
NDC 6275607164
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.90
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cigna of CA HMO |
$11.89
|
| Rate for Payer: Cigna of CA PPO |
$11.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.44
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.44
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.80
|
| Rate for Payer: EPIC Health Plan Senior |
$6.80
|
| Rate for Payer: Galaxy Health WC |
$14.44
|
| Rate for Payer: Global Benefits Group Commercial |
$10.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.89
|
| Rate for Payer: Multiplan Commercial |
$13.59
|
| Rate for Payer: Networks By Design Commercial |
$11.04
|
| Rate for Payer: Prime Health Services Commercial |
$14.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.49
|
| Rate for Payer: United Healthcare All Other HMO |
$8.49
|
| Rate for Payer: United Healthcare HMO Rider |
$8.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.44
|
| Rate for Payer: Vantage Medical Group Senior |
$14.44
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$17.81
|
|
|
Service Code
|
NDC 0008084402
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$15.14 |
| Rate for Payer: Adventist Health Commercial |
$3.56
|
| Rate for Payer: Blue Shield of California Commercial |
$13.70
|
| Rate for Payer: Blue Shield of California Commercial |
$9.03
|
| Rate for Payer: Cash Price |
$8.01
|
| Rate for Payer: Cigna of CA HMO |
$12.47
|
| Rate for Payer: Cigna of CA PPO |
$12.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.12
|
| Rate for Payer: EPIC Health Plan Senior |
$7.12
|
| Rate for Payer: Galaxy Health WC |
$15.14
|
| Rate for Payer: Global Benefits Group Commercial |
$10.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.27
|
| Rate for Payer: Multiplan Commercial |
$14.25
|
| Rate for Payer: Networks By Design Commercial |
$11.58
|
| Rate for Payer: Prime Health Services Commercial |
$15.14
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$7.98
|
|
|
Service Code
|
NDC 2724125611
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$6.78 |
| Rate for Payer: Adventist Health Commercial |
$1.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.12
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Cigna of CA HMO |
$5.59
|
| Rate for Payer: Cigna of CA PPO |
$5.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.78
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.19
|
| Rate for Payer: EPIC Health Plan Senior |
$3.19
|
| Rate for Payer: Galaxy Health WC |
$6.78
|
| Rate for Payer: Global Benefits Group Commercial |
$4.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.59
|
| Rate for Payer: Multiplan Commercial |
$6.38
|
| Rate for Payer: Networks By Design Commercial |
$5.19
|
| Rate for Payer: Prime Health Services Commercial |
$6.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.99
|
| Rate for Payer: United Healthcare All Other HMO |
$3.99
|
| Rate for Payer: United Healthcare HMO Rider |
$3.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.78
|
| Rate for Payer: Vantage Medical Group Senior |
$6.78
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$16.99
|
|
|
Service Code
|
NDC 6275607164
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Blue Shield of California Commercial |
$13.07
|
| Rate for Payer: Blue Shield of California Commercial |
$8.61
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cigna of CA HMO |
$11.89
|
| Rate for Payer: Cigna of CA PPO |
$11.89
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.80
|
| Rate for Payer: EPIC Health Plan Senior |
$6.80
|
| Rate for Payer: Galaxy Health WC |
$14.44
|
| Rate for Payer: Global Benefits Group Commercial |
$10.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.08
|
| Rate for Payer: Multiplan Commercial |
$13.59
|
| Rate for Payer: Networks By Design Commercial |
$11.04
|
| Rate for Payer: Prime Health Services Commercial |
$14.44
|
|
|
PAPAVERINE 30 MG/ML INJECTION SOLUTION [6030]
|
Facility
|
OP
|
$19.50
|
|
|
Service Code
|
HCPCS J2440
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$232.59 |
| Rate for Payer: Adventist Health Commercial |
$3.90
|
| Rate for Payer: Adventist Health Commercial |
$4.50
|
| Rate for Payer: Adventist Health Commercial |
$4.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$232.59
|
| Rate for Payer: Aetna of CA HMO/PPO |
$232.59
|
| Rate for Payer: Aetna of CA HMO/PPO |
$232.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.48
|
| Rate for Payer: Blue Shield of California Commercial |
$42.29
|
| Rate for Payer: Blue Shield of California Commercial |
$42.29
|
| Rate for Payer: Blue Shield of California Commercial |
$42.29
|
| Rate for Payer: Cash Price |
$10.12
|
| Rate for Payer: Cash Price |
$11.18
|
| Rate for Payer: Cash Price |
$10.12
|
| Rate for Payer: Cash Price |
$8.78
|
| Rate for Payer: Cash Price |
$8.78
|
| Rate for Payer: Cash Price |
$11.18
|
| Rate for Payer: Cigna of CA HMO |
$17.39
|
| Rate for Payer: Cigna of CA HMO |
$15.75
|
| Rate for Payer: Cigna of CA HMO |
$13.65
|
| Rate for Payer: Cigna of CA PPO |
$15.75
|
| Rate for Payer: Cigna of CA PPO |
$17.39
|
| Rate for Payer: Cigna of CA PPO |
$13.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$19.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$21.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$15.75
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$13.65
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$17.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.80
|
| Rate for Payer: EPIC Health Plan Senior |
$7.80
|
| Rate for Payer: EPIC Health Plan Senior |
$9.00
|
| Rate for Payer: EPIC Health Plan Senior |
$9.94
|
| Rate for Payer: Galaxy Health WC |
$19.12
|
| Rate for Payer: Galaxy Health WC |
$16.57
|
| Rate for Payer: Galaxy Health WC |
$21.12
|
| Rate for Payer: Global Benefits Group Commercial |
$11.70
|
| Rate for Payer: Global Benefits Group Commercial |
$13.50
|
| Rate for Payer: Global Benefits Group Commercial |
$14.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$15.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$12.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$14.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.75
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$19.88
|
| Rate for Payer: Multiplan Commercial |
$15.60
|
| Rate for Payer: Networks By Design Commercial |
$11.25
|
| Rate for Payer: Networks By Design Commercial |
$12.43
|
| Rate for Payer: Networks By Design Commercial |
$9.75
|
| Rate for Payer: Prime Health Services Commercial |
$16.57
|
| Rate for Payer: Prime Health Services Commercial |
$19.12
|
| Rate for Payer: Prime Health Services Commercial |
$21.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$14.91
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$14.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.32
|
| Rate for Payer: United Healthcare All Other HMO |
$9.08
|
| Rate for Payer: United Healthcare All Other HMO |
$8.22
|
| Rate for Payer: United Healthcare All Other HMO |
$7.12
|
| Rate for Payer: United Healthcare HMO Rider |
$8.88
|
| Rate for Payer: United Healthcare HMO Rider |
$8.04
|
| Rate for Payer: United Healthcare HMO Rider |
$6.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.12
|
| Rate for Payer: Vantage Medical Group Senior |
$19.12
|
| Rate for Payer: Vantage Medical Group Senior |
$21.12
|
| Rate for Payer: Vantage Medical Group Senior |
$16.57
|
|
|
PAPAVERINE 30 MG/ML INJECTION SOLUTION [6030]
|
Facility
|
IP
|
$19.50
|
|
|
Service Code
|
HCPCS J2440
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.90 |
| Max. Negotiated Rate |
$16.57 |
| Rate for Payer: Adventist Health Commercial |
$3.90
|
| Rate for Payer: Adventist Health Commercial |
$4.50
|
| Rate for Payer: Adventist Health Commercial |
$4.97
|
| Rate for Payer: Blue Shield of California Commercial |
$17.30
|
| Rate for Payer: Blue Shield of California Commercial |
$15.00
|
| Rate for Payer: Blue Shield of California Commercial |
$9.89
|
| Rate for Payer: Blue Shield of California Commercial |
$19.11
|
| Rate for Payer: Blue Shield of California Commercial |
$12.60
|
| Rate for Payer: Blue Shield of California Commercial |
$11.41
|
| Rate for Payer: Cash Price |
$11.18
|
| Rate for Payer: Cash Price |
$10.12
|
| Rate for Payer: Cash Price |
$8.78
|
| Rate for Payer: Cigna of CA HMO |
$17.39
|
| Rate for Payer: Cigna of CA HMO |
$15.75
|
| Rate for Payer: Cigna of CA HMO |
$13.65
|
| Rate for Payer: Cigna of CA PPO |
$13.65
|
| Rate for Payer: Cigna of CA PPO |
$17.39
|
| Rate for Payer: Cigna of CA PPO |
$15.75
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$17.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$15.75
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$13.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.80
|
| Rate for Payer: EPIC Health Plan Senior |
$9.00
|
| Rate for Payer: EPIC Health Plan Senior |
$7.80
|
| Rate for Payer: EPIC Health Plan Senior |
$9.94
|
| Rate for Payer: Galaxy Health WC |
$21.12
|
| Rate for Payer: Galaxy Health WC |
$16.57
|
| Rate for Payer: Galaxy Health WC |
$19.12
|
| Rate for Payer: Global Benefits Group Commercial |
$13.50
|
| Rate for Payer: Global Benefits Group Commercial |
$11.70
|
| Rate for Payer: Global Benefits Group Commercial |
$14.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$12.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$14.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$15.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.96
|
| Rate for Payer: Multiplan Commercial |
$15.60
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$19.88
|
| Rate for Payer: Networks By Design Commercial |
$11.25
|
| Rate for Payer: Networks By Design Commercial |
$12.43
|
| Rate for Payer: Networks By Design Commercial |
$9.75
|
| Rate for Payer: Prime Health Services Commercial |
$16.57
|
| Rate for Payer: Prime Health Services Commercial |
$19.12
|
| Rate for Payer: Prime Health Services Commercial |
$21.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.33
|
| Rate for Payer: United Healthcare All Other HMO |
$9.08
|
| Rate for Payer: United Healthcare All Other HMO |
$7.12
|
| Rate for Payer: United Healthcare All Other HMO |
$8.22
|
| Rate for Payer: United Healthcare HMO Rider |
$8.04
|
| Rate for Payer: United Healthcare HMO Rider |
$8.88
|
| Rate for Payer: United Healthcare HMO Rider |
$6.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.37
|
|
