|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 68084-813-11
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Distinction Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Media |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 68084-813-11
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 31722-713-90
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 65862-560-90
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Distinction Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 50268-639-11
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.22 |
| 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 |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Distinction Transplant |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| 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 Media |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| 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
|
| 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 DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$16.99
|
|
|
Service Code
|
NDC 62756-071-64
|
| Hospital Charge Code |
ERX89791
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$14.44 |
| 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 |
$9.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.12
|
| Rate for Payer: Blue Distinction Transplant |
$10.19
|
| Rate for Payer: Blue Shield of California Commercial |
$12.52
|
| Rate for Payer: Blue Shield of California EPN |
$9.92
|
| 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 Media |
$14.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.80
|
| Rate for Payer: Galaxy Health WC |
$14.44
|
| Rate for Payer: Global Benefits Group Commercial |
$10.19
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$12.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.47
|
| 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
|
| 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 |
$8.50
|
| Rate for Payer: United Healthcare All Other HMO |
$8.50
|
| Rate for Payer: United Healthcare HMO Rider |
$8.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.50
|
| 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
|
$20.83
|
|
|
Service Code
|
NDC 0008-0844-02
|
| Hospital Charge Code |
ERX89791
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$17.71 |
| Rate for Payer: Blue Shield of California Commercial |
$14.83
|
| Rate for Payer: Blue Shield of California EPN |
$10.66
|
| Rate for Payer: Cash Price |
$9.37
|
| Rate for Payer: Cigna of CA HMO |
$14.58
|
| Rate for Payer: Cigna of CA PPO |
$14.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.33
|
| Rate for Payer: Galaxy Health WC |
$17.71
|
| Rate for Payer: Global Benefits Group Commercial |
$12.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: Networks By Design Commercial |
$13.54
|
| Rate for Payer: Prime Health Services Commercial |
$17.71
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$16.99
|
|
|
Service Code
|
NDC 62756-071-64
|
| Hospital Charge Code |
ERX89791
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Blue Shield of California Commercial |
$12.10
|
| Rate for Payer: Blue Shield of California EPN |
$8.70
|
| 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: EPIC Health Plan Commercial |
$6.80
|
| Rate for Payer: Galaxy Health WC |
$14.44
|
| Rate for Payer: Global Benefits Group Commercial |
$10.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.47
|
| 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
|
$20.83
|
|
|
Service Code
|
NDC 0008-0844-01
|
| Hospital Charge Code |
ERX89791
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$17.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$13.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.41
|
| Rate for Payer: Blue Distinction Transplant |
$12.50
|
| Rate for Payer: Blue Shield of California Commercial |
$15.35
|
| Rate for Payer: Blue Shield of California EPN |
$12.16
|
| Rate for Payer: Cash Price |
$9.37
|
| Rate for Payer: Cigna of CA HMO |
$14.58
|
| Rate for Payer: Cigna of CA PPO |
$14.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.71
|
| Rate for Payer: Dignity Health Media |
$17.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.33
|
| Rate for Payer: Galaxy Health WC |
$17.71
|
| Rate for Payer: Global Benefits Group Commercial |
$12.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$15.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: Networks By Design Commercial |
$13.54
|
| Rate for Payer: Prime Health Services Commercial |
$17.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.42
|
| Rate for Payer: United Healthcare All Other HMO |
$10.42
|
| Rate for Payer: United Healthcare HMO Rider |
$10.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.71
|
| Rate for Payer: Vantage Medical Group Senior |
$17.71
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
NDC 0008-0844-01
|
| Hospital Charge Code |
ERX89791
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$17.71 |
| Rate for Payer: Blue Shield of California Commercial |
$14.83
|
| Rate for Payer: Blue Shield of California EPN |
$10.66
|
| Rate for Payer: Cash Price |
$9.37
|
| Rate for Payer: Cigna of CA HMO |
$14.58
|
| Rate for Payer: Cigna of CA PPO |
$14.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.33
|
| Rate for Payer: Galaxy Health WC |
$17.71
|
| Rate for Payer: Global Benefits Group Commercial |
$12.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: Networks By Design Commercial |
$13.54
|
| Rate for Payer: Prime Health Services Commercial |
$17.71
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
NDC 0008-0844-02
|
| Hospital Charge Code |
ERX89791
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$17.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$13.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.41
|
| Rate for Payer: Blue Distinction Transplant |
$12.50
|
| Rate for Payer: Blue Shield of California Commercial |
$15.35
|
| Rate for Payer: Blue Shield of California EPN |
$12.16
|
| Rate for Payer: Cash Price |
$9.37
|
| Rate for Payer: Cigna of CA HMO |
$14.58
|
| Rate for Payer: Cigna of CA PPO |
$14.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.71
|
| Rate for Payer: Dignity Health Media |
$17.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.33
|
| Rate for Payer: Galaxy Health WC |
$17.71
|
| Rate for Payer: Global Benefits Group Commercial |
$12.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$15.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: Networks By Design Commercial |
$13.54
|
| Rate for Payer: Prime Health Services Commercial |
$17.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.42
|
| Rate for Payer: United Healthcare All Other HMO |
$10.42
|
| Rate for Payer: United Healthcare HMO Rider |
$10.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.71
|
| Rate for Payer: Vantage Medical Group Senior |
$17.71
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$16.99
|
|
|
Service Code
|
NDC 62756-071-60
|
| Hospital Charge Code |
ERX89791
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$14.44 |
| 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 |
$9.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.12
|
| Rate for Payer: Blue Distinction Transplant |
$10.19
|
| Rate for Payer: Blue Shield of California Commercial |
$12.52
|
| Rate for Payer: Blue Shield of California EPN |
$9.92
|
| 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 Media |
$14.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.80
|
| Rate for Payer: Galaxy Health WC |
$14.44
|
| Rate for Payer: Global Benefits Group Commercial |
$10.19
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$12.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.47
|
| 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
|
| 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 |
$8.50
|
| Rate for Payer: United Healthcare All Other HMO |
$8.50
|
| Rate for Payer: United Healthcare HMO Rider |
$8.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.50
|
| 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
|
$16.99
|
|
|
Service Code
|
NDC 62756-071-60
|
| Hospital Charge Code |
ERX89791
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Blue Shield of California Commercial |
$12.10
|
| Rate for Payer: Blue Shield of California EPN |
$8.70
|
| 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: EPIC Health Plan Commercial |
$6.80
|
| Rate for Payer: Galaxy Health WC |
$14.44
|
| Rate for Payer: Global Benefits Group Commercial |
$10.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.47
|
| 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
|
IP
|
$22.50
|
|
|
Service Code
|
CPT J2440
|
| Hospital Charge Code |
NDG6030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.40 |
| Max. Negotiated Rate |
$19.12 |
| Rate for Payer: Blue Shield of California Commercial |
$16.02
|
| Rate for Payer: Blue Shield of California Commercial |
$17.69
|
| Rate for Payer: Blue Shield of California Commercial |
$13.88
|
| Rate for Payer: Blue Shield of California Commercial |
$16.60
|
| Rate for Payer: Blue Shield of California EPN |
$12.72
|
| Rate for Payer: Blue Shield of California EPN |
$11.52
|
| Rate for Payer: Blue Shield of California EPN |
$11.94
|
| Rate for Payer: Blue Shield of California EPN |
$9.98
|
| Rate for Payer: Cash Price |
$10.49
|
| Rate for Payer: Cash Price |
$8.78
|
| Rate for Payer: Cash Price |
$11.18
|
| Rate for Payer: Cash Price |
$10.13
|
| Rate for Payer: Cigna of CA HMO |
$15.75
|
| Rate for Payer: Cigna of CA HMO |
$16.32
|
| Rate for Payer: Cigna of CA HMO |
$17.40
|
| 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 |
$17.40
|
| Rate for Payer: Cigna of CA PPO |
$16.32
|
| Rate for Payer: Cigna of CA PPO |
$15.75
|
| 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 Commercial |
$9.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.94
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.33
|
| Rate for Payer: Galaxy Health WC |
$19.12
|
| Rate for Payer: Galaxy Health WC |
$16.58
|
| Rate for Payer: Galaxy Health WC |
$19.82
|
| 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 |
$13.99
|
| Rate for Payer: Global Benefits Group Commercial |
$14.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$15.60
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$18.66
|
| Rate for Payer: Multiplan Commercial |
$19.88
|
| Rate for Payer: Networks By Design Commercial |
$9.75
|
| Rate for Payer: Networks By Design Commercial |
$12.42
|
| Rate for Payer: Networks By Design Commercial |
$11.25
|
| Rate for Payer: Networks By Design Commercial |
$11.66
|
| Rate for Payer: Prime Health Services Commercial |
$19.82
|
| Rate for Payer: Prime Health Services Commercial |
$19.12
|
| Rate for Payer: Prime Health Services Commercial |
$21.12
|
| Rate for Payer: Prime Health Services Commercial |
$16.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.36
|
| Rate for Payer: United Healthcare All Other HMO |
$8.60
|
| Rate for Payer: United Healthcare All Other HMO |
$9.16
|
| Rate for Payer: United Healthcare All Other HMO |
$8.30
|
| Rate for Payer: United Healthcare All Other HMO |
$7.19
|
| Rate for Payer: United Healthcare HMO Rider |
$8.41
|
| Rate for Payer: United Healthcare HMO Rider |
$8.12
|
| Rate for Payer: United Healthcare HMO Rider |
$8.97
|
| Rate for Payer: United Healthcare HMO Rider |
$7.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.42
|
|
|
PAPAVERINE 30 MG/ML INJECTION SOLUTION [6030]
|
Facility
|
OP
|
$24.85
|
|
|
Service Code
|
CPT J2440
|
| Hospital Charge Code |
NDG6030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$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: 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 |
$19.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.12
|
| 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 Medi-Cal |
$13.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.90
|
| Rate for Payer: Blue Distinction Transplant |
$13.99
|
| Rate for Payer: Blue Distinction Transplant |
$13.50
|
| Rate for Payer: Blue Distinction Transplant |
$11.70
|
| Rate for Payer: Blue Distinction Transplant |
$14.91
|
| Rate for Payer: Blue Shield of California Commercial |
$14.37
|
| Rate for Payer: Blue Shield of California Commercial |
$16.58
|
| Rate for Payer: Blue Shield of California Commercial |
$17.19
|
| Rate for Payer: Blue Shield of California Commercial |
$18.31
|
| Rate for Payer: Blue Shield of California EPN |
$49.69
|
| Rate for Payer: Blue Shield of California EPN |
$49.69
|
| Rate for Payer: Blue Shield of California EPN |
$49.69
|
| Rate for Payer: Blue Shield of California EPN |
$49.69
|
| Rate for Payer: Cash Price |
$10.49
|
| Rate for Payer: Cash Price |
$8.78
|
| Rate for Payer: Cash Price |
$8.78
|
| Rate for Payer: Cash Price |
$10.13
|
| Rate for Payer: Cash Price |
$10.13
|
| Rate for Payer: Cash Price |
$11.18
|
| Rate for Payer: Cash Price |
$11.18
|
| Rate for Payer: Cash Price |
$10.49
|
| Rate for Payer: Cigna of CA HMO |
$17.40
|
| Rate for Payer: Cigna of CA HMO |
$13.65
|
| Rate for Payer: Cigna of CA HMO |
$15.75
|
| Rate for Payer: Cigna of CA HMO |
$16.32
|
| Rate for Payer: Cigna of CA PPO |
$15.75
|
| Rate for Payer: Cigna of CA PPO |
$13.65
|
| Rate for Payer: Cigna of CA PPO |
$17.40
|
| Rate for Payer: Cigna of CA PPO |
$16.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.58
|
| Rate for Payer: Dignity Health Media |
$16.58
|
| Rate for Payer: Dignity Health Media |
$21.12
|
| Rate for Payer: Dignity Health Media |
$19.12
|
| Rate for Payer: Dignity Health Media |
$19.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.80
|
| 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 |
$9.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.94
|
| Rate for Payer: Galaxy Health WC |
$21.12
|
| Rate for Payer: Galaxy Health WC |
$16.58
|
| Rate for Payer: Galaxy Health WC |
$19.12
|
| Rate for Payer: Galaxy Health WC |
$19.82
|
| Rate for Payer: Global Benefits Group Commercial |
$13.99
|
| Rate for Payer: Global Benefits Group Commercial |
$14.91
|
| Rate for Payer: Global Benefits Group Commercial |
$13.50
|
| Rate for Payer: Global Benefits Group Commercial |
$11.70
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$16.88
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$17.49
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$18.64
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$14.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.60
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$18.66
|
| 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 |
$12.42
|
| Rate for Payer: Networks By Design Commercial |
$11.66
|
| Rate for Payer: Networks By Design Commercial |
$9.75
|
| Rate for Payer: Prime Health Services Commercial |
$19.82
|
| Rate for Payer: Prime Health Services Commercial |
$16.58
|
| 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 |
$14.91
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.50
|
| 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 |
$13.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$14.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$12.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.25
|
| Rate for Payer: United Healthcare All Other HMO |
$9.75
|
| Rate for Payer: United Healthcare All Other HMO |
$12.42
|
| Rate for Payer: United Healthcare All Other HMO |
$11.25
|
| Rate for Payer: United Healthcare All Other HMO |
$11.66
|
| Rate for Payer: United Healthcare HMO Rider |
$12.42
|
| Rate for Payer: United Healthcare HMO Rider |
$11.66
|
| Rate for Payer: United Healthcare HMO Rider |
$9.75
|
| Rate for Payer: United Healthcare HMO Rider |
$11.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.58
|
| 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 |
$16.58
|
| Rate for Payer: Vantage Medical Group Senior |
$19.82
|
|
|
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION [222465]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0338-0502-06
|
| Hospital Charge Code |
NDG222465
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Distinction Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Media |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| 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 |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION [222465]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0338-0502-06
|
| Hospital Charge Code |
NDG222465
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION [224619]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 0264-4500-00
|
| Hospital Charge Code |
NDG119537B
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION [224619]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 0264-4500-00
|
| Hospital Charge Code |
NDG119537B
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Distinction Transplant |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Media |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| 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 |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
PARICALCITOL 1 MCG CAPSULE [41497]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 49483-687-03
|
| Hospital Charge Code |
1712296
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.71
|
| Rate for Payer: Blue Distinction Transplant |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.88
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Media |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
PARICALCITOL 1 MCG CAPSULE [41497]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 49483-687-03
|
| Hospital Charge Code |
1712296
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
|
|
PARICALCITOL 1 MCG CAPSULE [41497]
|
Facility
|
OP
|
$1.78
|
|
|
Service Code
|
NDC 65862-936-30
|
| Hospital Charge Code |
1712296
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.06
|
| Rate for Payer: Blue Distinction Transplant |
$1.07
|
| Rate for Payer: Blue Shield of California Commercial |
$1.31
|
| Rate for Payer: Blue Shield of California EPN |
$1.04
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Cigna of CA HMO |
$1.25
|
| Rate for Payer: Cigna of CA PPO |
$1.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.51
|
| Rate for Payer: Dignity Health Media |
$1.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.71
|
| Rate for Payer: Galaxy Health WC |
$1.51
|
| Rate for Payer: Global Benefits Group Commercial |
$1.07
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
| Rate for Payer: Networks By Design Commercial |
$1.16
|
| Rate for Payer: Prime Health Services Commercial |
$1.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.89
|
| Rate for Payer: United Healthcare All Other HMO |
$0.89
|
| Rate for Payer: United Healthcare HMO Rider |
$0.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: Vantage Medical Group Senior |
$1.51
|
|
|
PARICALCITOL 1 MCG CAPSULE [41497]
|
Facility
|
IP
|
$1.78
|
|
|
Service Code
|
NDC 65862-936-30
|
| Hospital Charge Code |
1712296
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Blue Shield of California Commercial |
$1.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.91
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Cigna of CA HMO |
$1.25
|
| Rate for Payer: Cigna of CA PPO |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Galaxy Health WC |
$1.51
|
| Rate for Payer: Global Benefits Group Commercial |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
| Rate for Payer: Networks By Design Commercial |
$1.16
|
| Rate for Payer: Prime Health Services Commercial |
$1.51
|
|
|
PARICALCITOL 2 MCG CAPSULE [41498]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 69452-146-13
|
| Hospital Charge Code |
1712331
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$8.50 |
| Rate for Payer: Blue Shield of California Commercial |
$7.12
|
| Rate for Payer: Blue Shield of California EPN |
$5.12
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna of CA HMO |
$7.00
|
| Rate for Payer: Cigna of CA PPO |
$7.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.00
|
| Rate for Payer: Galaxy Health WC |
$8.50
|
| Rate for Payer: Global Benefits Group Commercial |
$6.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Multiplan Commercial |
$8.00
|
| Rate for Payer: Networks By Design Commercial |
$6.50
|
| Rate for Payer: Prime Health Services Commercial |
$8.50
|
|
|
PARICALCITOL 2 MCG CAPSULE [41498]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 69452-146-13
|
| Hospital Charge Code |
1712331
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$8.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.96
|
| Rate for Payer: Blue Distinction Transplant |
$6.00
|
| Rate for Payer: Blue Shield of California Commercial |
$7.37
|
| Rate for Payer: Blue Shield of California EPN |
$5.84
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna of CA HMO |
$7.00
|
| Rate for Payer: Cigna of CA PPO |
$7.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.50
|
| Rate for Payer: Dignity Health Media |
$8.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.00
|
| Rate for Payer: Galaxy Health WC |
$8.50
|
| Rate for Payer: Global Benefits Group Commercial |
$6.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$7.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Multiplan Commercial |
$8.00
|
| Rate for Payer: Networks By Design Commercial |
$6.50
|
| Rate for Payer: Prime Health Services Commercial |
$8.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.00
|
| Rate for Payer: United Healthcare All Other HMO |
$5.00
|
| Rate for Payer: United Healthcare HMO Rider |
$5.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.50
|
| Rate for Payer: Vantage Medical Group Senior |
$8.50
|
|
