|
PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 13668-096-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.12
|
| Rate for Payer: InnovAge PACE Commercial |
$0.07
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.09
|
| 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
|
| Rate for Payer: Riverside University Health System MISP |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE [26224]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 13668-096-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| 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: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.12
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.08
|
| 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 20 MG TABLET,DELAYED RELEASE [26224]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 65862-559-90
|
| 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 |
$0.04
|
| 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 Exchange |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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 |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| 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: 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: Health Management Network EPO/PPO |
$0.06
|
| Rate for Payer: InnovAge PACE Commercial |
$0.04
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Riverside University Health System MISP |
$0.03
|
| 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 20 MG TABLET,DELAYED RELEASE [26224]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0378-6688-77
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| 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: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.12
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.08
|
| 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 INTRAVENOUS SOLUTION [26226]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Adventist Health Commercial |
$1.18
|
| Rate for Payer: Adventist Health Commercial |
$1.22
|
| Rate for Payer: Adventist Health Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$2.78
|
| Rate for Payer: Blue Shield of California Commercial |
$4.55
|
| Rate for Payer: Blue Shield of California Commercial |
$4.64
|
| Rate for Payer: Blue Shield of California Commercial |
$9.28
|
| Rate for Payer: Blue Shield of California Commercial |
$2.75
|
| Rate for Payer: Blue Shield of California Commercial |
$4.71
|
| Rate for Payer: Blue Shield of California EPN |
$3.07
|
| Rate for Payer: Blue Shield of California EPN |
$6.05
|
| Rate for Payer: Blue Shield of California EPN |
$1.81
|
| Rate for Payer: Blue Shield of California EPN |
$1.79
|
| Rate for Payer: Blue Shield of California EPN |
$2.96
|
| Rate for Payer: Blue Shield of California EPN |
$3.02
|
| Rate for Payer: Cash Price |
$3.35
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$3.23
|
| Rate for Payer: Central Health Plan Commercial |
$4.70
|
| Rate for Payer: Central Health Plan Commercial |
$2.85
|
| Rate for Payer: Central Health Plan Commercial |
$9.60
|
| Rate for Payer: Central Health Plan Commercial |
$2.88
|
| Rate for Payer: Central Health Plan Commercial |
$4.87
|
| Rate for Payer: Central Health Plan Commercial |
$4.80
|
| Rate for Payer: Cigna of CA HMO |
$2.49
|
| Rate for Payer: Cigna of CA HMO |
$8.40
|
| Rate for Payer: Cigna of CA HMO |
$4.12
|
| Rate for Payer: Cigna of CA HMO |
$4.26
|
| Rate for Payer: Cigna of CA HMO |
$2.52
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$8.40
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$2.52
|
| Rate for Payer: Cigna of CA PPO |
$2.49
|
| Rate for Payer: Cigna of CA PPO |
$4.26
|
| Rate for Payer: Cigna of CA PPO |
$4.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.44
|
| Rate for Payer: EPIC Health Plan Senior |
$4.80
|
| Rate for Payer: EPIC Health Plan Senior |
$2.35
|
| Rate for Payer: EPIC Health Plan Senior |
$2.44
|
| Rate for Payer: EPIC Health Plan Senior |
$1.42
|
| Rate for Payer: EPIC Health Plan Senior |
$1.44
|
| Rate for Payer: EPIC Health Plan Senior |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Galaxy Health WC |
$5.18
|
| Rate for Payer: Galaxy Health WC |
$3.03
|
| Rate for Payer: Galaxy Health WC |
$3.06
|
| Rate for Payer: Galaxy Health WC |
$10.20
|
| Rate for Payer: Galaxy Health WC |
$5.00
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Global Benefits Group Commercial |
$7.20
|
| Rate for Payer: Global Benefits Group Commercial |
$2.16
|
| Rate for Payer: Global Benefits Group Commercial |
$3.65
|
| Rate for Payer: Global Benefits Group Commercial |
$2.14
|
| Rate for Payer: Global Benefits Group Commercial |
$3.53
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$2.67
|
| Rate for Payer: Multiplan Commercial |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$4.57
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Networks By Design Commercial |
$1.78
|
| Rate for Payer: Networks By Design Commercial |
$2.94
|
| Rate for Payer: Networks By Design Commercial |
$1.80
|
| Rate for Payer: Networks By Design Commercial |
$6.00
|
| Rate for Payer: Networks By Design Commercial |
$3.00
|
| Rate for Payer: Networks By Design Commercial |
$3.04
|
| Rate for Payer: Prime Health Services Commercial |
$3.06
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
| Rate for Payer: Prime Health Services Commercial |
$3.03
|
| Rate for Payer: Prime Health Services Commercial |
$5.00
|
| Rate for Payer: Prime Health Services Commercial |
$5.18
|
| Rate for Payer: Prime Health Services Commercial |
$10.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.34
|
| Rate for Payer: United Healthcare All Other HMO |
$1.30
|
| Rate for Payer: United Healthcare All Other HMO |
$2.19
|
| Rate for Payer: United Healthcare All Other HMO |
$1.32
|
| Rate for Payer: United Healthcare All Other HMO |
$2.15
|
| Rate for Payer: United Healthcare All Other HMO |
$2.22
|
| Rate for Payer: United Healthcare All Other HMO |
$4.38
|
| Rate for Payer: United Healthcare HMO Rider |
$2.18
|
| Rate for Payer: United Healthcare HMO Rider |
$2.10
|
| Rate for Payer: United Healthcare HMO Rider |
$2.14
|
| Rate for Payer: United Healthcare HMO Rider |
$1.29
|
| Rate for Payer: United Healthcare HMO Rider |
$4.29
|
| Rate for Payer: United Healthcare HMO Rider |
$1.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.18
|
|
|
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$7.14 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Adventist Health Commercial |
$1.18
|
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Adventist Health Commercial |
$0.71
|
| Rate for Payer: Adventist Health Commercial |
$1.22
|
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.70
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.57
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.41
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$5.28
|
| Rate for Payer: Blue Shield of California Commercial |
$5.28
|
| Rate for Payer: Blue Shield of California Commercial |
$5.28
|
| Rate for Payer: Blue Shield of California Commercial |
$5.28
|
| Rate for Payer: Blue Shield of California Commercial |
$5.28
|
| Rate for Payer: Blue Shield of California Commercial |
$5.28
|
| Rate for Payer: Blue Shield of California EPN |
$4.80
|
| Rate for Payer: Blue Shield of California EPN |
$4.80
|
| Rate for Payer: Blue Shield of California EPN |
$4.80
|
| Rate for Payer: Blue Shield of California EPN |
$4.80
|
| Rate for Payer: Blue Shield of California EPN |
$4.80
|
| Rate for Payer: Blue Shield of California EPN |
$4.80
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Cash Price |
$3.35
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$3.35
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$3.23
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$3.23
|
| Rate for Payer: Central Health Plan Commercial |
$4.80
|
| Rate for Payer: Central Health Plan Commercial |
$4.70
|
| Rate for Payer: Central Health Plan Commercial |
$2.85
|
| Rate for Payer: Central Health Plan Commercial |
$9.60
|
| Rate for Payer: Central Health Plan Commercial |
$2.88
|
| Rate for Payer: Central Health Plan Commercial |
$4.87
|
| Rate for Payer: Cigna of CA HMO |
$4.12
|
| Rate for Payer: Cigna of CA HMO |
$2.52
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA HMO |
$8.40
|
| Rate for Payer: Cigna of CA HMO |
$4.26
|
| Rate for Payer: Cigna of CA HMO |
$2.49
|
| Rate for Payer: Cigna of CA PPO |
$4.26
|
| Rate for Payer: Cigna of CA PPO |
$2.49
|
| Rate for Payer: Cigna of CA PPO |
$8.40
|
| Rate for Payer: Cigna of CA PPO |
$2.52
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.44
|
| Rate for Payer: EPIC Health Plan Senior |
$1.42
|
| Rate for Payer: EPIC Health Plan Senior |
$2.35
|
| Rate for Payer: EPIC Health Plan Senior |
$2.44
|
| Rate for Payer: EPIC Health Plan Senior |
$4.80
|
| Rate for Payer: EPIC Health Plan Senior |
$2.40
|
| Rate for Payer: EPIC Health Plan Senior |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$3.06
|
| Rate for Payer: Galaxy Health WC |
$5.00
|
| Rate for Payer: Galaxy Health WC |
$5.18
|
| Rate for Payer: Galaxy Health WC |
$10.20
|
| Rate for Payer: Galaxy Health WC |
$3.03
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.53
|
| Rate for Payer: Global Benefits Group Commercial |
$3.65
|
| Rate for Payer: Global Benefits Group Commercial |
$2.14
|
| Rate for Payer: Global Benefits Group Commercial |
$7.20
|
| Rate for Payer: Global Benefits Group Commercial |
$2.16
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6.47
|
| Rate for Payer: InnovAge PACE Commercial |
$6.00
|
| Rate for Payer: InnovAge PACE Commercial |
$1.78
|
| Rate for Payer: InnovAge PACE Commercial |
$3.04
|
| Rate for Payer: InnovAge PACE Commercial |
$2.94
|
| Rate for Payer: InnovAge PACE Commercial |
$1.80
|
| Rate for Payer: InnovAge PACE Commercial |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.49
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$2.67
|
| Rate for Payer: Multiplan Commercial |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$4.57
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Networks By Design Commercial |
$6.00
|
| Rate for Payer: Networks By Design Commercial |
$2.94
|
| Rate for Payer: Networks By Design Commercial |
$3.00
|
| Rate for Payer: Networks By Design Commercial |
$1.78
|
| Rate for Payer: Networks By Design Commercial |
$3.04
|
| Rate for Payer: Networks By Design Commercial |
$1.80
|
| Rate for Payer: Prime Health Services Commercial |
$5.00
|
| Rate for Payer: Prime Health Services Commercial |
$3.06
|
| Rate for Payer: Prime Health Services Commercial |
$3.03
|
| Rate for Payer: Prime Health Services Commercial |
$10.20
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
| Rate for Payer: Prime Health Services Commercial |
$5.18
|
| Rate for Payer: Riverside University Health System MISP |
$1.42
|
| Rate for Payer: Riverside University Health System MISP |
$2.35
|
| Rate for Payer: Riverside University Health System MISP |
$2.44
|
| Rate for Payer: Riverside University Health System MISP |
$1.44
|
| Rate for Payer: Riverside University Health System MISP |
$2.40
|
| Rate for Payer: Riverside University Health System MISP |
$4.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.29
|
| Rate for Payer: United Healthcare All Other HMO |
$1.32
|
| Rate for Payer: United Healthcare All Other HMO |
$1.30
|
| Rate for Payer: United Healthcare All Other HMO |
$2.15
|
| Rate for Payer: United Healthcare All Other HMO |
$2.22
|
| Rate for Payer: United Healthcare All Other HMO |
$2.19
|
| Rate for Payer: United Healthcare All Other HMO |
$4.38
|
| Rate for Payer: United Healthcare HMO Rider |
$2.18
|
| Rate for Payer: United Healthcare HMO Rider |
$4.29
|
| Rate for Payer: United Healthcare HMO Rider |
$2.14
|
| Rate for Payer: United Healthcare HMO Rider |
$2.10
|
| Rate for Payer: United Healthcare HMO Rider |
$1.29
|
| Rate for Payer: United Healthcare HMO Rider |
$1.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.00
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$5.18
|
| Rate for Payer: Vantage Medical Group Senior |
$10.20
|
| Rate for Payer: Vantage Medical Group Senior |
$3.03
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 65862-560-99
|
| 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 Exchange |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| 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: 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: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: InnovAge PACE Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA 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: Riverside University Health System MISP |
$0.02
|
| 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
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 60687-736-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$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: Health Management Network EPO/PPO |
$0.23
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| 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
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 60687-736-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$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: Health Management Network EPO/PPO |
$0.23
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| 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 60687-736-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| 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 Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| 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: 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: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: InnovAge PACE Commercial |
$0.13
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| 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 |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| 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
|
$0.26
|
|
|
Service Code
|
NDC 60687-736-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| 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 Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| 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: 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: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: InnovAge PACE Commercial |
$0.13
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| 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 |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| 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
|
$0.07
|
|
|
Service Code
|
NDC 65862-560-90
|
| 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 |
$0.04
|
| 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 Exchange |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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 |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| 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: 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: Health Management Network EPO/PPO |
$0.06
|
| Rate for Payer: InnovAge PACE Commercial |
$0.04
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Riverside University Health System MISP |
$0.03
|
| 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
|
$0.07
|
|
|
Service Code
|
NDC 65862-560-90
|
| 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: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$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: Health Management Network EPO/PPO |
$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: Kaiser Permanente of CA 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 |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 60687-736-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| 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 Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| 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: 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: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: InnovAge PACE Commercial |
$0.13
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| 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 |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| 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
|
$0.26
|
|
|
Service Code
|
NDC 60687-736-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$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: Health Management Network EPO/PPO |
$0.23
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| 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
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 65862-560-99
|
| 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 |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$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: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA 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 DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$16.99
|
|
|
Service Code
|
NDC 62756-071-64
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$15.29 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Blue Shield of California Commercial |
$13.13
|
| Rate for Payer: Blue Shield of California EPN |
$8.56
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Central Health Plan Commercial |
$13.59
|
| 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: 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: Health Management Network EPO/PPO |
$15.29
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$10.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
| 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
|
$16.99
|
|
|
Service Code
|
NDC 27241-256-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$15.29 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.32
|
| 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 Exchange |
$8.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.98
|
| Rate for Payer: Blue Shield of California Commercial |
$10.38
|
| Rate for Payer: Blue Shield of California EPN |
$6.78
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Central Health Plan Commercial |
$13.59
|
| 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: 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: Health Management Network EPO/PPO |
$15.29
|
| Rate for Payer: InnovAge PACE Commercial |
$8.49
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$10.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| 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 |
$12.74
|
| Rate for Payer: Networks By Design Commercial |
$11.04
|
| Rate for Payer: Prime Health Services Commercial |
$14.44
|
| Rate for Payer: Riverside University Health System MISP |
$6.80
|
| 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 62756-071-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$15.29 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.32
|
| 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 Exchange |
$8.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.98
|
| Rate for Payer: Blue Shield of California Commercial |
$10.38
|
| Rate for Payer: Blue Shield of California EPN |
$6.78
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Central Health Plan Commercial |
$13.59
|
| 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: 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: Health Management Network EPO/PPO |
$15.29
|
| Rate for Payer: InnovAge PACE Commercial |
$8.49
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$10.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| 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 |
$12.74
|
| Rate for Payer: Networks By Design Commercial |
$11.04
|
| Rate for Payer: Prime Health Services Commercial |
$14.44
|
| Rate for Payer: Riverside University Health System MISP |
$6.80
|
| 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
|
$17.29
|
|
|
Service Code
|
NDC 0008-0844-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.46 |
| Max. Negotiated Rate |
$15.56 |
| Rate for Payer: Adventist Health Commercial |
$3.46
|
| Rate for Payer: Blue Shield of California Commercial |
$13.37
|
| Rate for Payer: Blue Shield of California EPN |
$8.71
|
| Rate for Payer: Cash Price |
$9.51
|
| Rate for Payer: Central Health Plan Commercial |
$13.83
|
| Rate for Payer: Cigna of CA HMO |
$12.10
|
| Rate for Payer: Cigna of CA PPO |
$12.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.92
|
| Rate for Payer: EPIC Health Plan Senior |
$6.92
|
| Rate for Payer: Galaxy Health WC |
$14.70
|
| Rate for Payer: Global Benefits Group Commercial |
$10.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: Multiplan Commercial |
$12.97
|
| Rate for Payer: Networks By Design Commercial |
$11.24
|
| Rate for Payer: Prime Health Services Commercial |
$14.70
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$16.99
|
|
|
Service Code
|
NDC 60687-767-99
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$15.29 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.32
|
| 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 Exchange |
$8.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.98
|
| Rate for Payer: Blue Shield of California Commercial |
$10.38
|
| Rate for Payer: Blue Shield of California EPN |
$6.78
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Central Health Plan Commercial |
$13.59
|
| 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: 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: Health Management Network EPO/PPO |
$15.29
|
| Rate for Payer: InnovAge PACE Commercial |
$8.49
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$10.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| 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 |
$12.74
|
| Rate for Payer: Networks By Design Commercial |
$11.04
|
| Rate for Payer: Prime Health Services Commercial |
$14.44
|
| Rate for Payer: Riverside University Health System MISP |
$6.80
|
| 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 60687-767-27
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$15.29 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.32
|
| 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 Exchange |
$8.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.98
|
| Rate for Payer: Blue Shield of California Commercial |
$10.38
|
| Rate for Payer: Blue Shield of California EPN |
$6.78
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Central Health Plan Commercial |
$13.59
|
| 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: 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: Health Management Network EPO/PPO |
$15.29
|
| Rate for Payer: InnovAge PACE Commercial |
$8.49
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$10.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| 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 |
$12.74
|
| Rate for Payer: Networks By Design Commercial |
$11.04
|
| Rate for Payer: Prime Health Services Commercial |
$14.44
|
| Rate for Payer: Riverside University Health System MISP |
$6.80
|
| 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
|
$16.99
|
|
|
Service Code
|
NDC 27241-256-38
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$15.29 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Blue Shield of California Commercial |
$13.13
|
| Rate for Payer: Blue Shield of California EPN |
$8.56
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Central Health Plan Commercial |
$13.59
|
| 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: 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: Health Management Network EPO/PPO |
$15.29
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$10.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
| 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 60687-767-99
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$15.29 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Blue Shield of California Commercial |
$13.13
|
| Rate for Payer: Blue Shield of California EPN |
$8.56
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Central Health Plan Commercial |
$13.59
|
| 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: 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: Health Management Network EPO/PPO |
$15.29
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$10.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
| 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
|
$16.99
|
|
|
Service Code
|
NDC 27241-256-38
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$15.29 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.32
|
| 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 Exchange |
$8.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.98
|
| Rate for Payer: Blue Shield of California Commercial |
$10.38
|
| Rate for Payer: Blue Shield of California EPN |
$6.78
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Central Health Plan Commercial |
$13.59
|
| 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: 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: Health Management Network EPO/PPO |
$15.29
|
| Rate for Payer: InnovAge PACE Commercial |
$8.49
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$10.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| 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 |
$12.74
|
| Rate for Payer: Networks By Design Commercial |
$11.04
|
| Rate for Payer: Prime Health Services Commercial |
$14.44
|
| Rate for Payer: Riverside University Health System MISP |
$6.80
|
| 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
|
|
