|
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 |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
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 |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| 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: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| 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: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 27241-256-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.67
|
| 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: Blue Shield of California Commercial |
$10.36
|
| Rate for Payer: Blue Shield of California EPN |
$8.29
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.44
|
| Rate for Payer: Dignity Health Senior |
$14.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Senior |
$10.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| 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: TriValley Medical Group Commercial |
$6.80
|
| Rate for Payer: TriValley Medical Group Senior |
$6.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 62756-071-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.50
|
| Rate for Payer: Heritage Provider Network Senior |
$11.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
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 |
$3.08 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.50
|
| Rate for Payer: Heritage Provider Network Senior |
$11.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$16.99
|
|
|
Service Code
|
NDC 60687-767-27
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.50
|
| Rate for Payer: Heritage Provider Network Senior |
$11.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
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 |
$3.08 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.67
|
| 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: Blue Shield of California Commercial |
$10.36
|
| Rate for Payer: Blue Shield of California EPN |
$8.29
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.44
|
| Rate for Payer: Dignity Health Senior |
$14.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Senior |
$10.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| 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: TriValley Medical Group Commercial |
$6.80
|
| Rate for Payer: TriValley Medical Group Senior |
$6.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 62756-071-64
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.50
|
| Rate for Payer: Heritage Provider Network Senior |
$11.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$16.99
|
|
|
Service Code
|
NDC 27241-256-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.50
|
| Rate for Payer: Heritage Provider Network Senior |
$11.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$17.29
|
|
|
Service Code
|
NDC 0008-0844-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.13 |
| Max. Negotiated Rate |
$14.70 |
| Rate for Payer: Adventist Health Commercial |
$3.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.97
|
| Rate for Payer: Blue Shield of California Commercial |
$10.55
|
| Rate for Payer: Blue Shield of California EPN |
$8.44
|
| Rate for Payer: Cash Price |
$9.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.70
|
| Rate for Payer: Dignity Health Senior |
$14.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.70
|
| Rate for Payer: Heritage Provider Network Senior |
$10.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.10
|
| Rate for Payer: Multiplan Commercial |
$12.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.92
|
| Rate for Payer: TriValley Medical Group Senior |
$6.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.70
|
| Rate for Payer: Vantage Medical Group Senior |
$14.70
|
|
|
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 |
$3.13 |
| Max. Negotiated Rate |
$12.97 |
| Rate for Payer: Adventist Health Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$9.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.71
|
| Rate for Payer: Heritage Provider Network Senior |
$11.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.32
|
| Rate for Payer: Multiplan Commercial |
$12.97
|
|
|
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 |
$3.08 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.67
|
| 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: Blue Shield of California Commercial |
$10.36
|
| Rate for Payer: Blue Shield of California EPN |
$8.29
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.44
|
| Rate for Payer: Dignity Health Senior |
$14.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Senior |
$10.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| 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: TriValley Medical Group Commercial |
$6.80
|
| Rate for Payer: TriValley Medical Group Senior |
$6.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 62756-071-64
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.67
|
| 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: Blue Shield of California Commercial |
$10.36
|
| Rate for Payer: Blue Shield of California EPN |
$8.29
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.44
|
| Rate for Payer: Dignity Health Senior |
$14.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Senior |
$10.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| 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: TriValley Medical Group Commercial |
$6.80
|
| Rate for Payer: TriValley Medical Group Senior |
$6.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.44
|
| Rate for Payer: Vantage Medical Group Senior |
$14.44
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
OP
|
$17.29
|
|
|
Service Code
|
NDC 0008-0844-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.13 |
| Max. Negotiated Rate |
$14.70 |
| Rate for Payer: Adventist Health Commercial |
$3.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.97
|
| Rate for Payer: Blue Shield of California Commercial |
$10.55
|
| Rate for Payer: Blue Shield of California EPN |
$8.44
|
| Rate for Payer: Cash Price |
$9.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.70
|
| Rate for Payer: Dignity Health Senior |
$14.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.70
|
| Rate for Payer: Heritage Provider Network Senior |
$10.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.10
|
| Rate for Payer: Multiplan Commercial |
$12.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.92
|
| Rate for Payer: TriValley Medical Group Senior |
$6.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.70
|
| Rate for Payer: Vantage Medical Group Senior |
$14.70
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
|
IP
|
$17.29
|
|
|
Service Code
|
NDC 0008-0844-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.13 |
| Max. Negotiated Rate |
$12.97 |
| Rate for Payer: Adventist Health Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$9.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.71
|
| Rate for Payer: Heritage Provider Network Senior |
$11.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.32
|
| Rate for Payer: Multiplan Commercial |
$12.97
|
|
|
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 |
$3.08 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.50
|
| Rate for Payer: Heritage Provider Network Senior |
$11.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| Rate for Payer: Multiplan Commercial |
$12.74
|
|
|
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 |
$3.08 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.67
|
| 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: Blue Shield of California Commercial |
$10.36
|
| Rate for Payer: Blue Shield of California EPN |
$8.29
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.44
|
| Rate for Payer: Dignity Health Senior |
$14.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Senior |
$10.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| 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: TriValley Medical Group Commercial |
$6.80
|
| Rate for Payer: TriValley Medical Group Senior |
$6.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 60687-767-99
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.67
|
| 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: Blue Shield of California Commercial |
$10.36
|
| Rate for Payer: Blue Shield of California EPN |
$8.29
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.44
|
| Rate for Payer: Dignity Health Senior |
$14.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Senior |
$10.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.25
|
| 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: TriValley Medical Group Commercial |
$6.80
|
| Rate for Payer: TriValley Medical Group Senior |
$6.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
PAPAVERINE 30 MG/ML INJECTION SOLUTION [6030]
|
Facility
|
OP
|
$22.50
|
|
|
Service Code
|
HCPCS J2440
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.07 |
| Max. Negotiated Rate |
$91.27 |
| Rate for Payer: Adventist Health Commercial |
$4.50
|
| Rate for Payer: Adventist Health Commercial |
$3.90
|
| Rate for Payer: Adventist Health Commercial |
$4.66
|
| Rate for Payer: Adventist Health Commercial |
$4.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.82
|
| 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 |
$12.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$91.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$91.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$91.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$91.27
|
| Rate for Payer: Blue Shield of California Commercial |
$35.95
|
| Rate for Payer: Blue Shield of California Commercial |
$35.95
|
| Rate for Payer: Blue Shield of California Commercial |
$35.95
|
| Rate for Payer: Blue Shield of California Commercial |
$35.95
|
| Rate for Payer: Blue Shield of California EPN |
$35.95
|
| Rate for Payer: Blue Shield of California EPN |
$35.95
|
| Rate for Payer: Blue Shield of California EPN |
$35.95
|
| Rate for Payer: Blue Shield of California EPN |
$35.95
|
| Rate for Payer: Cash Price |
$12.83
|
| Rate for Payer: Cash Price |
$10.73
|
| Rate for Payer: Cash Price |
$10.73
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Cash Price |
$13.67
|
| Rate for Payer: Cash Price |
$13.67
|
| Rate for Payer: Cash Price |
$12.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.12
|
| Rate for Payer: Dignity Health Senior |
$19.82
|
| Rate for Payer: Dignity Health Senior |
$19.12
|
| Rate for Payer: Dignity Health Senior |
$16.57
|
| Rate for Payer: Dignity Health Senior |
$21.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.42
|
| Rate for Payer: Heritage Provider Network Senior |
$10.80
|
| Rate for Payer: Heritage Provider Network Senior |
$11.51
|
| Rate for Payer: Heritage Provider Network Senior |
$10.42
|
| Rate for Payer: Heritage Provider Network Senior |
$9.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.39
|
| Rate for Payer: Multiplan Commercial |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$17.49
|
| Rate for Payer: Multiplan Commercial |
$14.62
|
| Rate for Payer: Multiplan Commercial |
$16.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.80
|
| Rate for Payer: TriValley Medical Group Senior |
$7.80
|
| Rate for Payer: TriValley Medical Group Senior |
$9.00
|
| Rate for Payer: TriValley Medical Group Senior |
$9.94
|
| Rate for Payer: TriValley Medical Group Senior |
$9.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.82
|
| 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 |
$16.57
|
| Rate for Payer: Vantage Medical Group Senior |
$19.12
|
| Rate for Payer: Vantage Medical Group Senior |
$21.12
|
| Rate for Payer: Vantage Medical Group Senior |
$16.57
|
| Rate for Payer: Vantage Medical Group Senior |
$19.82
|
|
|
PAPAVERINE 30 MG/ML INJECTION SOLUTION [6030]
|
Facility
|
IP
|
$23.32
|
|
|
Service Code
|
HCPCS J2440
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.22 |
| Max. Negotiated Rate |
$17.49 |
| Rate for Payer: Adventist Health Commercial |
$4.66
|
| Rate for Payer: Adventist Health Commercial |
$4.97
|
| Rate for Payer: Adventist Health Commercial |
$3.90
|
| Rate for Payer: Adventist Health Commercial |
$4.50
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Cash Price |
$12.83
|
| Rate for Payer: Cash Price |
$13.67
|
| Rate for Payer: Cash Price |
$10.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.03
|
| Rate for Payer: Heritage Provider Network Senior |
$11.51
|
| Rate for Payer: Heritage Provider Network Senior |
$9.03
|
| Rate for Payer: Heritage Provider Network Senior |
$10.42
|
| Rate for Payer: Heritage Provider Network Senior |
$10.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.88
|
| Rate for Payer: Multiplan Commercial |
$14.62
|
| Rate for Payer: Multiplan Commercial |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$17.49
|
| Rate for Payer: Multiplan Commercial |
$16.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.46
|
|
|
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION [222465]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0338-0502-06
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION [222465]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0338-0502-06
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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 |
$0.06
|
| 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: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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.6 INTRAVENOUS SOLUTION [224619]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 0264-4500-00
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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 |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| 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 |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION [224619]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 0264-4500-00
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
PARICALCITOL 1 MCG CAPSULE [41497]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 49483-687-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| 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 |
$0.90
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Senior |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
