|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
IP
|
$0.21
|
|
|
Service Code
|
NDC 68084-813-09
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
OP
|
$0.21
|
|
|
Service Code
|
NDC 68084-813-11
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
NDC 65862-560-90
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
IP
|
$0.13
|
|
|
Service Code
|
NDC 0378-6689-77
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
IP
|
$0.21
|
|
|
Service Code
|
NDC 68084-813-11
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
OP
|
$0.26
|
|
|
Service Code
|
NDC 50268-639-15
|
| Hospital Charge Code |
1712267
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare 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 |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| 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 |
$0.13
|
| 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
|
| 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
|
$0.21
|
|
|
Service Code
|
NDC 68084-813-09
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
IP
|
$0.13
|
|
|
Service Code
|
NDC 31722-713-90
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 0904-6474-61
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
OP
|
$0.13
|
|
|
Service Code
|
NDC 31722-713-90
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Senior |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
IP
|
$0.26
|
|
|
Service Code
|
NDC 50268-639-11
|
| Hospital Charge Code |
1712267
|
|
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: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| 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 50268-639-11
|
| Hospital Charge Code |
1712267
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare 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 |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| 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 |
$0.13
|
| 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
|
| 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
|
$0.13
|
|
|
Service Code
|
NDC 0378-6689-77
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Senior |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
IP
|
$0.26
|
|
|
Service Code
|
NDC 50268-639-15
|
| Hospital Charge Code |
1712267
|
|
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: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| 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
IP
|
$0.34
|
|
|
Service Code
|
NDC 51079-051-20
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
OP
|
$0.34
|
|
|
Service Code
|
NDC 51079-051-20
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
OP
|
$0.17
|
|
|
Service Code
|
NDC 65862-560-99
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
NDC 65862-560-99
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
OP
|
$0.17
|
|
|
Service Code
|
NDC 65862-560-90
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
OP
|
$0.34
|
|
|
Service Code
|
NDC 51079-051-01
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
IP
|
$0.34
|
|
|
Service Code
|
NDC 51079-051-01
|
| Hospital Charge Code |
1712267
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
IP
|
$16.99
|
|
|
Service Code
|
NDC 62756-071-60
|
| Hospital Charge Code |
ERX89791
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Adventist Health Commercial |
$3.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.67
|
| Rate for Payer: Cash Price |
$7.65
|
| 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 |
ERX89791
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$14.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.74
|
| Rate for Payer: Blue Shield of California Commercial |
$10.55
|
| Rate for Payer: Blue Shield of California EPN |
$9.97
|
| Rate for Payer: Cash Price |
$7.65
|
| 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 |
$8.19
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.44
|
| Rate for Payer: Vantage Medical Group Senior |
$14.44
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
IP
|
$20.83
|
|
|
Service Code
|
NDC 0008-0844-02
|
| Hospital Charge Code |
ERX89791
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.77 |
| Max. Negotiated Rate |
$15.62 |
| Rate for Payer: Adventist Health Commercial |
$4.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.31
|
| Rate for Payer: Cash Price |
$9.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.10
|
| Rate for Payer: Heritage Provider Network Senior |
$14.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.21
|
| Rate for Payer: Multiplan Commercial |
$15.62
|
|
|
PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET [89791]
|
Facility
OP
|
$20.83
|
|
|
Service Code
|
NDC 0008-0844-01
|
| Hospital Charge Code |
ERX89791
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.77 |
| Max. Negotiated Rate |
$17.71 |
| Rate for Payer: Adventist Health Commercial |
$4.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.62
|
| Rate for Payer: Blue Shield of California Commercial |
$12.94
|
| Rate for Payer: Blue Shield of California EPN |
$12.23
|
| Rate for Payer: Cash Price |
$9.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.71
|
| Rate for Payer: Dignity Health Senior |
$17.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.89
|
| Rate for Payer: Heritage Provider Network Senior |
$12.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.21
|
| Rate for Payer: Multiplan Commercial |
$15.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.71
|
| Rate for Payer: Vantage Medical Group Senior |
$17.71
|
|
