|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
OP
|
$542.19
|
|
|
Service Code
|
NDC 60505-4704-2
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$298.20 |
| Max. Negotiated Rate |
$406.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$325.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$325.31
|
| Rate for Payer: Cash Price |
$243.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$325.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$325.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$298.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$406.64
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
NDC 49884-768-54
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$43.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$43.20
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$43.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$54.00
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
OP
|
$542.19
|
|
|
Service Code
|
NDC 60505-4704-0
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$298.20 |
| Max. Negotiated Rate |
$406.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$325.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$325.31
|
| Rate for Payer: Cash Price |
$243.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$325.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$325.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$298.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$406.64
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
NDC 49884-768-54
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$43.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$54.00
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
NDC 49884-768-52
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$43.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$54.00
|
|
|
TOLVAPTAN 30 MG TABLET [97894]
|
Facility
|
IP
|
$647.57
|
|
|
Service Code
|
NDC 59148-021-50
|
| Hospital Charge Code |
1712439
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$356.16 |
| Max. Negotiated Rate |
$518.06 |
| Rate for Payer: Cash Price |
$291.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$518.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$388.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$356.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$485.68
|
|
|
TOLVAPTAN 30 MG TABLET [97894]
|
Facility
|
OP
|
$647.57
|
|
|
Service Code
|
NDC 59148-021-50
|
| Hospital Charge Code |
1712439
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$356.16 |
| Max. Negotiated Rate |
$485.68 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$388.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$388.54
|
| Rate for Payer: Cash Price |
$291.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$388.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$388.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$356.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$485.68
|
|
|
TOLVAPTAN 30 MG TABLET [97894]
|
Facility
|
IP
|
$576.63
|
|
|
Service Code
|
NDC 67877-636-02
|
| Hospital Charge Code |
1712439
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$317.15 |
| Max. Negotiated Rate |
$461.30 |
| Rate for Payer: Cash Price |
$259.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$461.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$345.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$317.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$432.47
|
|
|
TOLVAPTAN 30 MG TABLET [97894]
|
Facility
|
OP
|
$576.63
|
|
|
Service Code
|
NDC 67877-636-02
|
| Hospital Charge Code |
1712439
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$317.15 |
| Max. Negotiated Rate |
$432.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$345.98
|
| Rate for Payer: Aetna of CA Government/Medicare |
$345.98
|
| Rate for Payer: Cash Price |
$259.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$345.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$345.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$317.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$432.47
|
|
|
TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 1 MG/ML [40801044]
|
Facility
|
IP
|
$31.25
|
|
|
Service Code
|
NDC 9940-8010-44
|
| Hospital Charge Code |
ERX40801044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.44
|
|
|
TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 1 MG/ML [40801044]
|
Facility
|
OP
|
$31.25
|
|
|
Service Code
|
NDC 9940-8010-44
|
| Hospital Charge Code |
ERX40801044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.75
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.75
|
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.44
|
|
|
TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 3 MG/ML [4081044]
|
Facility
|
OP
|
$31.25
|
|
|
Service Code
|
NDC 9994-0810-44
|
| Hospital Charge Code |
ERX4081044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.75
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.75
|
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.44
|
|
|
TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 3 MG/ML [4081044]
|
Facility
|
IP
|
$31.25
|
|
|
Service Code
|
NDC 9994-0810-44
|
| Hospital Charge Code |
ERX4081044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.44
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
IP
|
$0.57
|
|
|
Service Code
|
NDC 68084-344-11
|
| Hospital Charge Code |
1713139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.43
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
OP
|
$0.57
|
|
|
Service Code
|
NDC 68084-344-11
|
| Hospital Charge Code |
1713139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.34
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.43
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 68382-140-14
|
| Hospital Charge Code |
1713139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
IP
|
$0.57
|
|
|
Service Code
|
NDC 68084-344-01
|
| Hospital Charge Code |
1713139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.43
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 68462-109-60
|
| Hospital Charge Code |
1713139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
OP
|
$0.57
|
|
|
Service Code
|
NDC 68084-344-01
|
| Hospital Charge Code |
1713139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.34
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.43
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 68462-109-60
|
| Hospital Charge Code |
1713139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 68382-140-14
|
| Hospital Charge Code |
1713139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
TOPIRAMATE 200 MG TABLET [18921]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 68084-345-21
|
| Hospital Charge Code |
1713140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.72
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.90
|
|
|
TOPIRAMATE 200 MG TABLET [18921]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 68084-345-11
|
| Hospital Charge Code |
1713140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.90
|
|
|
TOPIRAMATE 200 MG TABLET [18921]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 68462-110-60
|
| Hospital Charge Code |
1713140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
TOPIRAMATE 200 MG TABLET [18921]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 68382-141-14
|
| Hospital Charge Code |
1713140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
