|
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 |
$7.50 |
| Max. Negotiated Rate |
$26.56 |
| Rate for Payer: Blue Shield of California Commercial |
$22.25
|
| Rate for Payer: Blue Shield of California EPN |
$16.00
|
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Cigna of CA HMO |
$21.88
|
| Rate for Payer: Cigna of CA PPO |
$21.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.50
|
| Rate for Payer: Galaxy Health WC |
$26.56
|
| Rate for Payer: Global Benefits Group Commercial |
$18.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$25.00
|
| Rate for Payer: Networks By Design Commercial |
$20.31
|
| Rate for Payer: Prime Health Services Commercial |
$26.56
|
|
|
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 |
$7.50 |
| Max. Negotiated Rate |
$26.56 |
| Rate for Payer: Aetna of CA HMO/PPO |
$20.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.62
|
| Rate for Payer: Blue Distinction Transplant |
$18.75
|
| Rate for Payer: Blue Shield of California Commercial |
$23.03
|
| Rate for Payer: Blue Shield of California EPN |
$18.25
|
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Cigna of CA HMO |
$21.88
|
| Rate for Payer: Cigna of CA PPO |
$21.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.56
|
| Rate for Payer: Dignity Health Media |
$26.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.50
|
| Rate for Payer: Galaxy Health WC |
$26.56
|
| Rate for Payer: Global Benefits Group Commercial |
$18.75
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$23.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$25.00
|
| Rate for Payer: Networks By Design Commercial |
$20.31
|
| Rate for Payer: Prime Health Services Commercial |
$26.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.75
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.62
|
| Rate for Payer: United Healthcare All Other HMO |
$15.62
|
| Rate for Payer: United Healthcare HMO Rider |
$15.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.56
|
| Rate for Payer: Vantage Medical Group Senior |
$26.56
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
|
IP
|
$8,193.39
|
|
|
Service Code
|
APR-DRG 0971
|
| Min. Negotiated Rate |
$6,285.19 |
| Max. Negotiated Rate |
$8,193.39 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,285.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,193.39
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
|
IP
|
$11,873.31
|
|
|
Service Code
|
APR-DRG 0972
|
| Min. Negotiated Rate |
$9,108.08 |
| Max. Negotiated Rate |
$11,873.31 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,108.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11,873.31
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
|
IP
|
$41,944.10
|
|
|
Service Code
|
APR-DRG 0974
|
| Min. Negotiated Rate |
$32,175.54 |
| Max. Negotiated Rate |
$41,944.10 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$32,175.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41,944.10
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
|
IP
|
$18,261.32
|
|
|
Service Code
|
APR-DRG 0973
|
| Min. Negotiated Rate |
$14,008.35 |
| Max. Negotiated Rate |
$18,261.32 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$14,008.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,261.32
|
|
|
Tonsillectomy and adenoidectomy; age 12 or over
|
Facility
|
OP
|
$13,086.00
|
|
|
Service Code
|
CPT 42821
|
| Min. Negotiated Rate |
$384.81 |
| Max. Negotiated Rate |
$13,086.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$13,086.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,049.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Dignity Health Media |
$4,022.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,424.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,430.63
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,022.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,022.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,597.21
|
| Rate for Payer: Heritage Provider Network Transplant |
$6,597.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,516.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$6,516.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,022.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$384.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,022.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,068.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,390.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4,022.69
|
|
|
Tonsillectomy and adenoidectomy; younger than age 12
|
Facility
|
OP
|
$11,999.72
|
|
|
Service Code
|
CPT 42820
|
| Min. Negotiated Rate |
$320.44 |
| Max. Negotiated Rate |
$11,999.72 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9,590.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,049.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Media |
$7,316.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,877.82
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$7,316.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$11,999.72
|
| Rate for Payer: Heritage Provider Network Transplant |
$11,999.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11,853.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$11,853.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$320.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,316.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,804.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Tonsillectomy, primary or secondary; age 12 or over
|
Facility
|
OP
|
$12,491.00
|
|
|
Service Code
|
CPT 42826
|
| Min. Negotiated Rate |
$384.81 |
| Max. Negotiated Rate |
$12,491.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12,491.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,049.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Dignity Health Media |
$4,022.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,424.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,430.63
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,022.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,022.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,597.21
|
| Rate for Payer: Heritage Provider Network Transplant |
$6,597.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,516.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$6,516.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,022.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$384.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,022.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,068.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,390.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4,022.69
|
|
|
Tonsillectomy, primary or secondary; younger than age 12
|
Facility
|
OP
|
$12,491.00
|
|
|
Service Code
|
CPT 42825
|
| Min. Negotiated Rate |
$320.44 |
| Max. Negotiated Rate |
$12,491.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12,491.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,049.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Media |
$7,316.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,877.82
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$7,316.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$11,999.72
|
| Rate for Payer: Heritage Provider Network Transplant |
$11,999.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11,853.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$11,853.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$320.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,316.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,804.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
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 |
$0.14 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: Blue Distinction Transplant |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.40
|
| Rate for Payer: Cigna of CA PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Media |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.48
|
| Rate for Payer: Global Benefits Group Commercial |
$0.34
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.37
|
| Rate for Payer: Prime Health Services Commercial |
$0.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
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 |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| 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 |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
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 |
$0.14 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.40
|
| Rate for Payer: Cigna of CA PPO |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.48
|
| Rate for Payer: Global Benefits Group Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.37
|
| Rate for Payer: Prime Health Services Commercial |
$0.48
|
|
|
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 |
$0.14 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: Blue Distinction Transplant |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.40
|
| Rate for Payer: Cigna of CA PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Media |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.48
|
| Rate for Payer: Global Benefits Group Commercial |
$0.34
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.37
|
| Rate for Payer: Prime Health Services Commercial |
$0.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
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 |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| 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 |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
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 |
$0.14 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.40
|
| Rate for Payer: Cigna of CA PPO |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.48
|
| Rate for Payer: Global Benefits Group Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.37
|
| Rate for Payer: Prime Health Services Commercial |
$0.48
|
|
|
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 |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Distinction Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Media |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| 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 |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
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 |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Distinction Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Media |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| 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 |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
TOPIRAMATE 200 MG TABLET [18921]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 68462-110-60
|
| Hospital Charge Code |
1713140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Distinction Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Media |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
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 |
$0.29 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
|
|
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 |
$0.29 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.71
|
| Rate for Payer: Blue Distinction Transplant |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.88
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Media |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
TOPIRAMATE 200 MG TABLET [18921]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 62756-712-86
|
| Hospital Charge Code |
1713140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.50
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.50
|
|
|
TOPIRAMATE 200 MG TABLET [18921]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 68382-141-14
|
| Hospital Charge Code |
1713140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Distinction Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Media |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
TOPIRAMATE 200 MG TABLET [18921]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 68084-345-21
|
| Hospital Charge Code |
1713140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
|
