|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
OP
|
$3.03
|
|
|
Service Code
|
NDC 59762-0047-1
|
| Hospital Charge Code |
1711848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.81
|
| Rate for Payer: BCBS Transplant Transplant |
$1.82
|
| Rate for Payer: Blue Shield of California Commercial |
$2.23
|
| Rate for Payer: Blue Shield of California EPN |
$1.77
|
| Rate for Payer: Cash Price |
$1.36
|
| Rate for Payer: Cigna of CA HMO |
$2.12
|
| Rate for Payer: Cigna of CA PPO |
$2.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.58
|
| Rate for Payer: Dignity Health Media |
$2.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.21
|
| Rate for Payer: Galaxy Health WC |
$2.58
|
| Rate for Payer: Global Benefits Group Commercial |
$1.82
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
| Rate for Payer: Networks By Design Commercial |
$1.97
|
| Rate for Payer: Prime Health Services Commercial |
$2.58
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.52
|
| Rate for Payer: United Healthcare All Other HMO |
$1.52
|
| Rate for Payer: United Healthcare HMO Rider |
$1.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.58
|
| Rate for Payer: Vantage Medical Group Senior |
$2.58
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
IP
|
$3.03
|
|
|
Service Code
|
NDC 59762-0047-1
|
| Hospital Charge Code |
1711848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Blue Shield of California Commercial |
$2.16
|
| Rate for Payer: Blue Shield of California EPN |
$1.55
|
| Rate for Payer: Cash Price |
$1.36
|
| Rate for Payer: Cigna of CA HMO |
$2.12
|
| Rate for Payer: Cigna of CA PPO |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.21
|
| Rate for Payer: Galaxy Health WC |
$2.58
|
| Rate for Payer: Global Benefits Group Commercial |
$1.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
| Rate for Payer: Networks By Design Commercial |
$1.97
|
| Rate for Payer: Prime Health Services Commercial |
$2.58
|
|
|
TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]
|
Facility
IP
|
$7.71
|
|
|
Service Code
|
NDC 0093-7164-56
|
| Hospital Charge Code |
1711849
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$6.55 |
| Rate for Payer: Blue Shield of California Commercial |
$5.49
|
| Rate for Payer: Blue Shield of California EPN |
$3.95
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Cigna of CA HMO |
$5.40
|
| Rate for Payer: Cigna of CA PPO |
$5.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.08
|
| Rate for Payer: Galaxy Health WC |
$6.55
|
| Rate for Payer: Global Benefits Group Commercial |
$4.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$6.17
|
| Rate for Payer: Networks By Design Commercial |
$5.01
|
| Rate for Payer: Prime Health Services Commercial |
$6.55
|
|
|
TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]
|
Facility
OP
|
$7.71
|
|
|
Service Code
|
NDC 0093-7164-56
|
| Hospital Charge Code |
1711849
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$6.55 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.59
|
| Rate for Payer: BCBS Transplant Transplant |
$4.63
|
| Rate for Payer: Blue Shield of California Commercial |
$5.68
|
| Rate for Payer: Blue Shield of California EPN |
$4.50
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Cigna of CA HMO |
$5.40
|
| Rate for Payer: Cigna of CA PPO |
$5.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.55
|
| Rate for Payer: Dignity Health Media |
$6.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.08
|
| Rate for Payer: Galaxy Health WC |
$6.55
|
| Rate for Payer: Global Benefits Group Commercial |
$4.63
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$6.17
|
| Rate for Payer: Networks By Design Commercial |
$5.01
|
| Rate for Payer: Prime Health Services Commercial |
$6.55
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.86
|
| Rate for Payer: United Healthcare All Other HMO |
$3.86
|
| Rate for Payer: United Healthcare HMO Rider |
$3.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.55
|
| Rate for Payer: Vantage Medical Group Senior |
$6.55
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
OP
|
$72.00
|
|
|
Service Code
|
NDC 49884-768-52
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.28 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$47.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$39.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$39.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.90
|
| Rate for Payer: BCBS Transplant Transplant |
$43.20
|
| Rate for Payer: Blue Shield of California Commercial |
$53.06
|
| Rate for Payer: Blue Shield of California EPN |
$42.05
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna of CA HMO |
$50.40
|
| Rate for Payer: Cigna of CA PPO |
$50.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.20
|
| Rate for Payer: Dignity Health Media |
$61.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$28.80
|
| Rate for Payer: Galaxy Health WC |
$61.20
|
| Rate for Payer: Global Benefits Group Commercial |
$43.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$54.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$48.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.28
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: Networks By Design Commercial |
$46.80
|
| Rate for Payer: Prime Health Services Commercial |
$61.20
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$43.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$43.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$43.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.00
|
| Rate for Payer: United Healthcare All Other HMO |
$36.00
|
| Rate for Payer: United Healthcare HMO Rider |
$36.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$36.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.20
|
| Rate for Payer: Vantage Medical Group Senior |
$61.20
|
|
|
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 |
$17.28 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Blue Shield of California Commercial |
$51.26
|
| Rate for Payer: Blue Shield of California EPN |
$36.86
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna of CA HMO |
$50.40
|
| Rate for Payer: Cigna of CA PPO |
$50.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.80
|
| Rate for Payer: Galaxy Health WC |
$61.20
|
| Rate for Payer: Global Benefits Group Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$48.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.28
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: Networks By Design Commercial |
$46.80
|
| Rate for Payer: Prime Health Services Commercial |
$61.20
|
|
|
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 |
$17.28 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Galaxy Health WC |
$61.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$47.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$39.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$39.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.90
|
| Rate for Payer: BCBS Transplant Transplant |
$43.20
|
| Rate for Payer: Blue Shield of California Commercial |
$53.06
|
| Rate for Payer: Blue Shield of California EPN |
$42.05
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna of CA HMO |
$50.40
|
| Rate for Payer: Cigna of CA PPO |
$50.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.20
|
| Rate for Payer: Dignity Health Media |
$61.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$28.80
|
| Rate for Payer: Global Benefits Group Commercial |
$43.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$54.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$48.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.28
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: Networks By Design Commercial |
$46.80
|
| Rate for Payer: Prime Health Services Commercial |
$61.20
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$43.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$43.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$43.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.00
|
| Rate for Payer: United Healthcare All Other HMO |
$36.00
|
| Rate for Payer: United Healthcare HMO Rider |
$36.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$36.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.20
|
| Rate for Payer: Vantage Medical Group Senior |
$61.20
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
IP
|
$542.19
|
|
|
Service Code
|
NDC 60505-4704-2
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$130.13 |
| Max. Negotiated Rate |
$460.86 |
| Rate for Payer: Blue Shield of California Commercial |
$386.04
|
| Rate for Payer: Blue Shield of California EPN |
$277.60
|
| Rate for Payer: Cash Price |
$243.99
|
| Rate for Payer: Cigna of CA HMO |
$379.53
|
| Rate for Payer: Cigna of CA PPO |
$379.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$216.88
|
| Rate for Payer: Galaxy Health WC |
$460.86
|
| Rate for Payer: Global Benefits Group Commercial |
$325.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$361.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$206.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$130.13
|
| Rate for Payer: Multiplan Commercial |
$433.75
|
| Rate for Payer: Networks By Design Commercial |
$352.42
|
| Rate for Payer: Prime Health Services Commercial |
$460.86
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
IP
|
$542.19
|
|
|
Service Code
|
NDC 60505-4704-0
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$130.13 |
| Max. Negotiated Rate |
$460.86 |
| Rate for Payer: Blue Shield of California Commercial |
$386.04
|
| Rate for Payer: Blue Shield of California EPN |
$277.60
|
| Rate for Payer: Cash Price |
$243.99
|
| Rate for Payer: Cigna of CA HMO |
$379.53
|
| Rate for Payer: Cigna of CA PPO |
$379.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$216.88
|
| Rate for Payer: Galaxy Health WC |
$460.86
|
| Rate for Payer: Global Benefits Group Commercial |
$325.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$361.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$206.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$130.13
|
| Rate for Payer: Multiplan Commercial |
$433.75
|
| Rate for Payer: Networks By Design Commercial |
$352.42
|
| Rate for Payer: Prime Health Services Commercial |
$460.86
|
|
|
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 |
$17.28 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Blue Shield of California Commercial |
$51.26
|
| Rate for Payer: Blue Shield of California EPN |
$36.86
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna of CA HMO |
$50.40
|
| Rate for Payer: Cigna of CA PPO |
$50.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.80
|
| Rate for Payer: Galaxy Health WC |
$61.20
|
| Rate for Payer: Global Benefits Group Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$48.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.28
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: Networks By Design Commercial |
$46.80
|
| Rate for Payer: Prime Health Services Commercial |
$61.20
|
|
|
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 |
$130.13 |
| Max. Negotiated Rate |
$460.86 |
| Rate for Payer: Aetna of CA HMO/PPO |
$355.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$460.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$298.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$298.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$323.04
|
| Rate for Payer: BCBS Transplant Transplant |
$325.31
|
| Rate for Payer: Blue Shield of California Commercial |
$399.59
|
| Rate for Payer: Blue Shield of California EPN |
$316.64
|
| Rate for Payer: Cash Price |
$243.99
|
| Rate for Payer: Cigna of CA HMO |
$379.53
|
| Rate for Payer: Cigna of CA PPO |
$379.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$460.86
|
| Rate for Payer: Dignity Health Media |
$460.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$460.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$216.88
|
| Rate for Payer: EPIC Health Plan Transplant |
$216.88
|
| Rate for Payer: Galaxy Health WC |
$460.86
|
| Rate for Payer: Global Benefits Group Commercial |
$325.31
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$406.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$361.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$206.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$130.13
|
| Rate for Payer: Multiplan Commercial |
$433.75
|
| Rate for Payer: Networks By Design Commercial |
$352.42
|
| Rate for Payer: Prime Health Services Commercial |
$460.86
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$325.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$325.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$325.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$271.10
|
| Rate for Payer: United Healthcare All Other HMO |
$271.10
|
| Rate for Payer: United Healthcare HMO Rider |
$271.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$271.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$460.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$460.86
|
| Rate for Payer: Vantage Medical Group Senior |
$460.86
|
|
|
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 |
$130.13 |
| Max. Negotiated Rate |
$460.86 |
| Rate for Payer: Aetna of CA HMO/PPO |
$355.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$460.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$298.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$298.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$323.04
|
| Rate for Payer: BCBS Transplant Transplant |
$325.31
|
| Rate for Payer: Blue Shield of California Commercial |
$399.59
|
| Rate for Payer: Blue Shield of California EPN |
$316.64
|
| Rate for Payer: Cash Price |
$243.99
|
| Rate for Payer: Cigna of CA HMO |
$379.53
|
| Rate for Payer: Cigna of CA PPO |
$379.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$460.86
|
| Rate for Payer: Dignity Health Media |
$460.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$460.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$216.88
|
| Rate for Payer: EPIC Health Plan Transplant |
$216.88
|
| Rate for Payer: Galaxy Health WC |
$460.86
|
| Rate for Payer: Global Benefits Group Commercial |
$325.31
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$406.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$361.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$206.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$130.13
|
| Rate for Payer: Multiplan Commercial |
$433.75
|
| Rate for Payer: Networks By Design Commercial |
$352.42
|
| Rate for Payer: Prime Health Services Commercial |
$460.86
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$325.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$325.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$325.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$271.10
|
| Rate for Payer: United Healthcare All Other HMO |
$271.10
|
| Rate for Payer: United Healthcare HMO Rider |
$271.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$271.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$460.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$460.86
|
| Rate for Payer: Vantage Medical Group Senior |
$460.86
|
|
|
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 |
$155.42 |
| Max. Negotiated Rate |
$550.43 |
| Rate for Payer: Aetna of CA HMO/PPO |
$424.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$550.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$356.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$356.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$385.82
|
| Rate for Payer: BCBS Transplant Transplant |
$388.54
|
| Rate for Payer: Blue Shield of California Commercial |
$477.26
|
| Rate for Payer: Blue Shield of California EPN |
$378.18
|
| Rate for Payer: Cash Price |
$291.41
|
| Rate for Payer: Cigna of CA HMO |
$453.30
|
| Rate for Payer: Cigna of CA PPO |
$453.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$550.43
|
| Rate for Payer: Dignity Health Media |
$550.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$550.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$259.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$259.03
|
| Rate for Payer: Galaxy Health WC |
$550.43
|
| Rate for Payer: Global Benefits Group Commercial |
$388.54
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$485.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$431.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$246.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.42
|
| Rate for Payer: Multiplan Commercial |
$518.06
|
| Rate for Payer: Networks By Design Commercial |
$420.92
|
| Rate for Payer: Prime Health Services Commercial |
$550.43
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$388.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$388.54
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$388.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$323.78
|
| Rate for Payer: United Healthcare All Other HMO |
$323.78
|
| Rate for Payer: United Healthcare HMO Rider |
$323.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$323.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$550.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$550.43
|
| Rate for Payer: Vantage Medical Group Senior |
$550.43
|
|
|
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 |
$138.39 |
| Max. Negotiated Rate |
$490.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$378.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$490.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$317.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$317.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$343.56
|
| Rate for Payer: BCBS Transplant Transplant |
$345.98
|
| Rate for Payer: Blue Shield of California Commercial |
$424.98
|
| Rate for Payer: Blue Shield of California EPN |
$336.75
|
| Rate for Payer: Cash Price |
$259.48
|
| Rate for Payer: Cigna of CA HMO |
$403.64
|
| Rate for Payer: Cigna of CA PPO |
$403.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$490.14
|
| Rate for Payer: Dignity Health Media |
$490.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$490.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$230.65
|
| Rate for Payer: EPIC Health Plan Transplant |
$230.65
|
| Rate for Payer: Galaxy Health WC |
$490.14
|
| Rate for Payer: Global Benefits Group Commercial |
$345.98
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$432.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$384.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$219.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$138.39
|
| Rate for Payer: Multiplan Commercial |
$461.30
|
| Rate for Payer: Networks By Design Commercial |
$374.81
|
| Rate for Payer: Prime Health Services Commercial |
$490.14
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$345.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$345.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$345.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$288.32
|
| Rate for Payer: United Healthcare All Other HMO |
$288.32
|
| Rate for Payer: United Healthcare HMO Rider |
$288.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$288.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$490.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$490.14
|
| Rate for Payer: Vantage Medical Group Senior |
$490.14
|
|
|
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 |
$155.42 |
| Max. Negotiated Rate |
$550.43 |
| Rate for Payer: Blue Shield of California Commercial |
$461.07
|
| Rate for Payer: Blue Shield of California EPN |
$331.56
|
| Rate for Payer: Cash Price |
$291.41
|
| Rate for Payer: Cigna of CA HMO |
$453.30
|
| Rate for Payer: Cigna of CA PPO |
$453.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$259.03
|
| Rate for Payer: Galaxy Health WC |
$550.43
|
| Rate for Payer: Global Benefits Group Commercial |
$388.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$431.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$246.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.42
|
| Rate for Payer: Multiplan Commercial |
$518.06
|
| Rate for Payer: Networks By Design Commercial |
$420.92
|
| Rate for Payer: Prime Health Services Commercial |
$550.43
|
|
|
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 |
$138.39 |
| Max. Negotiated Rate |
$490.14 |
| Rate for Payer: Blue Shield of California Commercial |
$410.56
|
| Rate for Payer: Blue Shield of California EPN |
$295.23
|
| Rate for Payer: Cash Price |
$259.48
|
| Rate for Payer: Cigna of CA HMO |
$403.64
|
| Rate for Payer: Cigna of CA PPO |
$403.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$230.65
|
| Rate for Payer: Galaxy Health WC |
$490.14
|
| Rate for Payer: Global Benefits Group Commercial |
$345.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$384.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$219.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$138.39
|
| Rate for Payer: Multiplan Commercial |
$461.30
|
| Rate for Payer: Networks By Design Commercial |
$374.81
|
| Rate for Payer: Prime Health Services Commercial |
$490.14
|
|
|
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 |
$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 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 |
$7.50 |
| Max. Negotiated Rate |
$26.56 |
| Rate for Payer: Aetna of CA HMO/PPO |
$20.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$26.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.62
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$18.75
|
| 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
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$26.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.62
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$18.75
|
| 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
|
$18,261.32
|
|
|
Service Code
|
APR-DRG 0973
|
| Min. Negotiated Rate |
$14,008.35 |
| Max. Negotiated Rate |
$18,261.32 |
| Rate for Payer: IEHP Medi-Cal |
$14,008.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,261.32
|
|
|
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: IEHP Medi-Cal |
$9,108.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11,873.31
|
|
|
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: IEHP Medi-Cal |
$6,285.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,193.39
|
|
|
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: IEHP Medi-Cal |
$32,175.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41,944.10
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: AlphaCare 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: IEHP Medi-Cal |
$6,516.76
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$6,516.76
|
| Rate for Payer: 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
|
|
