|
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION [108062]
|
Facility
|
OP
|
$159.35
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$135.45 |
| Rate for Payer: Adventist Health Commercial |
$31.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$104.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.04
|
| Rate for Payer: Blue Shield of California Commercial |
$7.97
|
| Rate for Payer: Blue Shield of California EPN |
$7.97
|
| Rate for Payer: Cash Price |
$87.64
|
| Rate for Payer: Cash Price |
$87.64
|
| Rate for Payer: Cigna of CA HMO |
$111.55
|
| Rate for Payer: Cigna of CA PPO |
$111.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.81
|
| Rate for Payer: EPIC Health Plan Senior |
$5.79
|
| Rate for Payer: Galaxy Health WC |
$135.45
|
| Rate for Payer: Global Benefits Group Commercial |
$95.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$106.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.75
|
| Rate for Payer: Multiplan Commercial |
$127.48
|
| Rate for Payer: Networks By Design Commercial |
$79.67
|
| Rate for Payer: Prime Health Services Commercial |
$135.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$95.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$95.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$59.80
|
| Rate for Payer: United Healthcare All Other HMO |
$58.21
|
| Rate for Payer: United Healthcare HMO Rider |
$56.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.19
|
| Rate for Payer: Upland Medical Group Pediatric |
$5.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.36
|
| Rate for Payer: Vantage Medical Group Senior |
$6.36
|
|
|
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION [108062]
|
Facility
|
IP
|
$159.35
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.87 |
| Max. Negotiated Rate |
$135.45 |
| Rate for Payer: Adventist Health Commercial |
$31.87
|
| Rate for Payer: Blue Shield of California Commercial |
$117.60
|
| Rate for Payer: Blue Shield of California EPN |
$77.44
|
| Rate for Payer: Cash Price |
$87.64
|
| Rate for Payer: Cigna of CA HMO |
$111.55
|
| Rate for Payer: Cigna of CA PPO |
$111.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.74
|
| Rate for Payer: EPIC Health Plan Senior |
$63.74
|
| Rate for Payer: Galaxy Health WC |
$135.45
|
| Rate for Payer: Global Benefits Group Commercial |
$95.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$106.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$98.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.24
|
| Rate for Payer: Multiplan Commercial |
$127.48
|
| Rate for Payer: Networks By Design Commercial |
$79.67
|
| Rate for Payer: Prime Health Services Commercial |
$135.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$59.80
|
| Rate for Payer: United Healthcare All Other HMO |
$58.21
|
| Rate for Payer: United Healthcare HMO Rider |
$56.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.19
|
|
|
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [108061]
|
Facility
|
IP
|
$159.35
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.87 |
| Max. Negotiated Rate |
$135.45 |
| Rate for Payer: Adventist Health Commercial |
$31.87
|
| Rate for Payer: Blue Shield of California Commercial |
$117.60
|
| Rate for Payer: Blue Shield of California EPN |
$77.44
|
| Rate for Payer: Cash Price |
$87.64
|
| Rate for Payer: Cigna of CA HMO |
$111.55
|
| Rate for Payer: Cigna of CA PPO |
$111.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.74
|
| Rate for Payer: EPIC Health Plan Senior |
$63.74
|
| Rate for Payer: Galaxy Health WC |
$135.45
|
| Rate for Payer: Global Benefits Group Commercial |
$95.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$106.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$98.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.24
|
| Rate for Payer: Multiplan Commercial |
$127.48
|
| Rate for Payer: Networks By Design Commercial |
$79.67
|
| Rate for Payer: Prime Health Services Commercial |
$135.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$59.80
|
| Rate for Payer: United Healthcare All Other HMO |
$58.21
|
| Rate for Payer: United Healthcare HMO Rider |
$56.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.19
|
|
|
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [108061]
|
Facility
|
OP
|
$159.35
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$135.45 |
| Rate for Payer: Adventist Health Commercial |
$31.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$104.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.04
|
| Rate for Payer: Blue Shield of California Commercial |
$7.97
|
| Rate for Payer: Blue Shield of California EPN |
$7.97
|
| Rate for Payer: Cash Price |
$87.64
|
| Rate for Payer: Cash Price |
$87.64
|
| Rate for Payer: Cigna of CA HMO |
$111.55
|
| Rate for Payer: Cigna of CA PPO |
$111.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.81
|
| Rate for Payer: EPIC Health Plan Senior |
$5.79
|
| Rate for Payer: Galaxy Health WC |
$135.45
|
| Rate for Payer: Global Benefits Group Commercial |
$95.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$106.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.75
|
| Rate for Payer: Multiplan Commercial |
$127.48
|
| Rate for Payer: Networks By Design Commercial |
$79.67
|
| Rate for Payer: Prime Health Services Commercial |
$135.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$95.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$95.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$59.80
|
| Rate for Payer: United Healthcare All Other HMO |
$58.21
|
| Rate for Payer: United Healthcare HMO Rider |
$56.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.19
|
| Rate for Payer: Upland Medical Group Pediatric |
$5.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.36
|
| Rate for Payer: Vantage Medical Group Senior |
$6.36
|
|
|
TOCILIZUMAB-AAZG 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION [241038]
|
Facility
|
IP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$99.88 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Blue Shield of California Commercial |
$86.72
|
| Rate for Payer: Blue Shield of California EPN |
$57.10
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cigna of CA HMO |
$82.25
|
| Rate for Payer: Cigna of CA PPO |
$82.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.00
|
| Rate for Payer: EPIC Health Plan Senior |
$47.00
|
| Rate for Payer: Galaxy Health WC |
$99.88
|
| Rate for Payer: Global Benefits Group Commercial |
$70.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$72.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.20
|
| Rate for Payer: Multiplan Commercial |
$94.00
|
| Rate for Payer: Networks By Design Commercial |
$58.75
|
| Rate for Payer: Prime Health Services Commercial |
$99.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.10
|
| Rate for Payer: United Healthcare All Other HMO |
$42.92
|
| Rate for Payer: United Healthcare HMO Rider |
$41.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.48
|
|
|
TOCILIZUMAB-AAZG 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION [241038]
|
Facility
|
OP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.07 |
| Max. Negotiated Rate |
$99.88 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$77.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.11
|
| Rate for Payer: Blue Shield of California Commercial |
$5.79
|
| Rate for Payer: Blue Shield of California EPN |
$5.79
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cigna of CA HMO |
$82.25
|
| Rate for Payer: Cigna of CA PPO |
$82.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.33
|
| Rate for Payer: EPIC Health Plan Senior |
$4.69
|
| Rate for Payer: Galaxy Health WC |
$99.88
|
| Rate for Payer: Global Benefits Group Commercial |
$70.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.28
|
| Rate for Payer: Multiplan Commercial |
$94.00
|
| Rate for Payer: Networks By Design Commercial |
$58.75
|
| Rate for Payer: Prime Health Services Commercial |
$99.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.10
|
| Rate for Payer: United Healthcare All Other HMO |
$42.92
|
| Rate for Payer: United Healthcare HMO Rider |
$41.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.48
|
| Rate for Payer: Upland Medical Group Pediatric |
$4.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Vantage Medical Group Senior |
$5.16
|
|
|
TOCILIZUMAB-AAZG 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION [241039]
|
Facility
|
IP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$99.88 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Blue Shield of California Commercial |
$86.72
|
| Rate for Payer: Blue Shield of California EPN |
$57.10
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cigna of CA HMO |
$82.25
|
| Rate for Payer: Cigna of CA PPO |
$82.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.00
|
| Rate for Payer: EPIC Health Plan Senior |
$47.00
|
| Rate for Payer: Galaxy Health WC |
$99.88
|
| Rate for Payer: Global Benefits Group Commercial |
$70.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$72.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.20
|
| Rate for Payer: Multiplan Commercial |
$94.00
|
| Rate for Payer: Networks By Design Commercial |
$58.75
|
| Rate for Payer: Prime Health Services Commercial |
$99.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.10
|
| Rate for Payer: United Healthcare All Other HMO |
$42.92
|
| Rate for Payer: United Healthcare HMO Rider |
$41.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.48
|
|
|
TOCILIZUMAB-AAZG 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION [241039]
|
Facility
|
OP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.07 |
| Max. Negotiated Rate |
$99.88 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$77.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.11
|
| Rate for Payer: Blue Shield of California Commercial |
$5.79
|
| Rate for Payer: Blue Shield of California EPN |
$5.79
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cigna of CA HMO |
$82.25
|
| Rate for Payer: Cigna of CA PPO |
$82.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.33
|
| Rate for Payer: EPIC Health Plan Senior |
$4.69
|
| Rate for Payer: Galaxy Health WC |
$99.88
|
| Rate for Payer: Global Benefits Group Commercial |
$70.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.28
|
| Rate for Payer: Multiplan Commercial |
$94.00
|
| Rate for Payer: Networks By Design Commercial |
$58.75
|
| Rate for Payer: Prime Health Services Commercial |
$99.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.10
|
| Rate for Payer: United Healthcare All Other HMO |
$42.92
|
| Rate for Payer: United Healthcare HMO Rider |
$41.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.48
|
| Rate for Payer: Upland Medical Group Pediatric |
$4.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Vantage Medical Group Senior |
$5.16
|
|
|
TOCILIZUMAB-AAZG 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [241037]
|
Facility
|
OP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.07 |
| Max. Negotiated Rate |
$99.88 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$77.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.11
|
| Rate for Payer: Blue Shield of California Commercial |
$5.79
|
| Rate for Payer: Blue Shield of California EPN |
$5.79
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cigna of CA HMO |
$82.25
|
| Rate for Payer: Cigna of CA PPO |
$82.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.33
|
| Rate for Payer: EPIC Health Plan Senior |
$4.69
|
| Rate for Payer: Galaxy Health WC |
$99.88
|
| Rate for Payer: Global Benefits Group Commercial |
$70.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.28
|
| Rate for Payer: Multiplan Commercial |
$94.00
|
| Rate for Payer: Networks By Design Commercial |
$58.75
|
| Rate for Payer: Prime Health Services Commercial |
$99.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.10
|
| Rate for Payer: United Healthcare All Other HMO |
$42.92
|
| Rate for Payer: United Healthcare HMO Rider |
$41.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.48
|
| Rate for Payer: Upland Medical Group Pediatric |
$4.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Vantage Medical Group Senior |
$5.16
|
|
|
TOCILIZUMAB-AAZG 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [241037]
|
Facility
|
IP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$99.88 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Blue Shield of California Commercial |
$86.72
|
| Rate for Payer: Blue Shield of California EPN |
$57.10
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cigna of CA HMO |
$82.25
|
| Rate for Payer: Cigna of CA PPO |
$82.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.00
|
| Rate for Payer: EPIC Health Plan Senior |
$47.00
|
| Rate for Payer: Galaxy Health WC |
$99.88
|
| Rate for Payer: Global Benefits Group Commercial |
$70.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$72.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.20
|
| Rate for Payer: Multiplan Commercial |
$94.00
|
| Rate for Payer: Networks By Design Commercial |
$58.75
|
| Rate for Payer: Prime Health Services Commercial |
$99.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.10
|
| Rate for Payer: United Healthcare All Other HMO |
$42.92
|
| Rate for Payer: United Healthcare HMO Rider |
$41.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.48
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 24385-032-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| 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 |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| 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 Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| 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
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 24385-032-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| 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 |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| 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
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 51672-2020-2
|
| Hospital Charge Code |
901700029
|
|
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: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 51672-2020-2
|
| Hospital Charge Code |
901700029
|
|
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 HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
|
IP
|
$3.18
|
|
|
Service Code
|
NDC 0093-0010-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.35
|
| Rate for Payer: Blue Shield of California EPN |
$1.55
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: Cigna of CA HMO |
$2.23
|
| Rate for Payer: Cigna of CA PPO |
$2.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.27
|
| Rate for Payer: EPIC Health Plan Senior |
$1.27
|
| Rate for Payer: Galaxy Health WC |
$2.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
| Rate for Payer: Networks By Design Commercial |
$2.07
|
| Rate for Payer: Prime Health Services Commercial |
$2.70
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 33342-097-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
|
OP
|
$3.18
|
|
|
Service Code
|
NDC 0093-0010-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.95
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: Cigna of CA HMO |
$2.23
|
| Rate for Payer: Cigna of CA PPO |
$2.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.27
|
| Rate for Payer: EPIC Health Plan Senior |
$1.27
|
| Rate for Payer: Galaxy Health WC |
$2.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.23
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
| Rate for Payer: Networks By Design Commercial |
$2.07
|
| Rate for Payer: Prime Health Services Commercial |
$2.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.59
|
| Rate for Payer: United Healthcare All Other HMO |
$1.59
|
| Rate for Payer: United Healthcare HMO Rider |
$1.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.70
|
| Rate for Payer: Vantage Medical Group Senior |
$2.70
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 33342-097-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 33342-098-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 33342-098-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 31722-806-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 31722-806-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 27241-191-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.89
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.66
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.74
|
| 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
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 27241-191-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| 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 |
$0.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.74
|
| Rate for Payer: Cash Price |
$0.66
|
| 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 Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| 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
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
|
OP
|
$7.71
|
|
|
Service Code
|
NDC 0093-7163-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$6.55 |
| Rate for Payer: Adventist Health Commercial |
$1.54
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.73
|
| Rate for Payer: Cash Price |
$4.24
|
| 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 Medi-Cal |
$6.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.08
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$4.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.40
|
| 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: 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 |
$3.85
|
| Rate for Payer: United Healthcare All Other HMO |
$3.85
|
| Rate for Payer: United Healthcare HMO Rider |
$3.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.85
|
| 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
|
|
