|
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
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
|
OP
|
$3.03
|
|
|
Service Code
|
NDC 59762-0047-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.86
|
| Rate for Payer: Cash Price |
$1.67
|
| 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 Medi-Cal |
$2.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.21
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$1.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.12
|
| 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: 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 |
$1.51
|
| Rate for Payer: United Healthcare All Other HMO |
$1.51
|
| Rate for Payer: United Healthcare HMO Rider |
$1.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.51
|
| 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
|
$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 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 27241-192-30
|
| 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 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]
|
Facility
|
IP
|
$7.71
|
|
|
Service Code
|
NDC 0093-7164-56
|
| 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: Blue Shield of California Commercial |
$5.69
|
| Rate for Payer: Blue Shield of California EPN |
$3.75
|
| 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: 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: 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 |
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
|
|
|
TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 27241-192-30
|
| 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
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
NDC 31722-868-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$47.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$39.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$44.22
|
| Rate for Payer: Cash Price |
$39.60
|
| 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 Medi-Cal |
$61.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$61.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.80
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$44.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$50.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$50.40
|
| 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: 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 31722-868-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Blue Shield of California Commercial |
$53.14
|
| Rate for Payer: Blue Shield of California EPN |
$34.99
|
| Rate for Payer: Cash Price |
$39.60
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$44.57
|
| 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
|
IP
|
$72.00
|
|
|
Service Code
|
NDC 31722-868-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Blue Shield of California Commercial |
$53.14
|
| Rate for Payer: Blue Shield of California EPN |
$34.99
|
| Rate for Payer: Cash Price |
$39.60
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$44.57
|
| 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 49884-768-52
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$47.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$39.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$44.22
|
| Rate for Payer: Cash Price |
$39.60
|
| 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 Medi-Cal |
$61.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$61.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.80
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$44.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$50.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$50.40
|
| 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: 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 49884-768-54
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Blue Shield of California Commercial |
$53.14
|
| Rate for Payer: Blue Shield of California EPN |
$34.99
|
| Rate for Payer: Cash Price |
$39.60
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$44.57
|
| 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
|
IP
|
$72.00
|
|
|
Service Code
|
NDC 49884-768-52
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Blue Shield of California Commercial |
$53.14
|
| Rate for Payer: Blue Shield of California EPN |
$34.99
|
| Rate for Payer: Cash Price |
$39.60
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$44.57
|
| 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 31722-868-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$47.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$39.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$44.22
|
| Rate for Payer: Cash Price |
$39.60
|
| 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 Medi-Cal |
$61.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$61.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.80
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$44.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$50.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$50.40
|
| 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: 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
|
OP
|
$72.00
|
|
|
Service Code
|
NDC 49884-768-54
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$47.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$39.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$44.22
|
| Rate for Payer: Cash Price |
$39.60
|
| 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 Medi-Cal |
$61.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$61.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.80
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$44.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$50.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$50.40
|
| 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: 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 30 MG TABLET [97894]
|
Facility
|
OP
|
$562.46
|
|
|
Service Code
|
NDC 60505-4318-0
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$112.49 |
| Max. Negotiated Rate |
$478.09 |
| Rate for Payer: Adventist Health Commercial |
$112.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$368.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$478.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$309.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$421.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$345.41
|
| Rate for Payer: Cash Price |
$309.35
|
| Rate for Payer: Cigna of CA HMO |
$393.72
|
| Rate for Payer: Cigna of CA PPO |
$393.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$478.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$478.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$478.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$224.98
|
| Rate for Payer: EPIC Health Plan Senior |
$224.98
|
| Rate for Payer: Galaxy Health WC |
$478.09
|
| Rate for Payer: Global Benefits Group Commercial |
$337.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$375.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$214.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$348.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$393.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$393.72
|
| Rate for Payer: Multiplan Commercial |
$449.97
|
| Rate for Payer: Networks By Design Commercial |
$365.60
|
| Rate for Payer: Prime Health Services Commercial |
$478.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$337.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$337.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$281.23
|
| Rate for Payer: United Healthcare All Other HMO |
$281.23
|
| Rate for Payer: United Healthcare HMO Rider |
$281.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$281.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$478.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$478.09
|
| Rate for Payer: Vantage Medical Group Senior |
$478.09
|
|
|
TOLVAPTAN 30 MG TABLET [97894]
|
Facility
|
OP
|
$576.63
|
|
|
Service Code
|
NDC 67877-636-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$115.33 |
| Max. Negotiated Rate |
$490.14 |
| Rate for Payer: Adventist Health Commercial |
$115.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$378.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$490.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$317.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$432.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$354.11
|
| Rate for Payer: Cash Price |
$317.15
|
| 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 Medi-Cal |
$490.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$490.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$230.65
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$356.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$138.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$403.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$403.64
|
| 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: 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 |
$288.31
|
| Rate for Payer: United Healthcare All Other HMO |
$288.31
|
| Rate for Payer: United Healthcare HMO Rider |
$288.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$288.31
|
| 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
|
$576.63
|
|
|
Service Code
|
NDC 67877-636-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$115.33 |
| Max. Negotiated Rate |
$490.14 |
| Rate for Payer: Adventist Health Commercial |
$115.33
|
| Rate for Payer: Blue Shield of California Commercial |
$425.55
|
| Rate for Payer: Blue Shield of California EPN |
$280.24
|
| Rate for Payer: Cash Price |
$317.15
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$356.93
|
| 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 30 MG TABLET [97894]
|
Facility
|
IP
|
$562.46
|
|
|
Service Code
|
NDC 60505-4318-0
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$112.49 |
| Max. Negotiated Rate |
$478.09 |
| Rate for Payer: Adventist Health Commercial |
$112.49
|
| Rate for Payer: Blue Shield of California Commercial |
$415.10
|
| Rate for Payer: Blue Shield of California EPN |
$273.36
|
| Rate for Payer: Cash Price |
$309.35
|
| Rate for Payer: Cigna of CA HMO |
$393.72
|
| Rate for Payer: Cigna of CA PPO |
$393.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$224.98
|
| Rate for Payer: EPIC Health Plan Senior |
$224.98
|
| Rate for Payer: Galaxy Health WC |
$478.09
|
| Rate for Payer: Global Benefits Group Commercial |
$337.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$375.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$214.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$348.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.99
|
| Rate for Payer: Multiplan Commercial |
$449.97
|
| Rate for Payer: Networks By Design Commercial |
$365.60
|
| Rate for Payer: Prime Health Services Commercial |
$478.09
|
|
|
TOLVAPTAN 30 MG TABLET [97894]
|
Facility
|
IP
|
$647.57
|
|
|
Service Code
|
NDC 59148-021-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$129.51 |
| Max. Negotiated Rate |
$550.43 |
| Rate for Payer: Adventist Health Commercial |
$129.51
|
| Rate for Payer: Blue Shield of California Commercial |
$477.91
|
| Rate for Payer: Blue Shield of California EPN |
$314.72
|
| Rate for Payer: Cash Price |
$356.16
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$400.85
|
| 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
|
OP
|
$647.57
|
|
|
Service Code
|
NDC 59148-021-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$129.51 |
| Max. Negotiated Rate |
$550.43 |
| Rate for Payer: Adventist Health Commercial |
$129.51
|
| Rate for Payer: Aetna of CA HMO/PPO |
$424.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$550.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$356.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$485.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$397.67
|
| Rate for Payer: Cash Price |
$356.16
|
| 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 Medi-Cal |
$550.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$550.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$259.03
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$400.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$453.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$453.30
|
| 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: 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 |
$323.79
|
| Rate for Payer: United Healthcare All Other HMO |
$323.79
|
| Rate for Payer: United Healthcare HMO Rider |
$323.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$323.79
|
| 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 ORAL SOLUTION CRUSHED TABLET 1 MG/ML [40801044]
|
Facility
|
IP
|
$31.25
|
|
|
Service Code
|
NDC 9940-8010-44
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$26.56 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Blue Shield of California Commercial |
$23.06
|
| Rate for Payer: Blue Shield of California EPN |
$15.19
|
| Rate for Payer: Cash Price |
$17.19
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$19.34
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$26.56 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| 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 |
$23.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.19
|
| Rate for Payer: Cash Price |
$17.19
|
| 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 Medi-Cal |
$26.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$26.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.50
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$19.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.88
|
| 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
|
|
|
TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 3 MG/ML [4081044]
|
Facility
|
OP
|
$31.25
|
|
|
Service Code
|
NDC 9994-0810-44
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$26.56 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| 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 |
$23.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.19
|
| Rate for Payer: Cash Price |
$17.19
|
| 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 Medi-Cal |
$26.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$26.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.50
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$19.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.88
|
| 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
|
|
|
TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 3 MG/ML [4081044]
|
Facility
|
IP
|
$31.25
|
|
|
Service Code
|
NDC 9994-0810-44
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$26.56 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Blue Shield of California Commercial |
$23.06
|
| Rate for Payer: Blue Shield of California EPN |
$15.19
|
| Rate for Payer: Cash Price |
$17.19
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$19.34
|
| 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
|
|
