|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
|
IP
|
$7.71
|
|
|
Service Code
|
NDC 0093716356
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$6.94 |
| Rate for Payer: Adventist Health Commercial |
$1.54
|
| Rate for Payer: Blue Shield of California Commercial |
$6.18
|
| Rate for Payer: Blue Shield of California EPN |
$3.89
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Central Health Plan Commercial |
$6.17
|
| Rate for Payer: Cigna of CA HMO |
$5.40
|
| Rate for Payer: Cigna of CA PPO |
$5.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$6.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.54
|
| Rate for Payer: Multiplan Commercial |
$5.78
|
| Rate for Payer: Networks By Design Commercial |
$5.01
|
| Rate for Payer: Prime Health Services Commercial |
$6.55
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 2724119130
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.48
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
| Rate for Payer: Riverside University Health System MISP |
$0.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.30
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
|
OP
|
$3.03
|
|
|
Service Code
|
NDC 5976200471
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.73 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.84
|
| 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 Exchange |
$1.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.76
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Blue Shield of California EPN |
$1.21
|
| Rate for Payer: Cash Price |
$1.36
|
| Rate for Payer: Central Health Plan Commercial |
$2.42
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.12
|
| 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: Health Management Network EPO/PPO |
$2.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.12
|
| Rate for Payer: Multiplan Commercial |
$2.27
|
| Rate for Payer: Networks By Design Commercial |
$1.97
|
| Rate for Payer: Prime Health Services Commercial |
$2.58
|
| Rate for Payer: Riverside University Health System MISP |
$1.21
|
| 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
|
$3.03
|
|
|
Service Code
|
NDC 5976200471
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.73 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$2.43
|
| Rate for Payer: Blue Shield of California EPN |
$1.53
|
| Rate for Payer: Cash Price |
$1.36
|
| Rate for Payer: Central Health Plan Commercial |
$2.42
|
| Rate for Payer: Cigna of CA HMO |
$2.12
|
| Rate for Payer: Cigna of CA PPO |
$2.12
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.12
|
| 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: Health Management Network EPO/PPO |
$2.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.27
|
| Rate for Payer: Networks By Design Commercial |
$1.97
|
| Rate for Payer: Prime Health Services Commercial |
$2.58
|
|
|
TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 2724119230
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.48
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
| Rate for Payer: Riverside University Health System MISP |
$0.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.30
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]
|
Facility
|
OP
|
$7.71
|
|
|
Service Code
|
NDC 0093716456
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$6.94 |
| Rate for Payer: Adventist Health Commercial |
$1.54
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.68
|
| 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 Exchange |
$3.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.48
|
| Rate for Payer: Blue Shield of California Commercial |
$4.89
|
| Rate for Payer: Blue Shield of California EPN |
$3.08
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Central Health Plan Commercial |
$6.17
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$6.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.40
|
| Rate for Payer: Multiplan Commercial |
$5.78
|
| Rate for Payer: Networks By Design Commercial |
$5.01
|
| Rate for Payer: Prime Health Services Commercial |
$6.55
|
| Rate for Payer: Riverside University Health System MISP |
$3.08
|
| 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
|
$0.60
|
|
|
Service Code
|
NDC 2724119230
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.48
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
|
|
TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]
|
Facility
|
IP
|
$7.71
|
|
|
Service Code
|
NDC 0093716456
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$6.94 |
| Rate for Payer: Adventist Health Commercial |
$1.54
|
| Rate for Payer: Blue Shield of California Commercial |
$6.18
|
| Rate for Payer: Blue Shield of California EPN |
$3.89
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Central Health Plan Commercial |
$6.17
|
| Rate for Payer: Cigna of CA HMO |
$5.40
|
| Rate for Payer: Cigna of CA PPO |
$5.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$6.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.54
|
| Rate for Payer: Multiplan Commercial |
$5.78
|
| Rate for Payer: Networks By Design Commercial |
$5.01
|
| Rate for Payer: Prime Health Services Commercial |
$6.55
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
NDC 4988476854
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Blue Shield of California Commercial |
$57.74
|
| Rate for Payer: Blue Shield of California EPN |
$36.29
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Central Health Plan Commercial |
$57.60
|
| Rate for Payer: Cigna of CA HMO |
$50.40
|
| Rate for Payer: Cigna of CA PPO |
$50.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$64.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$45.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$42.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.40
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| 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 3172286831
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$43.73
|
| 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 Exchange |
$34.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$41.88
|
| Rate for Payer: Blue Shield of California Commercial |
$45.65
|
| Rate for Payer: Blue Shield of California EPN |
$28.73
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Central Health Plan Commercial |
$57.60
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$64.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$45.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$42.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$50.40
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: Networks By Design Commercial |
$46.80
|
| Rate for Payer: Prime Health Services Commercial |
$61.20
|
| Rate for Payer: Riverside University Health System MISP |
$28.80
|
| 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 3172286831
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Blue Shield of California Commercial |
$57.74
|
| Rate for Payer: Blue Shield of California EPN |
$36.29
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Central Health Plan Commercial |
$57.60
|
| Rate for Payer: Cigna of CA HMO |
$50.40
|
| Rate for Payer: Cigna of CA PPO |
$50.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$64.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$45.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$42.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.40
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| 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 3172286803
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Blue Shield of California Commercial |
$57.74
|
| Rate for Payer: Blue Shield of California EPN |
$36.29
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Central Health Plan Commercial |
$57.60
|
| Rate for Payer: Cigna of CA HMO |
$50.40
|
| Rate for Payer: Cigna of CA PPO |
$50.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$64.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$45.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$42.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.40
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| 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 3172286803
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$43.73
|
| 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 Exchange |
$34.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$41.88
|
| Rate for Payer: Blue Shield of California Commercial |
$45.65
|
| Rate for Payer: Blue Shield of California EPN |
$28.73
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Central Health Plan Commercial |
$57.60
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$64.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$45.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$42.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$50.40
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: Networks By Design Commercial |
$46.80
|
| Rate for Payer: Prime Health Services Commercial |
$61.20
|
| Rate for Payer: Riverside University Health System MISP |
$28.80
|
| 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 4988476852
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Blue Shield of California Commercial |
$57.74
|
| Rate for Payer: Blue Shield of California EPN |
$36.29
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Central Health Plan Commercial |
$57.60
|
| Rate for Payer: Cigna of CA HMO |
$50.40
|
| Rate for Payer: Cigna of CA PPO |
$50.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$64.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$45.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$42.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.40
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| 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 4988476854
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$43.73
|
| 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 Exchange |
$34.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$41.88
|
| Rate for Payer: Blue Shield of California Commercial |
$45.65
|
| Rate for Payer: Blue Shield of California EPN |
$28.73
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Central Health Plan Commercial |
$57.60
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$64.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$45.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$42.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$50.40
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: Networks By Design Commercial |
$46.80
|
| Rate for Payer: Prime Health Services Commercial |
$61.20
|
| Rate for Payer: Riverside University Health System MISP |
$28.80
|
| 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 4988476852
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$43.73
|
| 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 Exchange |
$34.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$41.88
|
| Rate for Payer: Blue Shield of California Commercial |
$45.65
|
| Rate for Payer: Blue Shield of California EPN |
$28.73
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Central Health Plan Commercial |
$57.60
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$64.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$45.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$42.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$50.40
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: Networks By Design Commercial |
$46.80
|
| Rate for Payer: Prime Health Services Commercial |
$61.20
|
| Rate for Payer: Riverside University Health System MISP |
$28.80
|
| 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
|
IP
|
$144.72
|
|
|
Service Code
|
NDC 6787763633
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.94 |
| Max. Negotiated Rate |
$130.25 |
| Rate for Payer: Adventist Health Commercial |
$28.94
|
| Rate for Payer: Blue Shield of California Commercial |
$116.07
|
| Rate for Payer: Blue Shield of California EPN |
$72.94
|
| Rate for Payer: Cash Price |
$65.12
|
| Rate for Payer: Central Health Plan Commercial |
$115.78
|
| Rate for Payer: Cigna of CA HMO |
$101.30
|
| Rate for Payer: Cigna of CA PPO |
$101.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$101.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.89
|
| Rate for Payer: EPIC Health Plan Senior |
$57.89
|
| Rate for Payer: Galaxy Health WC |
$123.01
|
| Rate for Payer: Global Benefits Group Commercial |
$86.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$130.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$91.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$85.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.94
|
| Rate for Payer: Multiplan Commercial |
$108.54
|
| Rate for Payer: Networks By Design Commercial |
$94.07
|
| Rate for Payer: Prime Health Services Commercial |
$123.01
|
|
|
TOLVAPTAN 30 MG TABLET [97894]
|
Facility
|
OP
|
$144.72
|
|
|
Service Code
|
NDC 6787763602
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.94 |
| Max. Negotiated Rate |
$130.25 |
| Rate for Payer: Adventist Health Commercial |
$28.94
|
| Rate for Payer: Aetna of CA HMO/PPO |
$87.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$123.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$79.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$108.54
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$70.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$84.18
|
| Rate for Payer: Blue Shield of California Commercial |
$91.75
|
| Rate for Payer: Blue Shield of California EPN |
$57.74
|
| Rate for Payer: Cash Price |
$65.12
|
| Rate for Payer: Central Health Plan Commercial |
$115.78
|
| Rate for Payer: Cigna of CA HMO |
$101.30
|
| Rate for Payer: Cigna of CA PPO |
$101.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$123.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$123.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$123.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$101.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.89
|
| Rate for Payer: EPIC Health Plan Senior |
$57.89
|
| Rate for Payer: Galaxy Health WC |
$123.01
|
| Rate for Payer: Global Benefits Group Commercial |
$86.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$130.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$91.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$52.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$85.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$101.30
|
| Rate for Payer: Multiplan Commercial |
$108.54
|
| Rate for Payer: Networks By Design Commercial |
$94.07
|
| Rate for Payer: Prime Health Services Commercial |
$123.01
|
| Rate for Payer: Riverside University Health System MISP |
$57.89
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$86.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$86.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$72.36
|
| Rate for Payer: United Healthcare All Other HMO |
$72.36
|
| Rate for Payer: United Healthcare HMO Rider |
$72.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$123.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$123.01
|
| Rate for Payer: Vantage Medical Group Senior |
$123.01
|
|
|
TOLVAPTAN 30 MG TABLET [97894]
|
Facility
|
IP
|
$562.46
|
|
|
Service Code
|
NDC 6050543180
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$112.49 |
| Max. Negotiated Rate |
$506.21 |
| Rate for Payer: Adventist Health Commercial |
$112.49
|
| Rate for Payer: Blue Shield of California Commercial |
$451.09
|
| Rate for Payer: Blue Shield of California EPN |
$283.48
|
| Rate for Payer: Cash Price |
$253.11
|
| Rate for Payer: Central Health Plan Commercial |
$449.97
|
| Rate for Payer: Cigna of CA HMO |
$393.72
|
| Rate for Payer: Cigna of CA PPO |
$393.72
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$506.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$357.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$331.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$112.49
|
| Rate for Payer: Multiplan Commercial |
$421.85
|
| Rate for Payer: Networks By Design Commercial |
$365.60
|
| Rate for Payer: Prime Health Services Commercial |
$478.09
|
|
|
TOLVAPTAN 30 MG TABLET [97894]
|
Facility
|
OP
|
$562.46
|
|
|
Service Code
|
NDC 6050543180
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$112.49 |
| Max. Negotiated Rate |
$506.21 |
| Rate for Payer: Adventist Health Commercial |
$112.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$341.58
|
| 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 Exchange |
$272.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$327.18
|
| Rate for Payer: Blue Shield of California Commercial |
$356.60
|
| Rate for Payer: Blue Shield of California EPN |
$224.42
|
| Rate for Payer: Cash Price |
$253.11
|
| Rate for Payer: Central Health Plan Commercial |
$449.97
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$506.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$357.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$204.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$331.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$112.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$393.72
|
| Rate for Payer: Multiplan Commercial |
$421.85
|
| Rate for Payer: Networks By Design Commercial |
$365.60
|
| Rate for Payer: Prime Health Services Commercial |
$478.09
|
| Rate for Payer: Riverside University Health System MISP |
$224.98
|
| 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
|
IP
|
$144.72
|
|
|
Service Code
|
NDC 6787763602
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.94 |
| Max. Negotiated Rate |
$130.25 |
| Rate for Payer: Adventist Health Commercial |
$28.94
|
| Rate for Payer: Blue Shield of California Commercial |
$116.07
|
| Rate for Payer: Blue Shield of California EPN |
$72.94
|
| Rate for Payer: Cash Price |
$65.12
|
| Rate for Payer: Central Health Plan Commercial |
$115.78
|
| Rate for Payer: Cigna of CA HMO |
$101.30
|
| Rate for Payer: Cigna of CA PPO |
$101.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$101.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.89
|
| Rate for Payer: EPIC Health Plan Senior |
$57.89
|
| Rate for Payer: Galaxy Health WC |
$123.01
|
| Rate for Payer: Global Benefits Group Commercial |
$86.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$130.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$91.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$85.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.94
|
| Rate for Payer: Multiplan Commercial |
$108.54
|
| Rate for Payer: Networks By Design Commercial |
$94.07
|
| Rate for Payer: Prime Health Services Commercial |
$123.01
|
|
|
TOLVAPTAN 30 MG TABLET [97894]
|
Facility
|
OP
|
$144.72
|
|
|
Service Code
|
NDC 6787763633
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.94 |
| Max. Negotiated Rate |
$130.25 |
| Rate for Payer: Adventist Health Commercial |
$28.94
|
| Rate for Payer: Aetna of CA HMO/PPO |
$87.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$123.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$79.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$108.54
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$70.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$84.18
|
| Rate for Payer: Blue Shield of California Commercial |
$91.75
|
| Rate for Payer: Blue Shield of California EPN |
$57.74
|
| Rate for Payer: Cash Price |
$65.12
|
| Rate for Payer: Central Health Plan Commercial |
$115.78
|
| Rate for Payer: Cigna of CA HMO |
$101.30
|
| Rate for Payer: Cigna of CA PPO |
$101.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$123.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$123.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$123.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$101.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.89
|
| Rate for Payer: EPIC Health Plan Senior |
$57.89
|
| Rate for Payer: Galaxy Health WC |
$123.01
|
| Rate for Payer: Global Benefits Group Commercial |
$86.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$130.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$91.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$52.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$85.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$101.30
|
| Rate for Payer: Multiplan Commercial |
$108.54
|
| Rate for Payer: Networks By Design Commercial |
$94.07
|
| Rate for Payer: Prime Health Services Commercial |
$123.01
|
| Rate for Payer: Riverside University Health System MISP |
$57.89
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$86.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$86.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$72.36
|
| Rate for Payer: United Healthcare All Other HMO |
$72.36
|
| Rate for Payer: United Healthcare HMO Rider |
$72.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$123.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$123.01
|
| Rate for Payer: Vantage Medical Group Senior |
$123.01
|
|
|
TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 1 MG/ML [40801044]
|
Facility
|
IP
|
$31.25
|
|
|
Service Code
|
NDC 9940801044
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$28.12 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Blue Shield of California Commercial |
$25.06
|
| Rate for Payer: Blue Shield of California EPN |
$15.75
|
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Central Health Plan Commercial |
$25.00
|
| Rate for Payer: Cigna of CA HMO |
$21.88
|
| Rate for Payer: Cigna of CA PPO |
$21.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$28.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$19.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.25
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
| 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 9940801044
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$28.12 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$18.98
|
| 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 Exchange |
$15.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.18
|
| Rate for Payer: Blue Shield of California Commercial |
$19.81
|
| Rate for Payer: Blue Shield of California EPN |
$12.47
|
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Central Health Plan Commercial |
$25.00
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$28.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$19.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$21.88
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
| Rate for Payer: Networks By Design Commercial |
$20.31
|
| Rate for Payer: Prime Health Services Commercial |
$26.56
|
| Rate for Payer: Riverside University Health System MISP |
$12.50
|
| 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 9994081044
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$28.12 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Blue Shield of California Commercial |
$25.06
|
| Rate for Payer: Blue Shield of California EPN |
$15.75
|
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Central Health Plan Commercial |
$25.00
|
| Rate for Payer: Cigna of CA HMO |
$21.88
|
| Rate for Payer: Cigna of CA PPO |
$21.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$28.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$19.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.25
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
| Rate for Payer: Networks By Design Commercial |
$20.31
|
| Rate for Payer: Prime Health Services Commercial |
$26.56
|
|
