|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
|
IP
|
$7.71
|
|
|
Service Code
|
NDC 0093-7163-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$6.94 |
| Rate for Payer: Adventist Health Commercial |
$1.54
|
| Rate for Payer: Blue Shield of California Commercial |
$5.96
|
| Rate for Payer: Blue Shield of California EPN |
$3.89
|
| Rate for Payer: Cash Price |
$4.24
|
| 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: 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 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 |
$1.54
|
| 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
|
IP
|
$3.03
|
|
|
Service Code
|
NDC 59762-0047-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.73 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$2.34
|
| Rate for Payer: Blue Shield of California EPN |
$1.53
|
| Rate for Payer: Cash Price |
$1.67
|
| 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: 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 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 |
$0.61
|
| 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
|
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 |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$0.96
|
| 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: Health Management Network EPO/PPO |
$1.08
|
| 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 |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| 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
|
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 |
$6.94 |
| Rate for Payer: Adventist Health Commercial |
$1.54
|
| Rate for Payer: Blue Shield of California Commercial |
$5.96
|
| Rate for Payer: Blue Shield of California EPN |
$3.89
|
| Rate for Payer: Cash Price |
$4.24
|
| 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: 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 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 |
$1.54
|
| 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 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 |
$6.94 |
| 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 |
$4.53
|
| Rate for Payer: Blue Shield of California Commercial |
$4.71
|
| Rate for Payer: Blue Shield of California EPN |
$3.08
|
| Rate for Payer: Cash Price |
$4.24
|
| 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: 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: InnovAge PACE Commercial |
$3.85
|
| 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 |
$1.54
|
| 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 |
$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
|
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 |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.73
|
| 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 Exchange |
$0.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$0.96
|
| 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: Health Management Network EPO/PPO |
$1.08
|
| Rate for Payer: InnovAge PACE Commercial |
$0.60
|
| 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 |
$0.24
|
| 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 |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Riverside University Health System MISP |
$0.48
|
| 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
|
|
|
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 |
$64.80 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Blue Shield of California Commercial |
$55.66
|
| Rate for Payer: Blue Shield of California EPN |
$36.29
|
| Rate for Payer: Cash Price |
$39.60
|
| 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: 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 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 |
$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 49884-768-54
|
| 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 |
$42.29
|
| Rate for Payer: Blue Shield of California Commercial |
$43.99
|
| Rate for Payer: Blue Shield of California EPN |
$28.73
|
| Rate for Payer: Cash Price |
$39.60
|
| 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: 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: InnovAge PACE Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$48.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$44.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.40
|
| 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 |
$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 49884-768-52
|
| 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 |
$42.29
|
| Rate for Payer: Blue Shield of California Commercial |
$43.99
|
| Rate for Payer: Blue Shield of California EPN |
$28.73
|
| Rate for Payer: Cash Price |
$39.60
|
| 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: 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: InnovAge PACE Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$48.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$44.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.40
|
| 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 |
$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 31722-868-31
|
| 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 |
$55.66
|
| Rate for Payer: Blue Shield of California EPN |
$36.29
|
| Rate for Payer: Cash Price |
$39.60
|
| 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: 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 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 |
$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 49884-768-54
|
| 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 |
$55.66
|
| Rate for Payer: Blue Shield of California EPN |
$36.29
|
| Rate for Payer: Cash Price |
$39.60
|
| 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: 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 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 |
$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 31722-868-03
|
| 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 |
$42.29
|
| Rate for Payer: Blue Shield of California Commercial |
$43.99
|
| Rate for Payer: Blue Shield of California EPN |
$28.73
|
| Rate for Payer: Cash Price |
$39.60
|
| 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: 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: InnovAge PACE Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$48.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$44.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.40
|
| 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 |
$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 49884-768-52
|
| 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 |
$55.66
|
| Rate for Payer: Blue Shield of California EPN |
$36.29
|
| Rate for Payer: Cash Price |
$39.60
|
| 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: 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 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 |
$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 31722-868-31
|
| 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 |
$42.29
|
| Rate for Payer: Blue Shield of California Commercial |
$43.99
|
| Rate for Payer: Blue Shield of California EPN |
$28.73
|
| Rate for Payer: Cash Price |
$39.60
|
| 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: 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: InnovAge PACE Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$48.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$44.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.40
|
| 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 |
$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
|
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 |
$518.97 |
| Rate for Payer: Adventist Health Commercial |
$115.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$350.19
|
| 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 Exchange |
$279.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$338.65
|
| Rate for Payer: Blue Shield of California Commercial |
$352.32
|
| Rate for Payer: Blue Shield of California EPN |
$230.08
|
| Rate for Payer: Cash Price |
$317.15
|
| Rate for Payer: Central Health Plan Commercial |
$461.30
|
| 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: Health Management Network EPO/PPO |
$518.97
|
| Rate for Payer: InnovAge PACE Commercial |
$288.31
|
| 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 |
$115.33
|
| 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 |
$432.47
|
| Rate for Payer: Networks By Design Commercial |
$374.81
|
| Rate for Payer: Prime Health Services Commercial |
$490.14
|
| Rate for Payer: Riverside University Health System MISP |
$230.65
|
| 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
|
$647.57
|
|
|
Service Code
|
NDC 59148-021-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$129.51 |
| Max. Negotiated Rate |
$582.81 |
| Rate for Payer: Adventist Health Commercial |
$129.51
|
| Rate for Payer: Blue Shield of California Commercial |
$500.57
|
| Rate for Payer: Blue Shield of California EPN |
$326.38
|
| Rate for Payer: Cash Price |
$356.16
|
| Rate for Payer: Central Health Plan Commercial |
$518.06
|
| 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: Health Management Network EPO/PPO |
$582.81
|
| 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 |
$129.51
|
| Rate for Payer: Multiplan Commercial |
$485.68
|
| 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 |
$582.81 |
| Rate for Payer: Adventist Health Commercial |
$129.51
|
| Rate for Payer: Aetna of CA HMO/PPO |
$393.27
|
| 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 Exchange |
$313.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$380.32
|
| Rate for Payer: Blue Shield of California Commercial |
$395.67
|
| Rate for Payer: Blue Shield of California EPN |
$258.38
|
| Rate for Payer: Cash Price |
$356.16
|
| Rate for Payer: Central Health Plan Commercial |
$518.06
|
| 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: Health Management Network EPO/PPO |
$582.81
|
| Rate for Payer: InnovAge PACE Commercial |
$323.79
|
| 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 |
$129.51
|
| 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 |
$485.68
|
| Rate for Payer: Networks By Design Commercial |
$420.92
|
| Rate for Payer: Prime Health Services Commercial |
$550.43
|
| Rate for Payer: Riverside University Health System MISP |
$259.03
|
| 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 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 |
$506.21 |
| Rate for Payer: Adventist Health Commercial |
$112.49
|
| Rate for Payer: Blue Shield of California Commercial |
$434.78
|
| Rate for Payer: Blue Shield of California EPN |
$283.48
|
| Rate for Payer: Cash Price |
$309.35
|
| 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: 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 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 |
$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 60505-4318-0
|
| 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 |
$330.33
|
| Rate for Payer: Blue Shield of California Commercial |
$343.66
|
| Rate for Payer: Blue Shield of California EPN |
$224.42
|
| Rate for Payer: Cash Price |
$309.35
|
| 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: 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: InnovAge PACE Commercial |
$281.23
|
| 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 |
$112.49
|
| 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 |
$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
|
$576.63
|
|
|
Service Code
|
NDC 67877-636-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$115.33 |
| Max. Negotiated Rate |
$518.97 |
| Rate for Payer: Adventist Health Commercial |
$115.33
|
| Rate for Payer: Blue Shield of California Commercial |
$445.73
|
| Rate for Payer: Blue Shield of California EPN |
$290.62
|
| Rate for Payer: Cash Price |
$317.15
|
| Rate for Payer: Central Health Plan Commercial |
$461.30
|
| 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: Health Management Network EPO/PPO |
$518.97
|
| 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 |
$115.33
|
| Rate for Payer: Multiplan Commercial |
$432.47
|
| Rate for Payer: Networks By Design Commercial |
$374.81
|
| Rate for Payer: Prime Health Services Commercial |
$490.14
|
|
|
TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 1 MG/ML [40801044]
|
Facility
|
IP
|
$31.25
|
|
|
Service Code
|
NDC 9940-8010-44
|
| Hospital Charge Code |
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 |
$24.16
|
| Rate for Payer: Blue Shield of California EPN |
$15.75
|
| Rate for Payer: Cash Price |
$17.19
|
| 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: 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 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 |
$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 9940-8010-44
|
| 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 |
$18.35
|
| Rate for Payer: Blue Shield of California Commercial |
$19.09
|
| Rate for Payer: Blue Shield of California EPN |
$12.47
|
| Rate for Payer: Cash Price |
$17.19
|
| 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: 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: InnovAge PACE Commercial |
$15.62
|
| 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 |
$6.25
|
| 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 |
$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 9994-0810-44
|
| 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 |
$24.16
|
| Rate for Payer: Blue Shield of California EPN |
$15.75
|
| Rate for Payer: Cash Price |
$17.19
|
| 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: 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 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 |
$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 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 |
$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 |
$18.35
|
| Rate for Payer: Blue Shield of California Commercial |
$19.09
|
| Rate for Payer: Blue Shield of California EPN |
$12.47
|
| Rate for Payer: Cash Price |
$17.19
|
| 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: 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: InnovAge PACE Commercial |
$15.62
|
| 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 |
$6.25
|
| 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 |
$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
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 68462-109-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
