|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
OP
|
$0.21
|
|
|
Service Code
|
NDC 51672-2020-2
|
| Hospital Charge Code |
NDG8020
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.19
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.16
|
| Rate for Payer: IEHP medi-cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: Riverside University Health MISP |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 24385-032-03
|
| Hospital Charge Code |
NDG8020
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 24385-032-03
|
| Hospital Charge Code |
NDG8020
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: BCBS Transplant Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.14
|
| Rate for Payer: IEHP medi-cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: Riverside University Health MISP |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
TOLNAFTATE 1 % TOPICAL POWDER [8021]
|
Facility
IP
|
$0.06
|
|
|
Service Code
|
NDC 0536-5150-26
|
| Hospital Charge Code |
1743283
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
TOLNAFTATE 1 % TOPICAL POWDER [8021]
|
Facility
OP
|
$0.06
|
|
|
Service Code
|
NDC 0536-5150-26
|
| Hospital Charge Code |
1743283
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: BCBS Transplant Transplant |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.05
|
| Rate for Payer: IEHP medi-cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: Riverside University Health MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
IP
|
$3.18
|
|
|
Service Code
|
NDC 0093-0010-06
|
| Hospital Charge Code |
1711744
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Blue Shield of California Commercial |
$2.38
|
| Rate for Payer: Blue Shield of California EPN |
$1.70
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Central Health Plan Commercial |
$2.54
|
| Rate for Payer: Cigna of CA HMO |
$2.23
|
| Rate for Payer: Cigna of CA PPO |
$2.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.27
|
| Rate for Payer: Galaxy Health WC |
$2.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.91
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$2.38
|
| Rate for Payer: Networks By Design Commercial |
$2.07
|
| Rate for Payer: Prime Health Services Commercial |
$2.70
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
OP
|
$3.18
|
|
|
Service Code
|
NDC 0093-0010-06
|
| Hospital Charge Code |
1711744
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.93
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.88
|
| Rate for Payer: BCBS Transplant Transplant |
$1.91
|
| Rate for Payer: Blue Shield of California Commercial |
$2.00
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Central Health Plan Commercial |
$2.54
|
| Rate for Payer: Cigna of CA HMO |
$2.23
|
| Rate for Payer: Cigna of CA PPO |
$2.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.27
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.27
|
| Rate for Payer: Galaxy Health WC |
$2.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.91
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.86
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.38
|
| Rate for Payer: IEHP medi-cal |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$2.38
|
| Rate for Payer: Networks By Design Commercial |
$2.07
|
| Rate for Payer: Prime Health Services Commercial |
$2.70
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.91
|
| Rate for Payer: Riverside University Health MISP |
$1.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.59
|
| Rate for Payer: United Healthcare All Other HMO |
$1.59
|
| Rate for Payer: United Healthcare HMO Rider |
$1.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.70
|
| Rate for Payer: Vantage Medical Group Senior |
$2.70
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
OP
|
$0.49
|
|
|
Service Code
|
NDC 33342-097-09
|
| Hospital Charge Code |
1711744
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: BCBS Transplant Transplant |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.44
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.37
|
| Rate for Payer: IEHP medi-cal |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: Riverside University Health MISP |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
IP
|
$0.49
|
|
|
Service Code
|
NDC 33342-097-09
|
| Hospital Charge Code |
1711744
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
IP
|
$0.50
|
|
|
Service Code
|
NDC 33342-098-09
|
| Hospital Charge Code |
1711745
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Central Health Plan Commercial |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
IP
|
$0.40
|
|
|
Service Code
|
NDC 31722-806-60
|
| Hospital Charge Code |
1711745
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
OP
|
$0.50
|
|
|
Service Code
|
NDC 33342-098-09
|
| Hospital Charge Code |
1711745
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: BCBS Transplant Transplant |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Central Health Plan Commercial |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.38
|
| Rate for Payer: IEHP medi-cal |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.30
|
| Rate for Payer: Riverside University Health MISP |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
OP
|
$0.40
|
|
|
Service Code
|
NDC 31722-806-60
|
| Hospital Charge Code |
1711745
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: BCBS Transplant Transplant |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.36
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.30
|
| Rate for Payer: IEHP medi-cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: Riverside University Health MISP |
$0.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
IP
|
$1.20
|
|
|
Service Code
|
NDC 27241-191-30
|
| Hospital Charge Code |
1711848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.54
|
| 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: 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: 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 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
OP
|
$3.03
|
|
|
Service Code
|
NDC 59762-0047-1
|
| Hospital Charge Code |
1711848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.73 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.67
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.79
|
| Rate for Payer: BCBS Transplant Transplant |
$1.82
|
| Rate for Payer: Blue Shield of California Commercial |
$1.91
|
| Rate for Payer: Blue Shield of California EPN |
$1.48
|
| 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: EPIC Health Plan Commercial |
$1.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.21
|
| Rate for Payer: Galaxy Health WC |
$2.58
|
| Rate for Payer: Global Benefits Group Commercial |
$1.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.73
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.27
|
| Rate for Payer: IEHP medi-cal |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.02
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.82
|
| Rate for Payer: Riverside University Health 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 |
$1.52
|
| Rate for Payer: United Healthcare All Other HMO |
$1.52
|
| Rate for Payer: United Healthcare HMO Rider |
$1.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.58
|
| Rate for Payer: Vantage Medical Group Senior |
$2.58
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
OP
|
$1.20
|
|
|
Service Code
|
NDC 27241-191-30
|
| Hospital Charge Code |
1711848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.71
|
| Rate for Payer: BCBS Transplant Transplant |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.54
|
| 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: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$0.90
|
| Rate for Payer: IEHP medi-cal |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
OP
|
$7.71
|
|
|
Service Code
|
NDC 0093-7163-56
|
| Hospital Charge Code |
1711848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$6.94 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.56
|
| Rate for Payer: BCBS Transplant Transplant |
$4.63
|
| Rate for Payer: Blue Shield of California Commercial |
$4.85
|
| Rate for Payer: Blue Shield of California EPN |
$3.77
|
| 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: EPIC Health Plan Commercial |
$3.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.08
|
| Rate for Payer: Galaxy Health WC |
$6.55
|
| Rate for Payer: Global Benefits Group Commercial |
$4.63
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.94
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.78
|
| Rate for Payer: IEHP medi-cal |
$2.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.14
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.63
|
| Rate for Payer: Riverside University Health 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 |
$3.86
|
| Rate for Payer: United Healthcare All Other HMO |
$3.86
|
| Rate for Payer: United Healthcare HMO Rider |
$3.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.55
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
1711848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.73 |
| Rate for Payer: Blue Shield of California Commercial |
$2.27
|
| Rate for Payer: Blue Shield of California EPN |
$1.62
|
| 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: EPIC Health Plan Commercial |
$1.21
|
| Rate for Payer: Galaxy Health WC |
$2.58
|
| Rate for Payer: Global Benefits Group Commercial |
$1.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.02
|
| 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 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
IP
|
$7.71
|
|
|
Service Code
|
NDC 0093-7163-56
|
| Hospital Charge Code |
1711848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$6.94 |
| Rate for Payer: Blue Shield of California Commercial |
$5.78
|
| Rate for Payer: Blue Shield of California EPN |
$4.12
|
| 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: EPIC Health Plan Commercial |
$3.08
|
| Rate for Payer: Galaxy Health WC |
$6.55
|
| Rate for Payer: Global Benefits Group Commercial |
$4.63
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.14
|
| 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
IP
|
$7.71
|
|
|
Service Code
|
NDC 0093-7164-56
|
| Hospital Charge Code |
1711849
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$6.94 |
| Rate for Payer: Blue Shield of California Commercial |
$5.78
|
| Rate for Payer: Blue Shield of California EPN |
$4.12
|
| 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: EPIC Health Plan Commercial |
$3.08
|
| Rate for Payer: Galaxy Health WC |
$6.55
|
| Rate for Payer: Global Benefits Group Commercial |
$4.63
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.14
|
| 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 |
1711849
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$6.94 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.56
|
| Rate for Payer: BCBS Transplant Transplant |
$4.63
|
| Rate for Payer: Blue Shield of California Commercial |
$4.85
|
| Rate for Payer: Blue Shield of California EPN |
$3.77
|
| 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: EPIC Health Plan Commercial |
$3.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.08
|
| Rate for Payer: Galaxy Health WC |
$6.55
|
| Rate for Payer: Global Benefits Group Commercial |
$4.63
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.94
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.78
|
| Rate for Payer: IEHP medi-cal |
$2.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.14
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.63
|
| Rate for Payer: Riverside University Health 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 |
$3.86
|
| Rate for Payer: United Healthcare All Other HMO |
$3.86
|
| Rate for Payer: United Healthcare HMO Rider |
$3.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.55
|
| Rate for Payer: Vantage Medical Group Senior |
$6.55
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
IP
|
$72.00
|
|
|
Service Code
|
NDC 49884-768-52
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Blue Shield of California Commercial |
$54.00
|
| Rate for Payer: Blue Shield of California EPN |
$38.45
|
| 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: EPIC Health Plan Commercial |
$28.80
|
| Rate for Payer: Galaxy Health WC |
$61.20
|
| Rate for Payer: Global Benefits Group Commercial |
$43.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$64.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$48.02
|
| 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
|
$542.19
|
|
|
Service Code
|
NDC 60505-4704-2
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$108.44 |
| Max. Negotiated Rate |
$487.97 |
| Rate for Payer: Aetna of CA HMO/PPO |
$329.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$460.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$298.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$298.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$262.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$320.33
|
| Rate for Payer: BCBS Transplant Transplant |
$325.31
|
| Rate for Payer: Blue Shield of California Commercial |
$341.04
|
| Rate for Payer: Blue Shield of California EPN |
$265.13
|
| Rate for Payer: Cash Price |
$243.99
|
| Rate for Payer: Central Health Plan Commercial |
$433.75
|
| Rate for Payer: Cigna of CA HMO |
$379.53
|
| Rate for Payer: Cigna of CA PPO |
$379.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$460.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$216.88
|
| Rate for Payer: EPIC Health Plan Transplant |
$216.88
|
| Rate for Payer: Galaxy Health WC |
$460.86
|
| Rate for Payer: Global Benefits Group Commercial |
$325.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$487.97
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$406.64
|
| Rate for Payer: IEHP medi-cal |
$189.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$361.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.44
|
| Rate for Payer: Multiplan Commercial |
$406.64
|
| Rate for Payer: Networks By Design Commercial |
$352.42
|
| Rate for Payer: Prime Health Services Commercial |
$460.86
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$325.31
|
| Rate for Payer: Riverside University Health MISP |
$216.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$325.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$325.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$271.10
|
| Rate for Payer: United Healthcare All Other HMO |
$271.10
|
| Rate for Payer: United Healthcare HMO Rider |
$271.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$271.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$460.86
|
| Rate for Payer: Vantage Medical Group Senior |
$460.86
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
OP
|
$72.00
|
|
|
Service Code
|
NDC 49884-768-54
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$43.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$39.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$39.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$34.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.54
|
| Rate for Payer: BCBS Transplant Transplant |
$43.20
|
| Rate for Payer: Blue Shield of California Commercial |
$45.29
|
| Rate for Payer: Blue Shield of California EPN |
$35.21
|
| 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: EPIC Health Plan Commercial |
$28.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$28.80
|
| Rate for Payer: Galaxy Health WC |
$61.20
|
| Rate for Payer: Global Benefits Group Commercial |
$43.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$64.80
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$54.00
|
| Rate for Payer: IEHP medi-cal |
$25.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$48.02
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$43.20
|
| Rate for Payer: Riverside University Health 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 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 |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$43.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$39.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$39.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$34.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.54
|
| Rate for Payer: BCBS Transplant Transplant |
$43.20
|
| Rate for Payer: Blue Shield of California Commercial |
$45.29
|
| Rate for Payer: Blue Shield of California EPN |
$35.21
|
| 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: EPIC Health Plan Commercial |
$28.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$28.80
|
| Rate for Payer: Galaxy Health WC |
$61.20
|
| Rate for Payer: Global Benefits Group Commercial |
$43.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$64.80
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$54.00
|
| Rate for Payer: IEHP medi-cal |
$25.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$48.02
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$43.20
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$61.20
|
| Rate for Payer: Vantage Medical Group Senior |
$61.20
|
|
