|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
IP
|
$542.19
|
|
|
Service Code
|
NDC 60505-4704-0
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$108.44 |
| Max. Negotiated Rate |
$487.97 |
| Rate for Payer: Blue Shield of California Commercial |
$406.64
|
| Rate for Payer: Blue Shield of California EPN |
$289.53
|
| 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: EPIC Health Plan Commercial |
$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: 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
|
|
|
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
IP
|
$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: 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
|
$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 30 MG TABLET [97894]
|
Facility
OP
|
$576.63
|
|
|
Service Code
|
NDC 67877-636-02
|
| Hospital Charge Code |
1712439
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$115.33 |
| Max. Negotiated Rate |
$518.97 |
| Rate for Payer: Aetna of CA HMO/PPO |
$350.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$490.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$317.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$317.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$279.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$340.67
|
| Rate for Payer: BCBS Transplant Transplant |
$345.98
|
| Rate for Payer: Blue Shield of California Commercial |
$362.70
|
| Rate for Payer: Blue Shield of California EPN |
$281.97
|
| Rate for Payer: Cash Price |
$259.48
|
| 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: EPIC Health Plan Commercial |
$230.65
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$432.47
|
| Rate for Payer: IEHP medi-cal |
$201.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$384.61
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$345.98
|
| Rate for Payer: Riverside University Health 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 |
$288.32
|
| Rate for Payer: United Healthcare All Other HMO |
$288.32
|
| Rate for Payer: United Healthcare HMO Rider |
$288.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$288.32
|
| 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
OP
|
$647.57
|
|
|
Service Code
|
NDC 59148-021-50
|
| Hospital Charge Code |
1712439
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$129.51 |
| Max. Negotiated Rate |
$582.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$393.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$550.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$356.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$356.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$313.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$382.58
|
| Rate for Payer: BCBS Transplant Transplant |
$388.54
|
| Rate for Payer: Blue Shield of California Commercial |
$407.32
|
| Rate for Payer: Blue Shield of California EPN |
$316.66
|
| Rate for Payer: Cash Price |
$291.41
|
| 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: EPIC Health Plan Commercial |
$259.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$485.68
|
| Rate for Payer: IEHP medi-cal |
$226.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$431.93
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$388.54
|
| Rate for Payer: Riverside University Health 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 |
$323.78
|
| Rate for Payer: United Healthcare All Other HMO |
$323.78
|
| Rate for Payer: United Healthcare HMO Rider |
$323.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$323.78
|
| 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
|
$576.63
|
|
|
Service Code
|
NDC 67877-636-02
|
| Hospital Charge Code |
1712439
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$115.33 |
| Max. Negotiated Rate |
$518.97 |
| Rate for Payer: Blue Shield of California Commercial |
$432.47
|
| Rate for Payer: Blue Shield of California EPN |
$307.92
|
| Rate for Payer: Cash Price |
$259.48
|
| 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: 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: 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 30 MG TABLET [97894]
|
Facility
IP
|
$647.57
|
|
|
Service Code
|
NDC 59148-021-50
|
| Hospital Charge Code |
1712439
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$129.51 |
| Max. Negotiated Rate |
$582.81 |
| Rate for Payer: Blue Shield of California Commercial |
$485.68
|
| Rate for Payer: Blue Shield of California EPN |
$345.80
|
| Rate for Payer: Cash Price |
$291.41
|
| 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: 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: 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 ORAL SOLUTION CRUSHED TABLET 1 MG/ML [40801044]
|
Facility
IP
|
$31.25
|
|
|
Service Code
|
NDC 9940-8010-44
|
| Hospital Charge Code |
ERX40801044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$28.12 |
| Rate for Payer: Blue Shield of California Commercial |
$23.44
|
| Rate for Payer: Blue Shield of California EPN |
$16.69
|
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Central Health Plan Commercial |
$25.00
|
| Rate for Payer: Cigna of CA HMO |
$21.88
|
| Rate for Payer: Cigna of CA PPO |
$21.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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 |
ERX40801044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$28.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$18.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$26.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$15.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.46
|
| Rate for Payer: BCBS Transplant Transplant |
$18.75
|
| Rate for Payer: Blue Shield of California Commercial |
$19.66
|
| Rate for Payer: Blue Shield of California EPN |
$15.28
|
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Central Health Plan Commercial |
$25.00
|
| Rate for Payer: Cigna of CA HMO |
$21.88
|
| Rate for Payer: Cigna of CA PPO |
$21.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$23.44
|
| Rate for Payer: IEHP medi-cal |
$10.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.84
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$18.75
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$26.56
|
| Rate for Payer: Vantage Medical Group Senior |
$26.56
|
|
|
TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 3 MG/ML [4081044]
|
Facility
OP
|
$31.25
|
|
|
Service Code
|
NDC 9994-0810-44
|
| Hospital Charge Code |
ERX4081044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$28.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$18.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$26.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$15.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.46
|
| Rate for Payer: BCBS Transplant Transplant |
$18.75
|
| Rate for Payer: Blue Shield of California Commercial |
$19.66
|
| Rate for Payer: Blue Shield of California EPN |
$15.28
|
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Central Health Plan Commercial |
$25.00
|
| Rate for Payer: Cigna of CA HMO |
$21.88
|
| Rate for Payer: Cigna of CA PPO |
$21.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$23.44
|
| Rate for Payer: IEHP medi-cal |
$10.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.84
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$18.75
|
| Rate for Payer: Riverside University Health 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 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 |
ERX4081044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$28.12 |
| Rate for Payer: Blue Shield of California Commercial |
$23.44
|
| Rate for Payer: Blue Shield of California EPN |
$16.69
|
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Central Health Plan Commercial |
$25.00
|
| Rate for Payer: Cigna of CA HMO |
$21.88
|
| Rate for Payer: Cigna of CA PPO |
$21.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
IP
|
$8,936.23
|
|
|
Service Code
|
APR-DRG 0972
|
| Min. Negotiated Rate |
$7,498.93 |
| Max. Negotiated Rate |
$8,936.23 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,498.93
|
| Rate for Payer: IEHP medi-cal |
$8,936.23
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
IP
|
$31,568.45
|
|
|
Service Code
|
APR-DRG 0974
|
| Min. Negotiated Rate |
$26,491.01 |
| Max. Negotiated Rate |
$31,568.45 |
| Rate for Payer: Adventist Health Medi-Cal |
$26,491.01
|
| Rate for Payer: IEHP medi-cal |
$31,568.45
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
IP
|
$13,744.04
|
|
|
Service Code
|
APR-DRG 0973
|
| Min. Negotiated Rate |
$11,533.46 |
| Max. Negotiated Rate |
$13,744.04 |
| Rate for Payer: Adventist Health Medi-Cal |
$11,533.46
|
| Rate for Payer: IEHP medi-cal |
$13,744.04
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
IP
|
$6,166.60
|
|
|
Service Code
|
APR-DRG 0971
|
| Min. Negotiated Rate |
$5,174.77 |
| Max. Negotiated Rate |
$6,166.60 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,174.77
|
| Rate for Payer: IEHP medi-cal |
$6,166.60
|
|
|
Tonsillectomy and adenoidectomy; age 12 or over
|
Facility
OP
|
$15,354.00
|
|
|
Service Code
|
CPT 42821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,022.69 |
| Max. Negotiated Rate |
$15,354.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,022.69
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11,071.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,830.00
|
| Rate for Payer: Blue Shield of California Commercial |
$6,621.66
|
| Rate for Payer: Blue Shield of California EPN |
$4,755.97
|
| Rate for Payer: Caremore Medicare Advantage |
$4,022.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,034.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,430.63
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,022.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,022.69
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,597.21
|
| Rate for Payer: IEHP medi-cal |
$6,637.44
|
| Rate for Payer: IEHP Medicare Advantage |
$4,022.69
|
| Rate for Payer: Innovage PACE Commercial |
$6,034.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,022.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,390.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,390.40
|
| Rate for Payer: Prime Health Services Medicare |
$4,264.05
|
| Rate for Payer: Riverside University Health MISP |
$4,424.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$11,375.00
|
| Rate for Payer: United Healthcare All Other HMO |
$15,354.00
|
| Rate for Payer: United Healthcare HMO Rider |
$9,681.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8,852.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4,022.69
|
|
|
Tonsillectomy and adenoidectomy; younger than age 12
|
Facility
OP
|
$15,354.00
|
|
|
Service Code
|
CPT 42820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,383.18 |
| Max. Negotiated Rate |
$15,354.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,316.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,830.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$10,003.24
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$7,316.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,877.82
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$7,316.90
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$11,999.72
|
| Rate for Payer: IEHP medi-cal |
$12,072.88
|
| Rate for Payer: IEHP Medicare Advantage |
$7,316.90
|
| Rate for Payer: Innovage PACE Commercial |
$10,975.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,316.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,804.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,804.65
|
| Rate for Payer: Multiplan WC |
$10,003.24
|
| Rate for Payer: Preferred Health Network WC |
$10,207.39
|
| Rate for Payer: Prime Health Services Medicare |
$7,755.91
|
| Rate for Payer: Prime Health Services WC |
$9,901.17
|
| Rate for Payer: Riverside University Health MISP |
$8,048.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$11,375.00
|
| Rate for Payer: United Healthcare All Other HMO |
$15,354.00
|
| Rate for Payer: United Healthcare HMO Rider |
$9,681.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8,852.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Tonsillectomy, primary or secondary; age 12 or over
|
Facility
OP
|
$15,354.00
|
|
|
Service Code
|
CPT 42826
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,022.69 |
| Max. Negotiated Rate |
$15,354.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,022.69
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10,567.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,830.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5,824.53
|
| Rate for Payer: Blue Shield of California EPN |
$4,183.44
|
| Rate for Payer: Caremore Medicare Advantage |
$4,022.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,034.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,430.63
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,022.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,022.69
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,597.21
|
| Rate for Payer: IEHP medi-cal |
$6,637.44
|
| Rate for Payer: IEHP Medicare Advantage |
$4,022.69
|
| Rate for Payer: Innovage PACE Commercial |
$6,034.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,022.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,390.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,390.40
|
| Rate for Payer: Prime Health Services Medicare |
$4,264.05
|
| Rate for Payer: Riverside University Health MISP |
$4,424.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$11,375.00
|
| Rate for Payer: United Healthcare All Other HMO |
$15,354.00
|
| Rate for Payer: United Healthcare HMO Rider |
$9,681.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8,852.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4,022.69
|
|
|
Tonsillectomy, primary or secondary; younger than age 12
|
Facility
OP
|
$15,354.00
|
|
|
Service Code
|
CPT 42825
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,183.44 |
| Max. Negotiated Rate |
$15,354.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,316.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10,567.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,830.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$10,003.24
|
| Rate for Payer: Blue Shield of California Commercial |
$5,824.53
|
| Rate for Payer: Blue Shield of California EPN |
$4,183.44
|
| Rate for Payer: Caremore Medicare Advantage |
$7,316.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,877.82
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$7,316.90
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$11,999.72
|
| Rate for Payer: IEHP medi-cal |
$12,072.88
|
| Rate for Payer: IEHP Medicare Advantage |
$7,316.90
|
| Rate for Payer: Innovage PACE Commercial |
$10,975.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,316.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,804.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,804.65
|
| Rate for Payer: Multiplan WC |
$10,003.24
|
| Rate for Payer: Preferred Health Network WC |
$10,207.39
|
| Rate for Payer: Prime Health Services Medicare |
$7,755.91
|
| Rate for Payer: Prime Health Services WC |
$9,901.17
|
| Rate for Payer: Riverside University Health MISP |
$8,048.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$11,375.00
|
| Rate for Payer: United Healthcare All Other HMO |
$15,354.00
|
| Rate for Payer: United Healthcare HMO Rider |
$9,681.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8,852.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
OP
|
$0.14
|
|
|
Service Code
|
NDC 68382-140-14
|
| Hospital Charge Code |
1713139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: BCBS Transplant Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| 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: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$0.11
|
| Rate for Payer: IEHP medi-cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: Riverside University Health MISP |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
OP
|
$0.57
|
|
|
Service Code
|
NDC 68084-344-01
|
| Hospital Charge Code |
1713139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: BCBS Transplant Transplant |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.40
|
| Rate for Payer: Cigna of CA PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.48
|
| Rate for Payer: Global Benefits Group Commercial |
$0.34
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.51
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.43
|
| Rate for Payer: IEHP medi-cal |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
| Rate for Payer: Networks By Design Commercial |
$0.37
|
| Rate for Payer: Prime Health Services Commercial |
$0.48
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.34
|
| Rate for Payer: Riverside University Health MISP |
$0.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
IP
|
$0.57
|
|
|
Service Code
|
NDC 68084-344-11
|
| Hospital Charge Code |
1713139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.40
|
| Rate for Payer: Cigna of CA PPO |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.48
|
| Rate for Payer: Global Benefits Group Commercial |
$0.34
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
| Rate for Payer: Networks By Design Commercial |
$0.37
|
| Rate for Payer: Prime Health Services Commercial |
$0.48
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
OP
|
$0.57
|
|
|
Service Code
|
NDC 68084-344-11
|
| Hospital Charge Code |
1713139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: BCBS Transplant Transplant |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.40
|
| Rate for Payer: Cigna of CA PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.48
|
| Rate for Payer: Global Benefits Group Commercial |
$0.34
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.51
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.43
|
| Rate for Payer: IEHP medi-cal |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
| Rate for Payer: Networks By Design Commercial |
$0.37
|
| Rate for Payer: Prime Health Services Commercial |
$0.48
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.34
|
| Rate for Payer: Riverside University Health MISP |
$0.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
NDC 68462-109-60
|
| Hospital Charge Code |
1713139
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| 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 |
$0.06
|
| 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: 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: 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
|
|
