|
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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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
|
$1.20
|
|
|
Service Code
|
NDC 27241-191-30
|
| Hospital Charge Code |
1711848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 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
|
|
|
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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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
|
|
|
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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 60505-4704-0
|
| 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 49884-768-52
|
| 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
|
|
|
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
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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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
|
$542.19
|
|
|
Service Code
|
NDC 60505-4704-0
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$108.44 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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
|
$542.19
|
|
|
Service Code
|
NDC 60505-4704-2
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$108.44 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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
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 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
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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 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 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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 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
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 0972
|
| Min. Negotiated Rate |
$7,498.93 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,498.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$8,936.23
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 0973
|
| Min. Negotiated Rate |
$11,533.46 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$11,533.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$13,744.04
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 0974
|
| Min. Negotiated Rate |
$26,491.01 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$26,491.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$31,568.45
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 0971
|
| Min. Negotiated Rate |
$5,174.77 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,174.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$6,166.60
|
|
