|
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION [108062]
|
Facility
|
IP
|
$159.35
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.84 |
| Max. Negotiated Rate |
$119.51 |
| Rate for Payer: Adventist Health Commercial |
$31.87
|
| Rate for Payer: Cash Price |
$87.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$73.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$86.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$73.78
|
| Rate for Payer: Heritage Provider Network Senior |
$73.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.84
|
| Rate for Payer: Multiplan Commercial |
$119.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$57.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$52.76
|
|
|
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [108061]
|
Facility
|
OP
|
$159.35
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$119.51 |
| Rate for Payer: Adventist Health Commercial |
$31.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$85.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$109.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.20
|
| Rate for Payer: Blue Shield of California Commercial |
$6.77
|
| Rate for Payer: Blue Shield of California EPN |
$6.77
|
| Rate for Payer: Cash Price |
$87.64
|
| Rate for Payer: Cash Price |
$87.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$73.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.36
|
| Rate for Payer: Dignity Health Senior |
$6.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$101.98
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$73.78
|
| Rate for Payer: Heritage Provider Network Senior |
$73.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$76.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.29
|
| Rate for Payer: Multiplan Commercial |
$119.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$63.74
|
| Rate for Payer: TriValley Medical Group Senior |
$63.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$57.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$52.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.36
|
| Rate for Payer: Vantage Medical Group Senior |
$6.36
|
|
|
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [108061]
|
Facility
|
IP
|
$159.35
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.84 |
| Max. Negotiated Rate |
$119.51 |
| Rate for Payer: Adventist Health Commercial |
$31.87
|
| Rate for Payer: Cash Price |
$87.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$73.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$86.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$73.78
|
| Rate for Payer: Heritage Provider Network Senior |
$73.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.84
|
| Rate for Payer: Multiplan Commercial |
$119.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$57.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$52.76
|
|
|
TOCILIZUMAB-AAZG 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION [241038]
|
Facility
|
OP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.07 |
| Max. Negotiated Rate |
$88.12 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$62.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.50
|
| Rate for Payer: Blue Shield of California Commercial |
$4.92
|
| Rate for Payer: Blue Shield of California EPN |
$4.92
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.16
|
| Rate for Payer: Dignity Health Senior |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$75.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.40
|
| Rate for Payer: Heritage Provider Network Senior |
$54.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$56.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.91
|
| Rate for Payer: Multiplan Commercial |
$88.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$47.00
|
| Rate for Payer: TriValley Medical Group Senior |
$47.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Vantage Medical Group Senior |
$5.16
|
|
|
TOCILIZUMAB-AAZG 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION [241038]
|
Facility
|
IP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.27 |
| Max. Negotiated Rate |
$88.12 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.40
|
| Rate for Payer: Heritage Provider Network Senior |
$54.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.38
|
| Rate for Payer: Multiplan Commercial |
$88.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.90
|
|
|
TOCILIZUMAB-AAZG 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION [241039]
|
Facility
|
IP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.27 |
| Max. Negotiated Rate |
$88.12 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.40
|
| Rate for Payer: Heritage Provider Network Senior |
$54.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.38
|
| Rate for Payer: Multiplan Commercial |
$88.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.90
|
|
|
TOCILIZUMAB-AAZG 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION [241039]
|
Facility
|
OP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.07 |
| Max. Negotiated Rate |
$88.12 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$62.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.50
|
| Rate for Payer: Blue Shield of California Commercial |
$4.92
|
| Rate for Payer: Blue Shield of California EPN |
$4.92
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.16
|
| Rate for Payer: Dignity Health Senior |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$75.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.40
|
| Rate for Payer: Heritage Provider Network Senior |
$54.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$56.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.91
|
| Rate for Payer: Multiplan Commercial |
$88.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$47.00
|
| Rate for Payer: TriValley Medical Group Senior |
$47.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Vantage Medical Group Senior |
$5.16
|
|
|
TOCILIZUMAB-AAZG 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [241037]
|
Facility
|
IP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.27 |
| Max. Negotiated Rate |
$88.12 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.40
|
| Rate for Payer: Heritage Provider Network Senior |
$54.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.38
|
| Rate for Payer: Multiplan Commercial |
$88.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.90
|
|
|
TOCILIZUMAB-AAZG 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [241037]
|
Facility
|
OP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.07 |
| Max. Negotiated Rate |
$88.12 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$62.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.50
|
| Rate for Payer: Blue Shield of California Commercial |
$4.92
|
| Rate for Payer: Blue Shield of California EPN |
$4.92
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cash Price |
$64.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.16
|
| Rate for Payer: Dignity Health Senior |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$75.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.40
|
| Rate for Payer: Heritage Provider Network Senior |
$54.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$56.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.91
|
| Rate for Payer: Multiplan Commercial |
$88.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$47.00
|
| Rate for Payer: TriValley Medical Group Senior |
$47.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Vantage Medical Group Senior |
$5.16
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 24385-032-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 51672-2020-2
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 24385-032-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| 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 |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 51672-2020-2
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| 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 |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
|
IP
|
$3.18
|
|
|
Service Code
|
NDC 0093-0010-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.15
|
| Rate for Payer: Heritage Provider Network Senior |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.38
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
|
OP
|
$3.18
|
|
|
Service Code
|
NDC 0093-0010-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.38
|
| Rate for Payer: Blue Shield of California Commercial |
$1.94
|
| Rate for Payer: Blue Shield of California EPN |
$1.55
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.70
|
| Rate for Payer: Dignity Health Senior |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.97
|
| Rate for Payer: Heritage Provider Network Senior |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.23
|
| Rate for Payer: Multiplan Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.27
|
| Rate for Payer: TriValley Medical Group Senior |
$1.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.70
|
| 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
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 33342-097-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 33342-097-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Senior |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 33342-098-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 33342-098-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| 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 |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| 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
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 31722-806-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 31722-806-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Senior |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| 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
|
OP
|
$3.03
|
|
|
Service Code
|
NDC 59762-0047-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.48
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.58
|
| Rate for Payer: Dignity Health Senior |
$2.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.88
|
| Rate for Payer: Heritage Provider Network Senior |
$1.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.12
|
| Rate for Payer: Multiplan Commercial |
$2.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.21
|
| Rate for Payer: TriValley Medical Group Senior |
$1.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.58
|
| Rate for Payer: Vantage Medical Group Senior |
$2.58
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
|
IP
|
$7.71
|
|
|
Service Code
|
NDC 0093-7163-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$5.78 |
| Rate for Payer: Adventist Health Commercial |
$1.54
|
| Rate for Payer: Cash Price |
$4.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.22
|
| Rate for Payer: Heritage Provider Network Senior |
$5.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.93
|
| Rate for Payer: Multiplan Commercial |
$5.78
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
|
OP
|
$7.71
|
|
|
Service Code
|
NDC 0093-7163-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$6.55 |
| Rate for Payer: Adventist Health Commercial |
$1.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.78
|
| Rate for Payer: Blue Shield of California Commercial |
$4.70
|
| Rate for Payer: Blue Shield of California EPN |
$3.76
|
| Rate for Payer: Cash Price |
$4.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.55
|
| Rate for Payer: Dignity Health Senior |
$6.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.77
|
| Rate for Payer: Heritage Provider Network Senior |
$4.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.40
|
| Rate for Payer: Multiplan Commercial |
$5.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.08
|
| Rate for Payer: TriValley Medical Group Senior |
$3.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.55
|
| Rate for Payer: Vantage Medical Group Senior |
$6.55
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 27241-191-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
