|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
NDC 3172286803
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.03 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$44.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$39.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$36.01
|
| Rate for Payer: Blue Shield of California Commercial |
$43.92
|
| Rate for Payer: Blue Shield of California EPN |
$35.14
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$46.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$61.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.57
|
| Rate for Payer: Heritage Provider Network Senior |
$44.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$34.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$50.40
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$28.80
|
| Rate for Payer: TriValley Medical Group Senior |
$28.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.20
|
| Rate for Payer: Vantage Medical Group Senior |
$61.20
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
NDC 4988476854
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.03 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$44.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$39.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$36.01
|
| Rate for Payer: Blue Shield of California Commercial |
$43.92
|
| Rate for Payer: Blue Shield of California EPN |
$35.14
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$46.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$61.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.57
|
| Rate for Payer: Heritage Provider Network Senior |
$44.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$34.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$50.40
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$28.80
|
| Rate for Payer: TriValley Medical Group Senior |
$28.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.20
|
| Rate for Payer: Vantage Medical Group Senior |
$61.20
|
|
|
TOLVAPTAN 30 MG TABLET [97894]
|
Facility
|
IP
|
$144.72
|
|
|
Service Code
|
NDC 6787763602
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.19 |
| Max. Negotiated Rate |
$108.54 |
| Rate for Payer: Adventist Health Commercial |
$28.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$93.20
|
| Rate for Payer: Cash Price |
$65.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$78.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$97.98
|
| Rate for Payer: Heritage Provider Network Senior |
$97.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.18
|
| Rate for Payer: Multiplan Commercial |
$108.54
|
|
|
TOLVAPTAN 30 MG TABLET [97894]
|
Facility
|
OP
|
$144.72
|
|
|
Service Code
|
NDC 6787763602
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.19 |
| Max. Negotiated Rate |
$123.01 |
| Rate for Payer: Adventist Health Commercial |
$28.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$89.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$123.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$79.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$108.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$72.39
|
| Rate for Payer: Blue Shield of California Commercial |
$88.28
|
| Rate for Payer: Blue Shield of California EPN |
$70.62
|
| Rate for Payer: Cash Price |
$65.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$94.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$123.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$123.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$123.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$92.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$89.58
|
| Rate for Payer: Heritage Provider Network Senior |
$89.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$69.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$101.30
|
| Rate for Payer: Multiplan Commercial |
$108.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$57.89
|
| Rate for Payer: TriValley Medical Group Senior |
$57.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$72.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$72.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$123.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$123.01
|
| Rate for Payer: Vantage Medical Group Senior |
$123.01
|
|
|
TOLVAPTAN 30 MG TABLET [97894]
|
Facility
|
IP
|
$144.72
|
|
|
Service Code
|
NDC 6787763633
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.19 |
| Max. Negotiated Rate |
$108.54 |
| Rate for Payer: Adventist Health Commercial |
$28.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$93.20
|
| Rate for Payer: Cash Price |
$65.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$78.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$97.98
|
| Rate for Payer: Heritage Provider Network Senior |
$97.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.18
|
| Rate for Payer: Multiplan Commercial |
$108.54
|
|
|
TOLVAPTAN 30 MG TABLET [97894]
|
Facility
|
OP
|
$144.72
|
|
|
Service Code
|
NDC 6787763633
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.19 |
| Max. Negotiated Rate |
$123.01 |
| Rate for Payer: Adventist Health Commercial |
$28.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$89.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$123.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$79.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$108.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$72.39
|
| Rate for Payer: Blue Shield of California Commercial |
$88.28
|
| Rate for Payer: Blue Shield of California EPN |
$70.62
|
| Rate for Payer: Cash Price |
$65.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$94.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$123.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$123.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$123.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$92.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$89.58
|
| Rate for Payer: Heritage Provider Network Senior |
$89.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$69.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$101.30
|
| Rate for Payer: Multiplan Commercial |
$108.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$57.89
|
| Rate for Payer: TriValley Medical Group Senior |
$57.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$72.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$72.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$123.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$123.01
|
| Rate for Payer: Vantage Medical Group Senior |
$123.01
|
|
|
TOLVAPTAN 30 MG TABLET [97894]
|
Facility
|
IP
|
$562.46
|
|
|
Service Code
|
NDC 6050543180
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$101.81 |
| Max. Negotiated Rate |
$421.85 |
| Rate for Payer: Adventist Health Commercial |
$112.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$362.22
|
| Rate for Payer: Cash Price |
$253.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$303.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$380.79
|
| Rate for Payer: Heritage Provider Network Senior |
$380.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$101.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$140.62
|
| Rate for Payer: Multiplan Commercial |
$421.85
|
|
|
TOLVAPTAN 30 MG TABLET [97894]
|
Facility
|
OP
|
$562.46
|
|
|
Service Code
|
NDC 6050543180
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$101.81 |
| Max. Negotiated Rate |
$478.09 |
| Rate for Payer: Adventist Health Commercial |
$112.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$347.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$478.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$309.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$421.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$281.34
|
| Rate for Payer: Blue Shield of California Commercial |
$343.10
|
| Rate for Payer: Blue Shield of California EPN |
$274.48
|
| Rate for Payer: Cash Price |
$253.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$365.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$478.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$478.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$478.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$359.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$348.16
|
| Rate for Payer: Heritage Provider Network Senior |
$348.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$268.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$101.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$140.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$393.72
|
| Rate for Payer: Multiplan Commercial |
$421.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$224.98
|
| Rate for Payer: TriValley Medical Group Senior |
$224.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$281.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$281.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$478.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$478.09
|
| Rate for Payer: Vantage Medical Group Senior |
$478.09
|
|
|
TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 1 MG/ML [40801044]
|
Facility
|
IP
|
$31.25
|
|
|
Service Code
|
NDC 9940801044
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.12
|
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.16
|
| Rate for Payer: Heritage Provider Network Senior |
$21.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.81
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
|
|
TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 1 MG/ML [40801044]
|
Facility
|
OP
|
$31.25
|
|
|
Service Code
|
NDC 9940801044
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$26.56 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$23.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.63
|
| Rate for Payer: Blue Shield of California Commercial |
$19.06
|
| Rate for Payer: Blue Shield of California EPN |
$15.25
|
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$26.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.34
|
| Rate for Payer: Heritage Provider Network Senior |
$19.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$21.88
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.50
|
| Rate for Payer: TriValley Medical Group Senior |
$12.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.56
|
| Rate for Payer: Vantage Medical Group Senior |
$26.56
|
|
|
TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 3 MG/ML [4081044]
|
Facility
|
IP
|
$31.25
|
|
|
Service Code
|
NDC 9994081044
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.12
|
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.16
|
| Rate for Payer: Heritage Provider Network Senior |
$21.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.81
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
|
|
TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 3 MG/ML [4081044]
|
Facility
|
OP
|
$31.25
|
|
|
Service Code
|
NDC 9994081044
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$26.56 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$23.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.63
|
| Rate for Payer: Blue Shield of California Commercial |
$19.06
|
| Rate for Payer: Blue Shield of California EPN |
$15.25
|
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$26.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.34
|
| Rate for Payer: Heritage Provider Network Senior |
$19.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$21.88
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.50
|
| Rate for Payer: TriValley Medical Group Senior |
$12.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.56
|
| Rate for Payer: Vantage Medical Group Senior |
$26.56
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 42826
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,264.23 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,396.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,690.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,264.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,435.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,396.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,690.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,264.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,264.23
|
| Rate for Payer: Heritage Provider Network Senior |
$5,245.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,264.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8,102.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,903.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,714.07
|
| Rate for Payer: Multiplan WC |
$6,565.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,690.65
|
| Rate for Payer: TriValley Medical Group Senior |
$4,690.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,396.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,690.65
|
| Rate for Payer: Vantage Medical Group Senior |
$4,264.23
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 6846210960
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| 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: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| 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
|
IP
|
$0.57
|
|
|
Service Code
|
NDC 6808434411
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
OP
|
$0.57
|
|
|
Service Code
|
NDC 6808434411
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
IP
|
$0.57
|
|
|
Service Code
|
NDC 6808434401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 6909712403
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| 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: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| 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
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 6838214014
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 6838214014
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| 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: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| 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
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 6846210960
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
OP
|
$0.57
|
|
|
Service Code
|
NDC 6808434401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.48
|
| 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 6909712403
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
TOPIRAMATE 200 MG TABLET [18921]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 6846211060
|
| 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 Non-Gatekeeper |
$0.11
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
TOPIRAMATE 200 MG TABLET [18921]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 6846211060
|
| 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: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| 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 Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
