|
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 |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Cash Price |
$0.54
|
| 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
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
OP
|
$3.03
|
|
|
Service Code
|
NDC 59762-0047-1
|
| Hospital Charge Code |
1711848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| 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: AlphaCare Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.88
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$1.36
|
| 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 |
$1.46
|
| 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: Multiplan Commercial |
$2.27
|
| 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
|
$3.03
|
|
|
Service Code
|
NDC 59762-0047-1
|
| Hospital Charge Code |
1711848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.08
|
| Rate for Payer: Cash Price |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.05
|
| Rate for Payer: Heritage Provider Network Senior |
$2.05
|
| 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: Multiplan Commercial |
$2.27
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
OP
|
$1.20
|
|
|
Service Code
|
NDC 27241-191-30
|
| Hospital Charge Code |
1711848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Senior |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.58
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$1.40 |
| 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: 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 |
$5.78
|
| Rate for Payer: Blue Shield of California Commercial |
$4.79
|
| Rate for Payer: Blue Shield of California EPN |
$4.53
|
| Rate for Payer: Cash Price |
$3.47
|
| 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 |
$3.72
|
| 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
|
| 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 |
$1.40 |
| Max. Negotiated Rate |
$5.78 |
| Rate for Payer: Adventist Health Commercial |
$1.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.30
|
| Rate for Payer: Cash Price |
$3.47
|
| 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
|
|
|
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 |
$98.14 |
| Max. Negotiated Rate |
$406.64 |
| Rate for Payer: Adventist Health Commercial |
$108.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$372.48
|
| Rate for Payer: Cash Price |
$243.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$292.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$367.06
|
| Rate for Payer: Heritage Provider Network Senior |
$367.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$98.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.55
|
| Rate for Payer: Multiplan Commercial |
$406.64
|
|
|
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 |
$13.03 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.46
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.74
|
| Rate for Payer: Heritage Provider Network Senior |
$48.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
|
|
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 |
$13.03 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.46
|
| 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 |
$54.00
|
| Rate for Payer: Blue Shield of California Commercial |
$44.71
|
| Rate for Payer: Blue Shield of California EPN |
$42.26
|
| 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 Senior |
$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 Permanente of CA Commercial |
$34.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| 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
|
$542.19
|
|
|
Service Code
|
NDC 60505-4704-2
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$98.14 |
| Max. Negotiated Rate |
$460.86 |
| Rate for Payer: Adventist Health Commercial |
$108.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$289.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$372.48
|
| 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 |
$406.64
|
| Rate for Payer: Blue Shield of California Commercial |
$336.70
|
| Rate for Payer: Blue Shield of California EPN |
$318.27
|
| Rate for Payer: Cash Price |
$243.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$352.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$460.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$460.86
|
| Rate for Payer: Dignity Health Senior |
$460.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$347.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$335.62
|
| Rate for Payer: Heritage Provider Network Senior |
$335.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$261.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$98.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.55
|
| Rate for Payer: Multiplan Commercial |
$406.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$460.86
|
| Rate for Payer: Vantage Medical Group Senior |
$460.86
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
OP
|
$72.00
|
|
|
Service Code
|
NDC 49884-768-54
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.03 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.46
|
| 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 |
$54.00
|
| Rate for Payer: Blue Shield of California Commercial |
$44.71
|
| Rate for Payer: Blue Shield of California EPN |
$42.26
|
| 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 Senior |
$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 Permanente of CA Commercial |
$34.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| 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
|
$542.19
|
|
|
Service Code
|
NDC 60505-4704-0
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$98.14 |
| Max. Negotiated Rate |
$406.64 |
| Rate for Payer: Adventist Health Commercial |
$108.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$372.48
|
| Rate for Payer: Cash Price |
$243.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$292.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$367.06
|
| Rate for Payer: Heritage Provider Network Senior |
$367.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$98.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.55
|
| Rate for Payer: Multiplan Commercial |
$406.64
|
|
|
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 |
$98.14 |
| Max. Negotiated Rate |
$460.86 |
| Rate for Payer: Adventist Health Commercial |
$108.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$289.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$372.48
|
| 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 |
$406.64
|
| Rate for Payer: Blue Shield of California Commercial |
$336.70
|
| Rate for Payer: Blue Shield of California EPN |
$318.27
|
| Rate for Payer: Cash Price |
$243.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$352.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$460.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$460.86
|
| Rate for Payer: Dignity Health Senior |
$460.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$347.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$335.62
|
| Rate for Payer: Heritage Provider Network Senior |
$335.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$261.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$98.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.55
|
| Rate for Payer: Multiplan Commercial |
$406.64
|
| 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
IP
|
$72.00
|
|
|
Service Code
|
NDC 49884-768-54
|
| Hospital Charge Code |
1712438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.03 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.46
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.74
|
| Rate for Payer: Heritage Provider Network Senior |
$48.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
|
|
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 |
$117.21 |
| Max. Negotiated Rate |
$550.43 |
| Rate for Payer: Adventist Health Commercial |
$129.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$346.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$444.88
|
| 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 |
$485.68
|
| Rate for Payer: Blue Shield of California Commercial |
$402.14
|
| Rate for Payer: Blue Shield of California EPN |
$380.12
|
| Rate for Payer: Cash Price |
$291.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$420.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$550.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$550.43
|
| Rate for Payer: Dignity Health Senior |
$550.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$414.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$400.85
|
| Rate for Payer: Heritage Provider Network Senior |
$400.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$312.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$117.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$161.89
|
| Rate for Payer: Multiplan Commercial |
$485.68
|
| 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
OP
|
$576.63
|
|
|
Service Code
|
NDC 67877-636-02
|
| Hospital Charge Code |
1712439
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$104.37 |
| Max. Negotiated Rate |
$490.14 |
| Rate for Payer: Adventist Health Commercial |
$115.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$308.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$396.14
|
| 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 |
$432.47
|
| Rate for Payer: Blue Shield of California Commercial |
$358.09
|
| Rate for Payer: Blue Shield of California EPN |
$338.48
|
| Rate for Payer: Cash Price |
$259.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$374.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$490.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$490.14
|
| Rate for Payer: Dignity Health Senior |
$490.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$369.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$356.93
|
| Rate for Payer: Heritage Provider Network Senior |
$356.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$277.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$104.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$144.16
|
| Rate for Payer: Multiplan Commercial |
$432.47
|
| 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
|
$576.63
|
|
|
Service Code
|
NDC 67877-636-02
|
| Hospital Charge Code |
1712439
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$104.37 |
| Max. Negotiated Rate |
$432.47 |
| Rate for Payer: Adventist Health Commercial |
$115.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$396.14
|
| Rate for Payer: Cash Price |
$259.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$311.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$390.38
|
| Rate for Payer: Heritage Provider Network Senior |
$390.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$104.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$144.16
|
| Rate for Payer: Multiplan Commercial |
$432.47
|
|
|
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 |
$117.21 |
| Max. Negotiated Rate |
$485.68 |
| Rate for Payer: Adventist Health Commercial |
$129.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$444.88
|
| Rate for Payer: Cash Price |
$291.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$349.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$438.40
|
| Rate for Payer: Heritage Provider Network Senior |
$438.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$117.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$161.89
|
| Rate for Payer: Multiplan Commercial |
$485.68
|
|
|
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 |
$5.66 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.47
|
| 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 Permanente of CA 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 9940-8010-44
|
| Hospital Charge Code |
ERX40801044
|
|
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 Gatekeeper |
$16.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.47
|
| 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 |
$23.44
|
| Rate for Payer: Blue Shield of California Commercial |
$19.41
|
| Rate for Payer: Blue Shield of California EPN |
$18.34
|
| 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 Senior |
$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 Permanente of CA Commercial |
$15.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.81
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.56
|
| Rate for Payer: Vantage Medical Group Senior |
$26.56
|
|
|
TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 3 MG/ML [4081044]
|
Facility
OP
|
$31.25
|
|
|
Service Code
|
NDC 9994-0810-44
|
| Hospital Charge Code |
ERX4081044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$26.56 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.47
|
| 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 |
$23.44
|
| Rate for Payer: Blue Shield of California Commercial |
$19.41
|
| Rate for Payer: Blue Shield of California EPN |
$18.34
|
| 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 Senior |
$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 Permanente of CA Commercial |
$15.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.81
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.56
|
| Rate for Payer: Vantage Medical Group Senior |
$26.56
|
|
|
TOLVAPTAN ORAL SOLUTION CRUSHED TABLET 3 MG/ML [4081044]
|
Facility
IP
|
$31.25
|
|
|
Service Code
|
NDC 9994-0810-44
|
| Hospital Charge Code |
ERX4081044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.47
|
| 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 Permanente of CA Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.81
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
IP
|
$23,530.28
|
|
|
Service Code
|
APR-DRG 0974
|
| Min. Negotiated Rate |
$23,530.28 |
| Max. Negotiated Rate |
$23,530.28 |
| Rate for Payer: IEHP Medi-Cal |
$23,530.28
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
IP
|
$6,660.82
|
|
|
Service Code
|
APR-DRG 0972
|
| Min. Negotiated Rate |
$6,660.82 |
| Max. Negotiated Rate |
$6,660.82 |
| Rate for Payer: IEHP Medi-Cal |
$6,660.82
|
|
|
TONSIL AND ADENOID PROCEDURES
|
Facility
IP
|
$10,244.45
|
|
|
Service Code
|
APR-DRG 0973
|
| Min. Negotiated Rate |
$10,244.45 |
| Max. Negotiated Rate |
$10,244.45 |
| Rate for Payer: IEHP Medi-Cal |
$10,244.45
|
|
