|
VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 68382-036-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 65862-697-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]
|
Facility
|
OP
|
$0.74
|
|
|
Service Code
|
NDC 68084-713-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.44
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
|
VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 65862-697-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR [27857]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 68084-698-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR [27857]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 68084-698-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR [27857]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 68084-698-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR [27857]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 68084-698-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 0093-7385-98
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 65862-528-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 68382-035-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.23
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 65862-528-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 68382-035-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0093-7385-98
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]
|
Facility
|
IP
|
$0.66
|
|
|
Service Code
|
NDC 68084-709-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
NDC 68084-709-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]
|
Facility
|
IP
|
$0.66
|
|
|
Service Code
|
NDC 68084-709-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR [27858]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
NDC 68084-709-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
VERAPAMIL 120 MG TABLET [8528]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 0591-0345-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
VERAPAMIL 120 MG TABLET [8528]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 0591-0345-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION [8527]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 70069-271-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.60
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
|
|
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION [8527]
|
Facility
|
IP
|
$2.76
|
|
|
Service Code
|
NDC 72485-108-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Multiplan Commercial |
$2.07
|
|
|
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION [8527]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 70710-1643-5
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.60
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
|
|
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION [8527]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 70710-1643-5
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
|
|
VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION [8527]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 70069-271-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.60
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
|
