|
VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE [11639]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 68462-292-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE [11639]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 75834-320-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE [11640]
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
NDC 68462-293-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.31
|
| 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
|
|
|
VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE [11640]
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
NDC 68462-293-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.31 |
| 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 |
$0.31
|
| 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
|
|
|
VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE [8531]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 75834-159-01
|
| 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
|
|
|
VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE [8531]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 68462-260-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
|
|
VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE [8531]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 68462-260-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
|
|
VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE [8531]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 75834-159-01
|
| 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
|
|
|
VERAPAMIL ORAL SUSPENSION COMPOUND 50 MG/ML [4080356]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 9994-0803-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
VERAPAMIL ORAL SUSPENSION COMPOUND 50 MG/ML [4080356]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 9994-0803-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
VILAZODONE 20 MG TABLET [109403]
|
Facility
|
IP
|
$6.13
|
|
|
Service Code
|
NDC 60505-4773-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.37 |
| Max. Negotiated Rate |
$4.90 |
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.37
|
| Rate for Payer: Multiplan Commercial |
$4.60
|
|
|
VILAZODONE 20 MG TABLET [109403]
|
Facility
|
IP
|
$1.35
|
|
|
Service Code
|
NDC 72205-261-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
|
|
VILAZODONE 20 MG TABLET [109403]
|
Facility
|
IP
|
$6.30
|
|
|
Service Code
|
NDC 62332-233-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.46 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: Multiplan Commercial |
$4.72
|
|
|
VILAZODONE 20 MG TABLET [109403]
|
Facility
|
OP
|
$6.13
|
|
|
Service Code
|
NDC 60505-4773-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.37 |
| Max. Negotiated Rate |
$4.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.68
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.68
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.37
|
| Rate for Payer: Multiplan Commercial |
$4.60
|
|
|
VILAZODONE 20 MG TABLET [109403]
|
Facility
|
OP
|
$6.30
|
|
|
Service Code
|
NDC 62332-233-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.46 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.78
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: Multiplan Commercial |
$4.72
|
|
|
VILAZODONE 20 MG TABLET [109403]
|
Facility
|
OP
|
$1.35
|
|
|
Service Code
|
NDC 72205-261-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.81
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.81
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
|
|
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION [8594]
|
Facility
|
IP
|
$6.45
|
|
|
Service Code
|
HCPCS J9360
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.55 |
| Max. Negotiated Rate |
$5.16 |
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.55
|
| Rate for Payer: Multiplan Commercial |
$4.84
|
|
|
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION [8594]
|
Facility
|
OP
|
$6.45
|
|
|
Service Code
|
HCPCS J9360
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.55 |
| Max. Negotiated Rate |
$5.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.87
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.87
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.55
|
| Rate for Payer: Multiplan Commercial |
$4.84
|
|
|
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION [8597]
|
Facility
|
IP
|
$21.30
|
|
|
Service Code
|
HCPCS J9370
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.71 |
| Max. Negotiated Rate |
$17.04 |
| Rate for Payer: Cash Price |
$11.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.71
|
| Rate for Payer: Multiplan Commercial |
$15.97
|
|
|
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION [8597]
|
Facility
|
OP
|
$21.30
|
|
|
Service Code
|
HCPCS J9370
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.71 |
| Max. Negotiated Rate |
$17.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$12.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$12.78
|
| Rate for Payer: Cash Price |
$11.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$12.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.71
|
| Rate for Payer: Multiplan Commercial |
$15.97
|
|
|
VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION [120009]
|
Facility
|
OP
|
$9.24
|
|
|
Service Code
|
HCPCS J9370
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.08 |
| Max. Negotiated Rate |
$7.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.54
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.08
|
| Rate for Payer: Multiplan Commercial |
$6.93
|
|
|
VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION [120009]
|
Facility
|
IP
|
$9.24
|
|
|
Service Code
|
HCPCS J9370
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.08 |
| Max. Negotiated Rate |
$7.39 |
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.08
|
| Rate for Payer: Multiplan Commercial |
$6.93
|
|
|
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION [14203]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J9390
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.00
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$24.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
|
|
VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION [14203]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J9390
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$24.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
|
|
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION [41673]
|
Facility
|
IP
|
$21.60
|
|
|
Service Code
|
HCPCS J9390
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$17.28 |
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.88
|
| Rate for Payer: Multiplan Commercial |
$16.20
|
|
