|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 6846257330
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.40
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$5.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
IP
|
$21.43
|
|
|
Service Code
|
NDC 5026880311
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.79 |
| Max. Negotiated Rate |
$17.14 |
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.79
|
| Rate for Payer: Multiplan Commercial |
$16.07
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
OP
|
$21.43
|
|
|
Service Code
|
NDC 5026880311
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.79 |
| Max. Negotiated Rate |
$17.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$12.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$12.86
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$12.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.79
|
| Rate for Payer: Multiplan Commercial |
$16.07
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
OP
|
$21.43
|
|
|
Service Code
|
NDC 5026880312
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.79 |
| Max. Negotiated Rate |
$17.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$12.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$12.86
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$12.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.79
|
| Rate for Payer: Multiplan Commercial |
$16.07
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 4354737803
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.40
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$5.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
|
|
VORICONAZOLE 50 MG TABLET [33008]
|
Facility
|
OP
|
$2.60
|
|
|
Service Code
|
NDC 4354737703
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.56
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$1.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
|
|
VORICONAZOLE 50 MG TABLET [33008]
|
Facility
|
IP
|
$2.60
|
|
|
Service Code
|
NDC 4354737703
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
|
|
VORICONAZOLE 50 MG TABLET [33008]
|
Facility
|
IP
|
$2.60
|
|
|
Service Code
|
NDC 6846257230
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
|
|
VORICONAZOLE 50 MG TABLET [33008]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 2724106203
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.96
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
|
|
VORICONAZOLE 50 MG TABLET [33008]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 2724106203
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
|
|
VORICONAZOLE 50 MG TABLET [33008]
|
Facility
|
OP
|
$2.60
|
|
|
Service Code
|
NDC 6846257230
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.56
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$1.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
|
|
VORINOSTAT 100 MG CAPSULE [77539]
|
Facility
|
IP
|
$150.10
|
|
|
Service Code
|
NDC 0006056840
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$82.56 |
| Max. Negotiated Rate |
$120.08 |
| Rate for Payer: Cash Price |
$67.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$120.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$90.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.56
|
| Rate for Payer: Multiplan Commercial |
$112.58
|
|
|
VORINOSTAT 100 MG CAPSULE [77539]
|
Facility
|
OP
|
$150.10
|
|
|
Service Code
|
NDC 0006056840
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$82.56 |
| Max. Negotiated Rate |
$120.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$90.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$90.06
|
| Rate for Payer: Cash Price |
$67.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$120.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$90.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$90.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.56
|
| Rate for Payer: Multiplan Commercial |
$112.58
|
|
|
VORINOSTAT ORAL SUSPENSION COMPOUND 50 MG/ML [4080357]
|
Facility
|
OP
|
$49.35
|
|
|
Service Code
|
NDC 9994080357
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.14 |
| Max. Negotiated Rate |
$39.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$29.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$29.61
|
| Rate for Payer: Cash Price |
$22.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$39.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$29.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$29.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.14
|
| Rate for Payer: Multiplan Commercial |
$37.01
|
|
|
VORINOSTAT ORAL SUSPENSION COMPOUND 50 MG/ML [4080357]
|
Facility
|
IP
|
$49.35
|
|
|
Service Code
|
NDC 9994080357
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.14 |
| Max. Negotiated Rate |
$39.48 |
| Rate for Payer: Cash Price |
$22.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$39.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$29.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.14
|
| Rate for Payer: Multiplan Commercial |
$37.01
|
|
|
WARFARIN 0.5 MG PARTIAL TABLET [4081492]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 9994081492
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
WARFARIN 0.5 MG PARTIAL TABLET [4081492]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 9994081492
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
WARFARIN 10 MG TABLET [8748]
|
Facility
|
OP
|
$0.73
|
|
|
Service Code
|
NDC 0832121901
|
| 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 |
$0.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.44
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
|
|
WARFARIN 10 MG TABLET [8748]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 6516276910
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.18
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
WARFARIN 10 MG TABLET [8748]
|
Facility
|
IP
|
$0.73
|
|
|
Service Code
|
NDC 0832121989
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
|
|
WARFARIN 10 MG TABLET [8748]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 6516276910
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
WARFARIN 10 MG TABLET [8748]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 0093172001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
|
|
WARFARIN 10 MG TABLET [8748]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 0093172001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
|
|
WARFARIN 10 MG TABLET [8748]
|
Facility
|
OP
|
$0.73
|
|
|
Service Code
|
NDC 0832121989
|
| 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 |
$0.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.44
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
|
|
WARFARIN 10 MG TABLET [8748]
|
Facility
|
IP
|
$0.73
|
|
|
Service Code
|
NDC 0832121901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
|
