|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
OP
|
$0.98
|
|
|
Service Code
|
NDC 31722-704-30
|
| Hospital Charge Code |
1710891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.74
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
OP
|
$0.98
|
|
|
Service Code
|
NDC 31722-704-90
|
| Hospital Charge Code |
1710891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.74
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
OP
|
$0.98
|
|
|
Service Code
|
NDC 63304-904-30
|
| Hospital Charge Code |
1710891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.74
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 0378-4275-77
|
| Hospital Charge Code |
1710891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.35
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
OP
|
$3.84
|
|
|
Service Code
|
NDC 68084-215-11
|
| Hospital Charge Code |
1710891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.30
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.88
|
|
|
VALACYCLOVIR ORAL SUSPENSION COMPOUND 50 MG/ML [4080355]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 9994-0803-55
|
| Hospital Charge Code |
1715245
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.54
|
|
|
VALACYCLOVIR ORAL SUSPENSION COMPOUND 50 MG/ML [4080355]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 9994-0803-55
|
| Hospital Charge Code |
1715245
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.54 |
| 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 |
$0.32
|
| 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 Beech St/Commercial/PHCS |
$0.54
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
OP
|
$20.19
|
|
|
Service Code
|
NDC 0603-6330-20
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.10 |
| Max. Negotiated Rate |
$15.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$12.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$12.11
|
| Rate for Payer: Cash Price |
$9.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$12.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$15.14
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
OP
|
$4.76
|
|
|
Service Code
|
NDC 69097-277-03
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.86
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.57
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
NDC 68084-965-95
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$38.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$30.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$30.60
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$30.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$38.25
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
IP
|
$106.08
|
|
|
Service Code
|
NDC 0004-0038-22
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.34 |
| Max. Negotiated Rate |
$84.86 |
| Rate for Payer: Cash Price |
$47.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$84.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$63.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$79.56
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
NDC 68084-965-25
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$38.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$30.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$30.60
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$30.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$38.25
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
IP
|
$4.76
|
|
|
Service Code
|
NDC 69097-277-03
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$3.81 |
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.57
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
IP
|
$28.11
|
|
|
Service Code
|
NDC 55111-762-60
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.46 |
| Max. Negotiated Rate |
$22.49 |
| Rate for Payer: Cash Price |
$12.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$21.08
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 27241-158-60
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$3.75 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.00
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.75
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
OP
|
$4.76
|
|
|
Service Code
|
NDC 65862-753-60
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.86
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.57
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
NDC 68084-965-25
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$40.80 |
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$30.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$38.25
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 27241-158-60
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.75
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 31722-832-60
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$4.50 |
| 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 |
$2.70
|
| 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 Beech St/Commercial/PHCS |
$4.50
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
IP
|
$4.76
|
|
|
Service Code
|
NDC 65862-753-60
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$3.81 |
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.57
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
OP
|
$28.11
|
|
|
Service Code
|
NDC 55111-762-60
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.46 |
| Max. Negotiated Rate |
$21.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.87
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.87
|
| Rate for Payer: Cash Price |
$12.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$21.08
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
IP
|
$20.19
|
|
|
Service Code
|
NDC 0603-6330-20
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.10 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Cash Price |
$9.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$15.14
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 31722-832-60
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$4.50
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
NDC 68084-965-95
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$40.80 |
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$30.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$38.25
|
|
|
VALGANCICLOVIR 450 MG TABLET [30148]
|
Facility
|
OP
|
$106.08
|
|
|
Service Code
|
NDC 0004-0038-22
|
| Hospital Charge Code |
1712248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.34 |
| Max. Negotiated Rate |
$79.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$63.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$63.65
|
| Rate for Payer: Cash Price |
$47.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$63.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$63.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$79.56
|
|
