|
VENLAFAXINE 50 MG TABLET [12204]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
NDC 57664-394-88
|
| Hospital Charge Code |
1712639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.31
|
|
|
VENLAFAXINE 75 MG TABLET [12206]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 57237-175-01
|
| Hospital Charge Code |
1712187
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
VENLAFAXINE 75 MG TABLET [12206]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 57237-175-01
|
| Hospital Charge Code |
1712187
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
VENLAFAXINE 75 MG TABLET [12206]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 57664-395-88
|
| Hospital Charge Code |
1712187
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
VENLAFAXINE 75 MG TABLET [12206]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 57664-395-88
|
| Hospital Charge Code |
1712187
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.32 |
| 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 |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
VENLAFAXINE 75 MG TABLET [12206]
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 68084-856-11
|
| Hospital Charge Code |
1712187
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.67
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.84
|
|
|
VENLAFAXINE 75 MG TABLET [12206]
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 68084-856-11
|
| Hospital Charge Code |
1712187
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.84
|
|
|
VENLAFAXINE 75 MG TABLET [12206]
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 68084-856-01
|
| Hospital Charge Code |
1712187
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.84
|
|
|
VENLAFAXINE 75 MG TABLET [12206]
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 68084-856-01
|
| Hospital Charge Code |
1712187
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.67
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.84
|
|
|
VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]
|
Facility
|
OP
|
$0.74
|
|
|
Service Code
|
NDC 68084-713-01
|
| Hospital Charge Code |
1711721
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.56 |
| 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: 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 Beech St/Commercial/PHCS |
$0.56
|
|
|
VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 65862-697-30
|
| Hospital Charge Code |
1711721
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.39
|
|
|
VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 65862-697-30
|
| Hospital Charge Code |
1711721
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.39
|
|
|
VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]
|
Facility
|
IP
|
$0.74
|
|
|
Service Code
|
NDC 68084-713-01
|
| Hospital Charge Code |
1711721
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.56
|
|
|
VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 65862-697-90
|
| Hospital Charge Code |
1711721
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.39
|
|
|
VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]
|
Facility
|
IP
|
$0.74
|
|
|
Service Code
|
NDC 68084-713-11
|
| Hospital Charge Code |
1711721
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.56
|
|
|
VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]
|
Facility
|
OP
|
$0.74
|
|
|
Service Code
|
NDC 68084-713-11
|
| Hospital Charge Code |
1711721
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.56 |
| 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: 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 Beech St/Commercial/PHCS |
$0.56
|
|
|
VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 68382-036-16
|
| Hospital Charge Code |
1711721
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.32
|
|
|
VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 65862-697-90
|
| Hospital Charge Code |
1711721
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.39
|
|
|
VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR [27859]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 68382-036-16
|
| Hospital Charge Code |
1711721
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR [27857]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 68084-698-01
|
| Hospital Charge Code |
1711772
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.44 |
| 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 |
$0.27
|
| 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 Beech St/Commercial/PHCS |
$0.44
|
|
|
VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR [27857]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 0904-6468-61
|
| Hospital Charge Code |
1711772
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.47
|
|
|
VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR [27857]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 0904-6468-61
|
| Hospital Charge Code |
1711772
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.47
|
|
|
VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR [27857]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 68084-698-11
|
| Hospital Charge Code |
1711772
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.44 |
| 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 |
$0.27
|
| 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 Beech St/Commercial/PHCS |
$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 |
1711772
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$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 |
1711772
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.44
|
|
