|
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 |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
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 |
$9.23 |
| Max. Negotiated Rate |
$38.25 |
| Rate for Payer: Adventist Health Commercial |
$10.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.04
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.53
|
| Rate for Payer: Heritage Provider Network Senior |
$34.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.75
|
| Rate for Payer: Multiplan Commercial |
$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 |
$0.86 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.27
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.22
|
| Rate for Payer: Heritage Provider Network Senior |
$3.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$3.57
|
|
|
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 |
$0.91 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.75
|
| Rate for Payer: Blue Shield of California Commercial |
$3.10
|
| Rate for Payer: Blue Shield of California EPN |
$2.94
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.25
|
| Rate for Payer: Dignity Health Senior |
$4.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.10
|
| Rate for Payer: Heritage Provider Network Senior |
$3.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.25
|
| Rate for Payer: Multiplan Commercial |
$3.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.25
|
| Rate for Payer: Vantage Medical Group Senior |
$4.25
|
|
|
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 |
$0.86 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.57
|
| Rate for Payer: Blue Shield of California Commercial |
$2.96
|
| Rate for Payer: Blue Shield of California EPN |
$2.79
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.05
|
| Rate for Payer: Dignity Health Senior |
$4.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.95
|
| Rate for Payer: Heritage Provider Network Senior |
$2.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.05
|
| Rate for Payer: Vantage Medical Group Senior |
$4.05
|
|
|
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 |
$1.09 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Blue Shield of California Commercial |
$3.73
|
| Rate for Payer: Blue Shield of California EPN |
$3.52
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: Dignity Health Senior |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.71
|
| Rate for Payer: Heritage Provider Network Senior |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
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 |
$0.86 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.57
|
| Rate for Payer: Blue Shield of California Commercial |
$2.96
|
| Rate for Payer: Blue Shield of California EPN |
$2.79
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.05
|
| Rate for Payer: Dignity Health Senior |
$4.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.95
|
| Rate for Payer: Heritage Provider Network Senior |
$2.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.05
|
| Rate for Payer: Vantage Medical Group Senior |
$4.05
|
|
|
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 |
$19.20 |
| Max. Negotiated Rate |
$79.56 |
| Rate for Payer: Adventist Health Commercial |
$21.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.88
|
| Rate for Payer: Cash Price |
$47.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.82
|
| Rate for Payer: Heritage Provider Network Senior |
$71.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.52
|
| Rate for Payer: Multiplan Commercial |
$79.56
|
|
|
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 |
$0.86 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.27
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.22
|
| Rate for Payer: Heritage Provider Network Senior |
$3.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$3.57
|
|
|
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 |
$19.20 |
| Max. Negotiated Rate |
$90.17 |
| Rate for Payer: Adventist Health Commercial |
$21.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$56.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$90.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$58.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$79.56
|
| Rate for Payer: Blue Shield of California Commercial |
$65.88
|
| Rate for Payer: Blue Shield of California EPN |
$62.27
|
| Rate for Payer: Cash Price |
$47.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$68.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$90.17
|
| Rate for Payer: Dignity Health Senior |
$90.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.66
|
| Rate for Payer: Heritage Provider Network Senior |
$65.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$51.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.52
|
| Rate for Payer: Multiplan Commercial |
$79.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$90.17
|
| Rate for Payer: Vantage Medical Group Senior |
$90.17
|
|
|
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 |
$3.65 |
| Max. Negotiated Rate |
$15.14 |
| Rate for Payer: Adventist Health Commercial |
$4.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.87
|
| Rate for Payer: Cash Price |
$9.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.67
|
| Rate for Payer: Heritage Provider Network Senior |
$13.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.05
|
| Rate for Payer: Multiplan Commercial |
$15.14
|
|
|
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 |
$9.23 |
| Max. Negotiated Rate |
$43.35 |
| Rate for Payer: Adventist Health Commercial |
$10.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$27.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$43.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$28.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$38.25
|
| Rate for Payer: Blue Shield of California Commercial |
$31.67
|
| Rate for Payer: Blue Shield of California EPN |
$29.94
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$43.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.35
|
| Rate for Payer: Dignity Health Senior |
$43.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.57
|
| Rate for Payer: Heritage Provider Network Senior |
$31.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.75
|
| Rate for Payer: Multiplan Commercial |
$38.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.35
|
| Rate for Payer: Vantage Medical Group Senior |
$43.35
|
|
|
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 |
$0.91 |
| Max. Negotiated Rate |
$3.75 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.44
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.38
|
| Rate for Payer: Heritage Provider Network Senior |
$3.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.25
|
| Rate for Payer: Multiplan Commercial |
$3.75
|
|
|
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 |
$5.09 |
| Max. Negotiated Rate |
$21.08 |
| Rate for Payer: Adventist Health Commercial |
$5.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.31
|
| Rate for Payer: Cash Price |
$12.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.03
|
| Rate for Payer: Heritage Provider Network Senior |
$19.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.03
|
| Rate for Payer: Multiplan Commercial |
$21.08
|
|
|
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 |
$3.65 |
| Max. Negotiated Rate |
$17.16 |
| Rate for Payer: Adventist Health Commercial |
$4.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.14
|
| Rate for Payer: Blue Shield of California Commercial |
$12.54
|
| Rate for Payer: Blue Shield of California EPN |
$11.85
|
| Rate for Payer: Cash Price |
$9.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.16
|
| Rate for Payer: Dignity Health Senior |
$17.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.50
|
| Rate for Payer: Heritage Provider Network Senior |
$12.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.05
|
| Rate for Payer: Multiplan Commercial |
$15.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.16
|
| Rate for Payer: Vantage Medical Group Senior |
$17.16
|
|
|
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 |
$9.23 |
| Max. Negotiated Rate |
$38.25 |
| Rate for Payer: Adventist Health Commercial |
$10.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.04
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.53
|
| Rate for Payer: Heritage Provider Network Senior |
$34.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.75
|
| Rate for Payer: Multiplan Commercial |
$38.25
|
|
|
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 |
$5.09 |
| Max. Negotiated Rate |
$23.89 |
| Rate for Payer: Adventist Health Commercial |
$5.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$23.89
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$21.08
|
| Rate for Payer: Blue Shield of California Commercial |
$17.46
|
| Rate for Payer: Blue Shield of California EPN |
$16.50
|
| Rate for Payer: Cash Price |
$12.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.89
|
| Rate for Payer: Dignity Health Senior |
$23.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.40
|
| Rate for Payer: Heritage Provider Network Senior |
$17.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.03
|
| Rate for Payer: Multiplan Commercial |
$21.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.89
|
| Rate for Payer: Vantage Medical Group Senior |
$23.89
|
|
|
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 |
$9.23 |
| Max. Negotiated Rate |
$43.35 |
| Rate for Payer: Adventist Health Commercial |
$10.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$27.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$43.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$28.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$38.25
|
| Rate for Payer: Blue Shield of California Commercial |
$31.67
|
| Rate for Payer: Blue Shield of California EPN |
$29.94
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$43.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.35
|
| Rate for Payer: Dignity Health Senior |
$43.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.57
|
| Rate for Payer: Heritage Provider Network Senior |
$31.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.75
|
| Rate for Payer: Multiplan Commercial |
$38.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.35
|
| Rate for Payer: Vantage Medical Group Senior |
$43.35
|
|
|
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 |
$1.09 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.12
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.06
|
| Rate for Payer: Heritage Provider Network Senior |
$4.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
|
|
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION [99443]
|
Facility
OP
|
$10.91
|
|
|
Service Code
|
NDC 70010-051-40
|
| Hospital Charge Code |
1715257
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$9.27 |
| Rate for Payer: Adventist Health Commercial |
$2.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.18
|
| Rate for Payer: Blue Shield of California Commercial |
$6.78
|
| Rate for Payer: Blue Shield of California EPN |
$6.40
|
| Rate for Payer: Cash Price |
$4.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.27
|
| Rate for Payer: Dignity Health Senior |
$9.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.75
|
| Rate for Payer: Heritage Provider Network Senior |
$6.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.73
|
| Rate for Payer: Multiplan Commercial |
$8.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.27
|
| Rate for Payer: Vantage Medical Group Senior |
$9.27
|
|
|
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION [99443]
|
Facility
OP
|
$10.91
|
|
|
Service Code
|
NDC 0591-2579-20
|
| Hospital Charge Code |
1715257
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$9.27 |
| Rate for Payer: Adventist Health Commercial |
$2.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.18
|
| Rate for Payer: Blue Shield of California Commercial |
$6.78
|
| Rate for Payer: Blue Shield of California EPN |
$6.40
|
| Rate for Payer: Cash Price |
$4.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.27
|
| Rate for Payer: Dignity Health Senior |
$9.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.75
|
| Rate for Payer: Heritage Provider Network Senior |
$6.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.73
|
| Rate for Payer: Multiplan Commercial |
$8.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.27
|
| Rate for Payer: Vantage Medical Group Senior |
$9.27
|
|
|
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION [99443]
|
Facility
IP
|
$10.91
|
|
|
Service Code
|
NDC 0591-2579-20
|
| Hospital Charge Code |
1715257
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$8.18 |
| Rate for Payer: Adventist Health Commercial |
$2.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.50
|
| Rate for Payer: Cash Price |
$4.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.39
|
| Rate for Payer: Heritage Provider Network Senior |
$7.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.73
|
| Rate for Payer: Multiplan Commercial |
$8.18
|
|
|
VALGANCICLOVIR 50 MG/ML ORAL SOLUTION [99443]
|
Facility
IP
|
$10.91
|
|
|
Service Code
|
NDC 70010-051-40
|
| Hospital Charge Code |
1715257
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$8.18 |
| Rate for Payer: Adventist Health Commercial |
$2.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.50
|
| Rate for Payer: Cash Price |
$4.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.39
|
| Rate for Payer: Heritage Provider Network Senior |
$7.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.73
|
| Rate for Payer: Multiplan Commercial |
$8.18
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]
|
Facility
OP
|
$0.49
|
|
|
Service Code
|
NDC 63323-494-16
|
| Hospital Charge Code |
1721089
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Senior |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION [20887]
|
Facility
OP
|
$1.61
|
|
|
Service Code
|
NDC 63323-494-05
|
| Hospital Charge Code |
1721089
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.95
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.37
|
| Rate for Payer: Dignity Health Senior |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.37
|
| Rate for Payer: Vantage Medical Group Senior |
$1.37
|
|
