|
VENLAFAXINE 100 MG TABLET [12205]
|
Facility
OP
|
$0.46
|
|
|
Service Code
|
NDC 68382-101-01
|
| Hospital Charge Code |
1712185
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Senior |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
VENLAFAXINE 100 MG TABLET [12205]
|
Facility
IP
|
$0.46
|
|
|
Service Code
|
NDC 68382-101-01
|
| Hospital Charge Code |
1712185
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
VENLAFAXINE 25 MG TABLET [12203]
|
Facility
OP
|
$1.26
|
|
|
Service Code
|
NDC 68084-896-25
|
| Hospital Charge Code |
1712239
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: Dignity Health Senior |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Senior |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
VENLAFAXINE 25 MG TABLET [12203]
|
Facility
IP
|
$1.26
|
|
|
Service Code
|
NDC 68084-896-25
|
| Hospital Charge Code |
1712239
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
VENLAFAXINE 25 MG TABLET [12203]
|
Facility
OP
|
$1.26
|
|
|
Service Code
|
NDC 68084-896-95
|
| Hospital Charge Code |
1712239
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: Dignity Health Senior |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Senior |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
VENLAFAXINE 25 MG TABLET [12203]
|
Facility
IP
|
$1.26
|
|
|
Service Code
|
NDC 68084-896-95
|
| Hospital Charge Code |
1712239
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
VENLAFAXINE 37.5 MG TABLET [12207]
|
Facility
IP
|
$1.03
|
|
|
Service Code
|
NDC 68084-844-01
|
| Hospital Charge Code |
1712223
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.71
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
|
|
VENLAFAXINE 37.5 MG TABLET [12207]
|
Facility
IP
|
$1.03
|
|
|
Service Code
|
NDC 68084-844-11
|
| Hospital Charge Code |
1712223
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.71
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
|
|
VENLAFAXINE 37.5 MG TABLET [12207]
|
Facility
OP
|
$1.03
|
|
|
Service Code
|
NDC 68084-844-01
|
| Hospital Charge Code |
1712223
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.88
|
| Rate for Payer: Dignity Health Senior |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Vantage Medical Group Senior |
$0.88
|
|
|
VENLAFAXINE 37.5 MG TABLET [12207]
|
Facility
OP
|
$0.40
|
|
|
Service Code
|
NDC 57664-393-88
|
| Hospital Charge Code |
1712223
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Senior |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
VENLAFAXINE 37.5 MG TABLET [12207]
|
Facility
IP
|
$0.40
|
|
|
Service Code
|
NDC 57664-393-88
|
| Hospital Charge Code |
1712223
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
VENLAFAXINE 37.5 MG TABLET [12207]
|
Facility
OP
|
$1.03
|
|
|
Service Code
|
NDC 68084-844-11
|
| Hospital Charge Code |
1712223
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.88
|
| Rate for Payer: Dignity Health Senior |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Vantage Medical Group Senior |
$0.88
|
|
|
VENLAFAXINE 50 MG TABLET [12204]
|
Facility
OP
|
$0.17
|
|
|
Service Code
|
NDC 57237-174-01
|
| Hospital Charge Code |
1712639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
VENLAFAXINE 50 MG TABLET [12204]
|
Facility
IP
|
$0.41
|
|
|
Service Code
|
NDC 68382-020-01
|
| Hospital Charge Code |
1712639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
|
|
VENLAFAXINE 50 MG TABLET [12204]
|
Facility
OP
|
$0.41
|
|
|
Service Code
|
NDC 68001-159-00
|
| Hospital Charge Code |
1712639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: Dignity Health Senior |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
|
|
VENLAFAXINE 50 MG TABLET [12204]
|
Facility
IP
|
$0.41
|
|
|
Service Code
|
NDC 57664-394-88
|
| Hospital Charge Code |
1712639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
|
|
VENLAFAXINE 50 MG TABLET [12204]
|
Facility
IP
|
$0.41
|
|
|
Service Code
|
NDC 68001-159-00
|
| Hospital Charge Code |
1712639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
|
|
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 |
$0.07 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: Dignity Health Senior |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
|
|
VENLAFAXINE 50 MG TABLET [12204]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
NDC 57237-174-01
|
| Hospital Charge Code |
1712639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
VENLAFAXINE 50 MG TABLET [12204]
|
Facility
OP
|
$0.41
|
|
|
Service Code
|
NDC 68382-020-01
|
| Hospital Charge Code |
1712639
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: Dignity Health Senior |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
|
|
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 |
$0.20 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.77
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Senior |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
|
|
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 |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
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 |
$0.20 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.84
|
| Rate for Payer: Blue Shield of California Commercial |
$0.70
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.95
|
| Rate for Payer: Dignity Health Senior |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Senior |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.95
|
| Rate for Payer: Vantage Medical Group Senior |
$0.95
|
|
|
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 |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
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 |
$0.20 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.84
|
| Rate for Payer: Blue Shield of California Commercial |
$0.70
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.95
|
| Rate for Payer: Dignity Health Senior |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Senior |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.95
|
| Rate for Payer: Vantage Medical Group Senior |
$0.95
|
|
