|
OLANZAPINE 5 MG TABLET [17936]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 0904-6377-61
|
| Hospital Charge Code |
1713141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
OLANZAPINE 5 MG TABLET [17936]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 43598-164-30
|
| Hospital Charge Code |
1713141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Distinction Transplant |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Media |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
OLANZAPINE 5 MG TABLET [17936]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 0904-6377-61
|
| Hospital Charge Code |
1713141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Blue Distinction Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Media |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
OLANZAPINE 5 MG TABLET [17936]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 60505-3111-0
|
| Hospital Charge Code |
1713141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.24
|
|
|
OLANZAPINE 5 MG TABLET [17936]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 65862-562-30
|
| Hospital Charge Code |
1713141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Blue Distinction Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Media |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
OLANZAPINE 5 MG TABLET [17936]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 69543-381-30
|
| Hospital Charge Code |
1713141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
|
OLANZAPINE 5 MG TABLET [17936]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 69543-381-30
|
| Hospital Charge Code |
1713141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Blue Distinction Transplant |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Media |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
OLANZAPINE 5 MG TABLET [17936]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 65862-562-30
|
| Hospital Charge Code |
1713141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
OLANZAPINE 5 MG TABLET [17936]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 43598-164-30
|
| Hospital Charge Code |
1713141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.24
|
|
|
OLANZAPINE 5 MG TABLET [17936]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 69543-381-90
|
| Hospital Charge Code |
1713141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
|
|
OLANZAPINE 7.5 MG TABLET [17938]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 60505-3112-0
|
| Hospital Charge Code |
1713142
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Blue Distinction Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Media |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
OLANZAPINE 7.5 MG TABLET [17938]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 43598-165-30
|
| Hospital Charge Code |
1713142
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
|
|
OLANZAPINE 7.5 MG TABLET [17938]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 43598-165-30
|
| Hospital Charge Code |
1713142
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Blue Distinction Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Media |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
OLANZAPINE 7.5 MG TABLET [17938]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 60505-3112-0
|
| Hospital Charge Code |
1713142
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
|
|
OLOPATADINE 0.1 % EYE DROPS [19452]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 70069-007-01
|
| Hospital Charge Code |
1740310
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.57
|
| Rate for Payer: Blue Distinction Transplant |
$3.60
|
| Rate for Payer: Blue Shield of California Commercial |
$4.42
|
| Rate for Payer: Blue Shield of California EPN |
$3.50
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Media |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.00
|
| Rate for Payer: United Healthcare All Other HMO |
$3.00
|
| Rate for Payer: United Healthcare HMO Rider |
$3.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
OLOPATADINE 0.1 % EYE DROPS [19452]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 70069-007-01
|
| Hospital Charge Code |
1740310
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Blue Shield of California Commercial |
$4.27
|
| Rate for Payer: Blue Shield of California EPN |
$3.07
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
|
|
OLOPATADINE 0.1 % EYE DROPS [19452]
|
Facility
|
OP
|
$1.81
|
|
|
Service Code
|
NDC 46122-672-64
|
| Hospital Charge Code |
1740310
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.08
|
| Rate for Payer: Blue Distinction Transplant |
$1.09
|
| Rate for Payer: Blue Shield of California Commercial |
$1.33
|
| Rate for Payer: Blue Shield of California EPN |
$1.06
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO |
$1.27
|
| Rate for Payer: Cigna of CA PPO |
$1.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.54
|
| Rate for Payer: Dignity Health Media |
$1.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.54
|
| Rate for Payer: Global Benefits Group Commercial |
$1.09
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.45
|
| Rate for Payer: Networks By Design Commercial |
$1.18
|
| Rate for Payer: Prime Health Services Commercial |
$1.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.91
|
| Rate for Payer: United Healthcare All Other HMO |
$0.91
|
| Rate for Payer: United Healthcare HMO Rider |
$0.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.54
|
| Rate for Payer: Vantage Medical Group Senior |
$1.54
|
|
|
OLOPATADINE 0.1 % EYE DROPS [19452]
|
Facility
|
OP
|
$9.49
|
|
|
Service Code
|
NDC 60505-0575-1
|
| Hospital Charge Code |
1740310
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$8.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.65
|
| Rate for Payer: Blue Distinction Transplant |
$5.69
|
| Rate for Payer: Blue Shield of California Commercial |
$6.99
|
| Rate for Payer: Blue Shield of California EPN |
$5.54
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Cigna of CA HMO |
$6.64
|
| Rate for Payer: Cigna of CA PPO |
$6.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.07
|
| Rate for Payer: Dignity Health Media |
$8.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.80
|
| Rate for Payer: Galaxy Health WC |
$8.07
|
| Rate for Payer: Global Benefits Group Commercial |
$5.69
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$7.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Multiplan Commercial |
$7.59
|
| Rate for Payer: Networks By Design Commercial |
$6.17
|
| Rate for Payer: Prime Health Services Commercial |
$8.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.74
|
| Rate for Payer: United Healthcare All Other HMO |
$4.74
|
| Rate for Payer: United Healthcare HMO Rider |
$4.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.07
|
| Rate for Payer: Vantage Medical Group Senior |
$8.07
|
|
|
OLOPATADINE 0.1 % EYE DROPS [19452]
|
Facility
|
IP
|
$1.81
|
|
|
Service Code
|
NDC 46122-672-64
|
| Hospital Charge Code |
1740310
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Blue Shield of California Commercial |
$1.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.93
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO |
$1.27
|
| Rate for Payer: Cigna of CA PPO |
$1.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.54
|
| Rate for Payer: Global Benefits Group Commercial |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.45
|
| Rate for Payer: Networks By Design Commercial |
$1.18
|
| Rate for Payer: Prime Health Services Commercial |
$1.54
|
|
|
OLOPATADINE 0.1 % EYE DROPS [19452]
|
Facility
|
IP
|
$9.49
|
|
|
Service Code
|
NDC 60505-0575-1
|
| Hospital Charge Code |
1740310
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$8.07 |
| Rate for Payer: Blue Shield of California Commercial |
$6.76
|
| Rate for Payer: Blue Shield of California EPN |
$4.86
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Cigna of CA HMO |
$6.64
|
| Rate for Payer: Cigna of CA PPO |
$6.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.80
|
| Rate for Payer: Galaxy Health WC |
$8.07
|
| Rate for Payer: Global Benefits Group Commercial |
$5.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Multiplan Commercial |
$7.59
|
| Rate for Payer: Networks By Design Commercial |
$6.17
|
| Rate for Payer: Prime Health Services Commercial |
$8.07
|
|
|
OLUTASIDENIB 150 MG CAPSULE [236323]
|
Facility
|
IP
|
$644.00
|
|
|
Service Code
|
NDC 71332-005-01
|
| Hospital Charge Code |
ERX236323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$154.56 |
| Max. Negotiated Rate |
$547.40 |
| Rate for Payer: Blue Shield of California Commercial |
$458.53
|
| Rate for Payer: Blue Shield of California EPN |
$329.73
|
| Rate for Payer: Cash Price |
$289.80
|
| Rate for Payer: Cigna of CA HMO |
$450.80
|
| Rate for Payer: Cigna of CA PPO |
$450.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$257.60
|
| Rate for Payer: Galaxy Health WC |
$547.40
|
| Rate for Payer: Global Benefits Group Commercial |
$386.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$429.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$245.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.56
|
| Rate for Payer: Multiplan Commercial |
$515.20
|
| Rate for Payer: Networks By Design Commercial |
$418.60
|
| Rate for Payer: Prime Health Services Commercial |
$547.40
|
|
|
OLUTASIDENIB 150 MG CAPSULE [236323]
|
Facility
|
OP
|
$644.00
|
|
|
Service Code
|
NDC 71332-005-01
|
| Hospital Charge Code |
ERX236323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$154.56 |
| Max. Negotiated Rate |
$547.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$422.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$547.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$354.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$354.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$383.70
|
| Rate for Payer: Blue Distinction Transplant |
$386.40
|
| Rate for Payer: Blue Shield of California Commercial |
$474.63
|
| Rate for Payer: Blue Shield of California EPN |
$376.10
|
| Rate for Payer: Cash Price |
$289.80
|
| Rate for Payer: Cigna of CA HMO |
$450.80
|
| Rate for Payer: Cigna of CA PPO |
$450.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$547.40
|
| Rate for Payer: Dignity Health Media |
$547.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$547.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$257.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$257.60
|
| Rate for Payer: Galaxy Health WC |
$547.40
|
| Rate for Payer: Global Benefits Group Commercial |
$386.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$483.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$429.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$245.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.56
|
| Rate for Payer: Multiplan Commercial |
$515.20
|
| Rate for Payer: Networks By Design Commercial |
$418.60
|
| Rate for Payer: Prime Health Services Commercial |
$547.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$386.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$386.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$322.00
|
| Rate for Payer: United Healthcare All Other HMO |
$322.00
|
| Rate for Payer: United Healthcare HMO Rider |
$322.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$322.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$547.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$547.40
|
| Rate for Payer: Vantage Medical Group Senior |
$547.40
|
|
|
OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE [223366]
|
Facility
|
IP
|
$1,567.88
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
NDG223366
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$376.29 |
| Max. Negotiated Rate |
$1,332.70 |
| Rate for Payer: Blue Shield of California Commercial |
$1,116.33
|
| Rate for Payer: Blue Shield of California EPN |
$802.75
|
| Rate for Payer: Cash Price |
$705.55
|
| Rate for Payer: Cigna of CA HMO |
$1,097.52
|
| Rate for Payer: Cigna of CA PPO |
$1,097.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$627.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$627.15
|
| Rate for Payer: Galaxy Health WC |
$1,332.70
|
| Rate for Payer: Global Benefits Group Commercial |
$940.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,045.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$597.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$376.29
|
| Rate for Payer: Multiplan Commercial |
$1,254.30
|
| Rate for Payer: Networks By Design Commercial |
$783.94
|
| Rate for Payer: Prime Health Services Commercial |
$1,332.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$592.03
|
| Rate for Payer: United Healthcare All Other HMO |
$578.23
|
| Rate for Payer: United Healthcare HMO Rider |
$565.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$517.40
|
|
|
OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE [223366]
|
Facility
|
OP
|
$1,567.88
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
NDG223366
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.71 |
| Max. Negotiated Rate |
$1,332.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$248.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$49.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$43.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$43.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.71
|
| Rate for Payer: Blue Distinction Transplant |
$940.73
|
| Rate for Payer: Blue Shield of California Commercial |
$1,155.53
|
| Rate for Payer: Blue Shield of California EPN |
$45.14
|
| Rate for Payer: Cash Price |
$705.55
|
| Rate for Payer: Cash Price |
$705.55
|
| Rate for Payer: Cigna of CA HMO |
$1,097.52
|
| Rate for Payer: Cigna of CA PPO |
$1,097.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.19
|
| Rate for Payer: Dignity Health Media |
$39.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.27
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$39.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$39.46
|
| Rate for Payer: Galaxy Health WC |
$1,332.70
|
| Rate for Payer: Global Benefits Group Commercial |
$940.73
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,175.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.71
|
| Rate for Payer: Heritage Provider Network Transplant |
$64.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$63.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$63.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$39.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,045.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$83.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$39.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$376.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$49.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$52.88
|
| Rate for Payer: Multiplan Commercial |
$1,254.30
|
| Rate for Payer: Networks By Design Commercial |
$783.94
|
| Rate for Payer: Prime Health Services Commercial |
$1,332.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$940.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$940.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$783.94
|
| Rate for Payer: United Healthcare All Other HMO |
$783.94
|
| Rate for Payer: United Healthcare HMO Rider |
$783.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$783.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$59.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.40
|
| Rate for Payer: Vantage Medical Group Senior |
$39.46
|
|
|
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION [36151]
|
Facility
|
OP
|
$1,567.88
|
|
|
Service Code
|
CPT J2357
|
| Hospital Charge Code |
ERX36151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.71 |
| Max. Negotiated Rate |
$1,332.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$248.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$49.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$43.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$43.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.71
|
| Rate for Payer: Blue Distinction Transplant |
$940.73
|
| Rate for Payer: Blue Shield of California Commercial |
$1,155.53
|
| Rate for Payer: Blue Shield of California EPN |
$45.14
|
| Rate for Payer: Cash Price |
$705.55
|
| Rate for Payer: Cash Price |
$705.55
|
| Rate for Payer: Cigna of CA HMO |
$1,097.52
|
| Rate for Payer: Cigna of CA PPO |
$1,097.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.19
|
| Rate for Payer: Dignity Health Media |
$39.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.27
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$39.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$39.46
|
| Rate for Payer: Galaxy Health WC |
$1,332.70
|
| Rate for Payer: Global Benefits Group Commercial |
$940.73
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,175.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.71
|
| Rate for Payer: Heritage Provider Network Transplant |
$64.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$63.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$63.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$39.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,045.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$83.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$39.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$376.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$49.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$52.88
|
| Rate for Payer: Multiplan Commercial |
$1,254.30
|
| Rate for Payer: Networks By Design Commercial |
$783.94
|
| Rate for Payer: Prime Health Services Commercial |
$1,332.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$940.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$940.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$783.94
|
| Rate for Payer: United Healthcare All Other HMO |
$783.94
|
| Rate for Payer: United Healthcare HMO Rider |
$783.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$783.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$59.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.40
|
| Rate for Payer: Vantage Medical Group Senior |
$39.46
|
|
