|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
OP
|
$1.51
|
|
|
Service Code
|
NDC 59746-307-12
|
| Hospital Charge Code |
1712250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.89
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.28
|
| Rate for Payer: Dignity Health Senior |
$1.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Vantage Medical Group Senior |
$1.28
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
OP
|
$1.51
|
|
|
Service Code
|
NDC 49884-321-55
|
| Hospital Charge Code |
1712250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.89
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.28
|
| Rate for Payer: Dignity Health Senior |
$1.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Vantage Medical Group Senior |
$1.28
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
IP
|
$1.51
|
|
|
Service Code
|
NDC 49884-321-55
|
| Hospital Charge Code |
1712250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.13
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
OP
|
$3.15
|
|
|
Service Code
|
NDC 60505-3276-0
|
| Hospital Charge Code |
1712250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.68 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1.96
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.68
|
| Rate for Payer: Dignity Health Senior |
$2.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Senior |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2.68
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
IP
|
$3.15
|
|
|
Service Code
|
NDC 60505-3276-0
|
| Hospital Charge Code |
1712250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.16
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.13
|
| Rate for Payer: Heritage Provider Network Senior |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
IP
|
$1.51
|
|
|
Service Code
|
NDC 59746-307-32
|
| Hospital Charge Code |
1712250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.13
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
IP
|
$1.51
|
|
|
Service Code
|
NDC 60505-3276-3
|
| Hospital Charge Code |
1712250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.13
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
OP
|
$1.51
|
|
|
Service Code
|
NDC 60505-3276-3
|
| Hospital Charge Code |
1712250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.89
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.28
|
| Rate for Payer: Dignity Health Senior |
$1.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Vantage Medical Group Senior |
$1.28
|
|
|
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]
|
Facility
OP
|
$27.89
|
|
|
Service Code
|
CPT J2359
|
| Hospital Charge Code |
1720945
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$20.92 |
| Rate for Payer: Adventist Health Commercial |
$5.58
|
| Rate for Payer: Adventist Health Commercial |
$9.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.04
|
| Rate for Payer: Blue Shield of California Commercial |
$17.32
|
| Rate for Payer: Blue Shield of California Commercial |
$28.08
|
| Rate for Payer: Blue Shield of California EPN |
$16.37
|
| Rate for Payer: Blue Shield of California EPN |
$26.54
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cash Price |
$12.55
|
| Rate for Payer: Cash Price |
$12.55
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.04
|
| Rate for Payer: Dignity Health Senior |
$1.04
|
| Rate for Payer: Dignity Health Senior |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.94
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.95
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.91
|
| Rate for Payer: Heritage Provider Network Senior |
$20.94
|
| Rate for Payer: Heritage Provider Network Senior |
$12.91
|
| Rate for Payer: Humana Medicare |
$0.95
|
| Rate for Payer: Humana Medicare |
$0.95
|
| Rate for Payer: IEHP Medi-Cal |
$8.44
|
| Rate for Payer: IEHP Medi-Cal |
$8.44
|
| Rate for Payer: IEHP Medicare Advantage |
$0.95
|
| Rate for Payer: IEHP Medicare Advantage |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$33.92
|
| Rate for Payer: Multiplan Commercial |
$20.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.95
|
| Rate for Payer: TriValley Medical Group Senior |
$0.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.95
|
| Rate for Payer: Vantage Medical Group Senior |
$0.95
|
|
|
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]
|
Facility
IP
|
$45.22
|
|
|
Service Code
|
CPT J2359
|
| Hospital Charge Code |
1720945
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$33.92 |
| Rate for Payer: Adventist Health Commercial |
$9.04
|
| Rate for Payer: Adventist Health Commercial |
$5.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.16
|
| Rate for Payer: Cash Price |
$12.55
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.61
|
| Rate for Payer: Heritage Provider Network Senior |
$18.88
|
| Rate for Payer: Heritage Provider Network Senior |
$30.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.97
|
| Rate for Payer: Multiplan Commercial |
$20.92
|
| Rate for Payer: Multiplan Commercial |
$33.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.11
|
|
|
OLANZAPINE 10 MG TABLET [17937]
|
Facility
OP
|
$0.58
|
|
|
Service Code
|
NDC 0904-6376-61
|
| Hospital Charge Code |
1713143
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Senior |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
OLANZAPINE 10 MG TABLET [17937]
|
Facility
OP
|
$0.42
|
|
|
Service Code
|
NDC 60505-3113-0
|
| Hospital Charge Code |
1713143
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| 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 |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| 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 |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Senior |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| 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 |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
OLANZAPINE 10 MG TABLET [17937]
|
Facility
IP
|
$0.42
|
|
|
Service Code
|
NDC 60505-3113-0
|
| Hospital Charge Code |
1713143
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| 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 |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
OLANZAPINE 10 MG TABLET [17937]
|
Facility
OP
|
$0.42
|
|
|
Service Code
|
NDC 43598-166-30
|
| Hospital Charge Code |
1713143
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| 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 |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| 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 |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Senior |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| 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 |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
OLANZAPINE 10 MG TABLET [17937]
|
Facility
OP
|
$0.29
|
|
|
Service Code
|
NDC 69543-383-30
|
| Hospital Charge Code |
1713143
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Senior |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
OLANZAPINE 10 MG TABLET [17937]
|
Facility
IP
|
$0.28
|
|
|
Service Code
|
NDC 69543-383-90
|
| Hospital Charge Code |
1713143
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
|
|
OLANZAPINE 10 MG TABLET [17937]
|
Facility
OP
|
$0.28
|
|
|
Service Code
|
NDC 69543-383-90
|
| Hospital Charge Code |
1713143
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
OLANZAPINE 10 MG TABLET [17937]
|
Facility
IP
|
$0.58
|
|
|
Service Code
|
NDC 0904-6376-61
|
| Hospital Charge Code |
1713143
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
OLANZAPINE 10 MG TABLET [17937]
|
Facility
IP
|
$0.29
|
|
|
Service Code
|
NDC 69543-383-30
|
| Hospital Charge Code |
1713143
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
OLANZAPINE 10 MG TABLET [17937]
|
Facility
IP
|
$0.42
|
|
|
Service Code
|
NDC 43598-166-30
|
| Hospital Charge Code |
1713143
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| 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 |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
OLANZAPINE 2.5 MG TABLET [21057]
|
Facility
OP
|
$0.53
|
|
|
Service Code
|
NDC 68084-525-01
|
| Hospital Charge Code |
1710896
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: Dignity Health Senior |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
OLANZAPINE 2.5 MG TABLET [21057]
|
Facility
OP
|
$0.53
|
|
|
Service Code
|
NDC 68084-525-11
|
| Hospital Charge Code |
1710896
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: Dignity Health Senior |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
OLANZAPINE 2.5 MG TABLET [21057]
|
Facility
IP
|
$0.53
|
|
|
Service Code
|
NDC 68084-525-01
|
| Hospital Charge Code |
1710896
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
OLANZAPINE 2.5 MG TABLET [21057]
|
Facility
IP
|
$0.53
|
|
|
Service Code
|
NDC 68084-525-11
|
| Hospital Charge Code |
1710896
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
OLANZAPINE 2.5 MG TABLET [21057]
|
Facility
OP
|
$0.24
|
|
|
Service Code
|
NDC 60505-3110-0
|
| Hospital Charge Code |
1710896
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
