|
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
|
$0.17
|
|
|
Service Code
|
NDC 69543-380-30
|
| Hospital Charge Code |
1710896
|
|
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
|
|
|
OLANZAPINE 2.5 MG TABLET [21057]
|
Facility
OP
|
$0.24
|
|
|
Service Code
|
NDC 55111-163-30
|
| 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
|
|
|
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 68084-525-11
|
| 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 5 MG DISINTEGRATING TABLET [28159]
|
Facility
OP
|
$1.03
|
|
|
Service Code
|
NDC 59746-306-32
|
| Hospital Charge Code |
1712249
|
|
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
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
IP
|
$20.08
|
|
|
Service Code
|
NDC 0002-4453-85
|
| Hospital Charge Code |
1712249
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.63 |
| Max. Negotiated Rate |
$15.06 |
| Rate for Payer: Adventist Health Commercial |
$4.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.79
|
| Rate for Payer: Cash Price |
$9.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.59
|
| Rate for Payer: Heritage Provider Network Senior |
$13.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.02
|
| Rate for Payer: Multiplan Commercial |
$15.06
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
IP
|
$2.08
|
|
|
Service Code
|
NDC 55111-262-79
|
| Hospital Charge Code |
1712249
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.43
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Senior |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.56
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
IP
|
$1.03
|
|
|
Service Code
|
NDC 0378-5510-93
|
| Hospital Charge Code |
1712249
|
|
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
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
OP
|
$1.03
|
|
|
Service Code
|
NDC 59746-306-12
|
| Hospital Charge Code |
1712249
|
|
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
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
IP
|
$20.08
|
|
|
Service Code
|
NDC 0002-4453-01
|
| Hospital Charge Code |
1712249
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.63 |
| Max. Negotiated Rate |
$15.06 |
| Rate for Payer: Adventist Health Commercial |
$4.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.79
|
| Rate for Payer: Cash Price |
$9.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.59
|
| Rate for Payer: Heritage Provider Network Senior |
$13.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.02
|
| Rate for Payer: Multiplan Commercial |
$15.06
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
OP
|
$2.08
|
|
|
Service Code
|
NDC 55111-262-79
|
| Hospital Charge Code |
1712249
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.77 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.29
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.77
|
| Rate for Payer: Dignity Health Senior |
$1.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Senior |
$1.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.77
|
| Rate for Payer: Vantage Medical Group Senior |
$1.77
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
IP
|
$1.03
|
|
|
Service Code
|
NDC 59746-306-32
|
| Hospital Charge Code |
1712249
|
|
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
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
IP
|
$1.03
|
|
|
Service Code
|
NDC 59746-306-12
|
| Hospital Charge Code |
1712249
|
|
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
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
OP
|
$1.03
|
|
|
Service Code
|
NDC 60505-3275-3
|
| Hospital Charge Code |
1712249
|
|
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
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
OP
|
$20.08
|
|
|
Service Code
|
NDC 0002-4453-01
|
| Hospital Charge Code |
1712249
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.63 |
| Max. Negotiated Rate |
$17.07 |
| Rate for Payer: Adventist Health Commercial |
$4.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.06
|
| Rate for Payer: Blue Shield of California Commercial |
$12.47
|
| Rate for Payer: Blue Shield of California EPN |
$11.79
|
| Rate for Payer: Cash Price |
$9.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.07
|
| Rate for Payer: Dignity Health Senior |
$17.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.43
|
| Rate for Payer: Heritage Provider Network Senior |
$12.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.02
|
| Rate for Payer: Multiplan Commercial |
$15.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.07
|
| Rate for Payer: Vantage Medical Group Senior |
$17.07
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
IP
|
$1.03
|
|
|
Service Code
|
NDC 60505-3275-3
|
| Hospital Charge Code |
1712249
|
|
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
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
IP
|
$2.08
|
|
|
Service Code
|
NDC 55111-262-81
|
| Hospital Charge Code |
1712249
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.43
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Senior |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.56
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
OP
|
$1.03
|
|
|
Service Code
|
NDC 49884-320-55
|
| Hospital Charge Code |
1712249
|
|
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
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
IP
|
$1.03
|
|
|
Service Code
|
NDC 49884-320-55
|
| Hospital Charge Code |
1712249
|
|
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
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
OP
|
$1.03
|
|
|
Service Code
|
NDC 0378-5510-93
|
| Hospital Charge Code |
1712249
|
|
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
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
OP
|
$20.08
|
|
|
Service Code
|
NDC 0002-4453-85
|
| Hospital Charge Code |
1712249
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.63 |
| Max. Negotiated Rate |
$17.07 |
| Rate for Payer: Adventist Health Commercial |
$4.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.06
|
| Rate for Payer: Blue Shield of California Commercial |
$12.47
|
| Rate for Payer: Blue Shield of California EPN |
$11.79
|
| Rate for Payer: Cash Price |
$9.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.07
|
| Rate for Payer: Dignity Health Senior |
$17.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.43
|
| Rate for Payer: Heritage Provider Network Senior |
$12.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.02
|
| Rate for Payer: Multiplan Commercial |
$15.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.07
|
| Rate for Payer: Vantage Medical Group Senior |
$17.07
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET [28159]
|
Facility
OP
|
$2.08
|
|
|
Service Code
|
NDC 55111-262-81
|
| Hospital Charge Code |
1712249
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.77 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.29
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.77
|
| Rate for Payer: Dignity Health Senior |
$1.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Senior |
$1.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.77
|
| Rate for Payer: Vantage Medical Group Senior |
$1.77
|
|
|
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 |
$0.05 |
| 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 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 |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Senior |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| 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 Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
