|
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
|
|
|
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 |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| 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 5 MG TABLET [17936]
|
Facility
OP
|
$0.19
|
|
|
Service Code
|
NDC 69543-381-90
|
| Hospital Charge Code |
1713141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Senior |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| 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 |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
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
IP
|
$0.28
|
|
|
Service Code
|
NDC 60505-3111-0
|
| Hospital Charge Code |
1713141
|
|
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 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 |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| 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 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 |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
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 |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| 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
|
|
|
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 |
$0.05 |
| 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 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 |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| 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 |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
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 |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| 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 |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
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 |
$0.33 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$1.06
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.54
|
| Rate for Payer: Dignity Health Senior |
$1.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.12
|
| Rate for Payer: Heritage Provider Network Senior |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.36
|
| 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
IP
|
$6.00
|
|
|
Service Code
|
NDC 70069-007-01
|
| Hospital Charge Code |
1740310
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.12
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.06
|
| Rate for Payer: Heritage Provider Network Senior |
$4.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
|
|
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 |
$1.72 |
| Max. Negotiated Rate |
$7.12 |
| Rate for Payer: Adventist Health Commercial |
$1.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.52
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.42
|
| Rate for Payer: Heritage Provider Network Senior |
$6.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$7.12
|
|
|
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 |
$0.33 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Senior |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.36
|
|
|
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 |
$1.72 |
| Max. Negotiated Rate |
$8.07 |
| Rate for Payer: Adventist Health Commercial |
$1.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.22
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.12
|
| Rate for Payer: Blue Shield of California Commercial |
$5.89
|
| Rate for Payer: Blue Shield of California EPN |
$5.57
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.07
|
| Rate for Payer: Dignity Health Senior |
$8.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.87
|
| Rate for Payer: Heritage Provider Network Senior |
$5.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$7.12
|
| 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
OP
|
$6.00
|
|
|
Service Code
|
NDC 70069-007-01
|
| Hospital Charge Code |
1740310
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Blue Shield of California Commercial |
$3.73
|
| Rate for Payer: Blue Shield of California EPN |
$3.52
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: Dignity Health Senior |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.71
|
| Rate for Payer: Heritage Provider Network Senior |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
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 |
$116.56 |
| Max. Negotiated Rate |
$483.00 |
| Rate for Payer: Adventist Health Commercial |
$128.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$442.43
|
| Rate for Payer: Cash Price |
$289.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$347.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$435.99
|
| Rate for Payer: Heritage Provider Network Senior |
$435.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$116.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$161.00
|
| Rate for Payer: Multiplan Commercial |
$483.00
|
|
|
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 |
$116.56 |
| Max. Negotiated Rate |
$547.40 |
| Rate for Payer: Adventist Health Commercial |
$128.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$344.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$442.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$547.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$354.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$483.00
|
| Rate for Payer: Blue Shield of California Commercial |
$399.92
|
| Rate for Payer: Blue Shield of California EPN |
$378.03
|
| Rate for Payer: Cash Price |
$289.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$418.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$547.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$547.40
|
| Rate for Payer: Dignity Health Senior |
$547.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$412.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$398.64
|
| Rate for Payer: Heritage Provider Network Senior |
$398.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$310.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$116.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$161.00
|
| Rate for Payer: Multiplan Commercial |
$483.00
|
| 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 |
$283.79 |
| Max. Negotiated Rate |
$1,175.91 |
| Rate for Payer: Adventist Health Commercial |
$313.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,077.13
|
| Rate for Payer: Cash Price |
$705.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$721.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$846.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,061.45
|
| Rate for Payer: Heritage Provider Network Senior |
$1,061.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$283.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$391.97
|
| Rate for Payer: Multiplan Commercial |
$1,175.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$571.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$523.83
|
|
|
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 |
$33.80 |
| Max. Negotiated Rate |
$1,175.91 |
| Rate for Payer: Adventist Health Commercial |
$313.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$96.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,077.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$49.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$43.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$43.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.80
|
| Rate for Payer: Blue Shield of California Commercial |
$41.52
|
| Rate for Payer: Blue Shield of California EPN |
$41.52
|
| Rate for Payer: Cash Price |
$705.55
|
| Rate for Payer: Cash Price |
$705.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$721.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.40
|
| Rate for Payer: Dignity Health Senior |
$43.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,003.44
|
| Rate for Payer: EPIC Health Plan Medicare |
$39.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$725.93
|
| Rate for Payer: Heritage Provider Network Senior |
$725.93
|
| Rate for Payer: Humana Medicare |
$39.46
|
| Rate for Payer: IEHP Medi-Cal |
$68.52
|
| Rate for Payer: IEHP Medicare Advantage |
$39.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$74.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$283.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$46.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$391.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$49.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$49.72
|
| Rate for Payer: Multiplan Commercial |
$1,175.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.40
|
| Rate for Payer: TriValley Medical Group Senior |
$39.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$571.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$523.83
|
| 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 |
$33.80 |
| Max. Negotiated Rate |
$1,175.91 |
| Rate for Payer: Adventist Health Commercial |
$313.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$96.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,077.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$49.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$43.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$43.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.80
|
| Rate for Payer: Blue Shield of California Commercial |
$41.52
|
| Rate for Payer: Blue Shield of California EPN |
$41.52
|
| Rate for Payer: Cash Price |
$705.55
|
| Rate for Payer: Cash Price |
$705.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$721.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.40
|
| Rate for Payer: Dignity Health Senior |
$43.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,003.44
|
| Rate for Payer: EPIC Health Plan Medicare |
$39.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$725.93
|
| Rate for Payer: Heritage Provider Network Senior |
$725.93
|
| Rate for Payer: Humana Medicare |
$39.46
|
| Rate for Payer: IEHP Medi-Cal |
$68.52
|
| Rate for Payer: IEHP Medicare Advantage |
$39.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$74.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$283.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$46.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$391.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$49.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$49.72
|
| Rate for Payer: Multiplan Commercial |
$1,175.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.40
|
| Rate for Payer: TriValley Medical Group Senior |
$39.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$571.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$523.83
|
| 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
|
|
