St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

OFFICE O/P NEW MOD 45-59MIN,MOD25

Facility

$503.49

Service Code	HCPCS 99204 25
Hospital Charge Code	42500123
Hospital Revenue Code	510
Min. Negotiated Rate	$118.00
Max. Negotiated Rate	$276.92
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$276.92
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$118.00
Rate for Payer: Aetna Government	$118.00
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$251.74
Rate for Payer: Hamaspik Choice Inc Medicare	$251.74
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P NEW MOD 45-59MIN,TELEM

Facility

$415.16

Service Code	HCPCS 99204 95
Hospital Charge Code	30300994
Hospital Revenue Code	510
Min. Negotiated Rate	$118.00
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$228.34
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$118.00
Rate for Payer: Aetna Government	$118.00
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$207.58
Rate for Payer: Hamaspik Choice Inc Medicare	$207.58
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P NEW SF 15-29 MIN

Facility

$435.92

Service Code	HCPCS 99202 25
Hospital Charge Code	42500116
Hospital Revenue Code	510
Min. Negotiated Rate	$55.51
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$239.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$55.51
Rate for Payer: Aetna Government	$55.51
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$217.96
Rate for Payer: Hamaspik Choice Inc Medicare	$217.96
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P NEW SF 15-29 MIN

Facility

$435.92

Service Code	HCPCS 99202
Hospital Charge Code	30400206
Hospital Revenue Code	510
Min. Negotiated Rate	$37.08
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$239.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$37.08
Rate for Payer: Aetna Government	$37.08
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$217.96
Rate for Payer: Hamaspik Choice Inc Medicare	$217.96
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P NEW SF 15-29MIN

Facility

$435.92

Service Code	HCPCS 99202
Hospital Charge Code	30100100
Hospital Revenue Code	510
Min. Negotiated Rate	$37.08
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$239.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$37.08
Rate for Payer: Aetna Government	$37.08
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$217.96
Rate for Payer: Hamaspik Choice Inc Medicare	$217.96
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P NEW SF 15-29 MIN,MOD25

Facility

$435.92

Service Code	HCPCS 99202 25
Hospital Charge Code	42500117
Hospital Revenue Code	510
Min. Negotiated Rate	$55.51
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$239.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$55.51
Rate for Payer: Aetna Government	$55.51
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$217.96
Rate for Payer: Hamaspik Choice Inc Medicare	$217.96
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE O/P NEW SF 15-29 MIN,TELEM

Facility

$415.16

Service Code	HCPCS 99202 95
Hospital Charge Code	30300996
Hospital Revenue Code	510
Min. Negotiated Rate	$55.51
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$228.34
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$55.51
Rate for Payer: Aetna Government	$55.51
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$207.58
Rate for Payer: Hamaspik Choice Inc Medicare	$207.58
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE/OP VISIT MEDICAL DECISION

Facility

$712.75

Service Code	HCPCS 99202
Hospital Charge Code	30300002
Hospital Revenue Code	510
Min. Negotiated Rate	$37.08
Max. Negotiated Rate	$392.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$392.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$37.08
Rate for Payer: Aetna Government	$37.08
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$356.38
Rate for Payer: Hamaspik Choice Inc Medicare	$356.38
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE SERVICES CONSULTATION

Facility

$358.63

Service Code	HCPCS 99241
Hospital Charge Code	42201120
Hospital Revenue Code	519
Min. Negotiated Rate	$24.02
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$197.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$24.02
Rate for Payer: Aetna Government	$24.02
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$179.32
Rate for Payer: Hamaspik Choice Inc Medicare	$179.32
Rate for Payer: United Healthcare Commercial	$222.00

OFFICE VISIT-AFTER REGULAR HOURS

Facility

$50.00

Service Code	HCPCS D9440
Hospital Charge Code	42302350
Hospital Revenue Code	361
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$27.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$36.14
Rate for Payer: Aetna Government	$36.14
Rate for Payer: Brighton Health Commercial	$37.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Group Health Inc Commercial	$25.00
Rate for Payer: Group Health Inc Medicare	$17.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$25.00
Rate for Payer: Hamaspik Choice Inc Medicare	$25.00

OFFICE VISIT FOR OBSER (REG.HOURS

Facility

$50.00

Service Code	HCPCS D9430
Hospital Charge Code	42302345
Hospital Revenue Code	361
Min. Negotiated Rate	$16.93
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$27.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.93
Rate for Payer: Aetna Government	$16.93
Rate for Payer: Brighton Health Commercial	$37.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Group Health Inc Commercial	$25.00
Rate for Payer: Group Health Inc Medicare	$17.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$25.00
Rate for Payer: Hamaspik Choice Inc Medicare	$25.00

OFFSET 2MM

Facility

$4,593.75

Hospital Charge Code	64903974
Hospital Revenue Code	279
Min. Negotiated Rate	$1,607.81
Max. Negotiated Rate	$3,675.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,526.56
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2,296.88
Rate for Payer: Aetna Government	$2,296.88
Rate for Payer: Brighton Health Commercial	$3,445.31
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3,675.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3,123.75
Rate for Payer: Group Health Inc Commercial	$2,296.88
Rate for Payer: Group Health Inc Medicare	$1,607.81
Rate for Payer: Hamaspik Choice Inc Medicaid	$2,296.88
Rate for Payer: Hamaspik Choice Inc Medicare	$2,296.88

OFFSET ADAPTER 4MM

Facility

$2,962.00

Hospital Charge Code	40201381
Hospital Revenue Code	270
Min. Negotiated Rate	$1,036.70
Max. Negotiated Rate	$2,369.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,629.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,481.00
Rate for Payer: Aetna Government	$1,481.00
Rate for Payer: Brighton Health Commercial	$2,221.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,369.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,014.16
Rate for Payer: Group Health Inc Commercial	$1,481.00
Rate for Payer: Group Health Inc Medicare	$1,036.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,481.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,481.00

OFFSET ADAPTER 8MM

Facility

$2,962.00

Hospital Charge Code	40201382
Hospital Revenue Code	270
Min. Negotiated Rate	$1,036.70
Max. Negotiated Rate	$2,369.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,629.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,481.00
Rate for Payer: Aetna Government	$1,481.00
Rate for Payer: Brighton Health Commercial	$2,221.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,369.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,014.16
Rate for Payer: Group Health Inc Commercial	$1,481.00
Rate for Payer: Group Health Inc Medicare	$1,036.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,481.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,481.00

OFLOXACIN 0.3 % OP SOLN [19746]

Facility

$4.04

Service Code	NDC 17478071311
Hospital Charge Code	17478071311
Hospital Revenue Code	250
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$3.23
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.22
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.02
Rate for Payer: Aetna Government	$2.02
Rate for Payer: Brighton Health Commercial	$3.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.23
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.75
Rate for Payer: Group Health Inc Commercial	$2.02
Rate for Payer: Group Health Inc Medicare	$1.41
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.02
Rate for Payer: Hamaspik Choice Inc Medicare	$2.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.62

OFLOXACIN 0.3 % OP SOLN [19746]

Facility

$4.19

Service Code	NDC 17478071310
Hospital Charge Code	17478071310
Hospital Revenue Code	250
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$3.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.09
Rate for Payer: Aetna Government	$2.09
Rate for Payer: Brighton Health Commercial	$3.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.85
Rate for Payer: Group Health Inc Commercial	$2.09
Rate for Payer: Group Health Inc Medicare	$1.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.09
Rate for Payer: Hamaspik Choice Inc Medicare	$2.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.72

OFLOXACIN 0.3 % OP SOLN [19746]

Facility

$29.77

Service Code	NDC 11980077905
Hospital Charge Code	11980077905
Hospital Revenue Code	250
Min. Negotiated Rate	$10.42
Max. Negotiated Rate	$23.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$16.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$14.89
Rate for Payer: Aetna Government	$14.89
Rate for Payer: Brighton Health Commercial	$22.33
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$23.82
Rate for Payer: Cigna LocalPlus Benefit Plan	$20.25
Rate for Payer: Group Health Inc Commercial	$14.89
Rate for Payer: Group Health Inc Medicare	$10.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.89
Rate for Payer: Hamaspik Choice Inc Medicare	$14.89
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$19.35

OFLOXACIN 0.3 % OP SOLN [19746]

Facility

$4.19

Service Code	NDC 60505056000
Hospital Charge Code	60505056000
Hospital Revenue Code	250
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$3.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.09
Rate for Payer: Aetna Government	$2.09
Rate for Payer: Brighton Health Commercial	$3.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.85
Rate for Payer: Group Health Inc Commercial	$2.09
Rate for Payer: Group Health Inc Medicare	$1.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.09
Rate for Payer: Hamaspik Choice Inc Medicare	$2.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.72

OFLOXACIN 0.3 % OP SOLN [19746]

Facility

$14.07

Service Code	NDC 64980051505
Hospital Charge Code	64980051505
Hospital Revenue Code	250
Min. Negotiated Rate	$4.92
Max. Negotiated Rate	$11.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.74
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.04
Rate for Payer: Aetna Government	$7.04
Rate for Payer: Brighton Health Commercial	$10.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.57
Rate for Payer: Group Health Inc Commercial	$7.04
Rate for Payer: Group Health Inc Medicare	$4.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.04
Rate for Payer: Hamaspik Choice Inc Medicare	$7.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.15

OIL RETENTION TRAY

Facility

$12.05

Hospital Charge Code	40204510
Hospital Revenue Code	270
Min. Negotiated Rate	$4.22
Max. Negotiated Rate	$9.64
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.02
Rate for Payer: Aetna Government	$6.02
Rate for Payer: Brighton Health Commercial	$9.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.64
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.19
Rate for Payer: Group Health Inc Commercial	$6.02
Rate for Payer: Group Health Inc Medicare	$4.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.02
Rate for Payer: Hamaspik Choice Inc Medicare	$6.02

OLANZAPINE 10 MG IM SOLR [38263]

Facility

$41.50

Service Code	NDC 00781315972
Hospital Charge Code	00781315972
Hospital Revenue Code	250
Min. Negotiated Rate	$14.52
Max. Negotiated Rate	$33.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$22.82
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.75
Rate for Payer: Aetna Government	$20.75
Rate for Payer: Brighton Health Commercial	$31.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$33.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$28.22
Rate for Payer: Group Health Inc Commercial	$20.75
Rate for Payer: Group Health Inc Medicare	$14.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$20.75
Rate for Payer: Hamaspik Choice Inc Medicare	$20.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$26.98

OLANZAPINE 10 MG IM SOLR [38263]

Facility

$41.50

Service Code	NDC 00781910572
Hospital Charge Code	00781910572
Hospital Revenue Code	250
Min. Negotiated Rate	$14.52
Max. Negotiated Rate	$33.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$22.82
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.75
Rate for Payer: Aetna Government	$20.75
Rate for Payer: Brighton Health Commercial	$31.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$33.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$28.22
Rate for Payer: Group Health Inc Commercial	$20.75
Rate for Payer: Group Health Inc Medicare	$14.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$20.75
Rate for Payer: Hamaspik Choice Inc Medicare	$20.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$26.98

OLANZAPINE 10 MG IM SOLR [38263]

Facility

$42.53

Service Code	NDC 55150030801
Hospital Charge Code	55150030801
Hospital Revenue Code	250
Min. Negotiated Rate	$14.89
Max. Negotiated Rate	$34.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$23.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$21.26
Rate for Payer: Aetna Government	$21.26
Rate for Payer: Brighton Health Commercial	$31.90
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$34.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$28.92
Rate for Payer: Group Health Inc Commercial	$21.26
Rate for Payer: Group Health Inc Medicare	$14.89
Rate for Payer: Hamaspik Choice Inc Medicaid	$21.26
Rate for Payer: Hamaspik Choice Inc Medicare	$21.26
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$27.64

OLANZAPINE 10 MG IM SOLR [38263]

Facility

$47.39

Service Code	NDC 00517095501
Hospital Charge Code	00517095501
Hospital Revenue Code	250
Min. Negotiated Rate	$16.59
Max. Negotiated Rate	$37.91
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$26.06
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$23.70
Rate for Payer: Aetna Government	$23.70
Rate for Payer: Brighton Health Commercial	$35.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$37.91
Rate for Payer: Cigna LocalPlus Benefit Plan	$32.23
Rate for Payer: Group Health Inc Commercial	$23.70
Rate for Payer: Group Health Inc Medicare	$16.59
Rate for Payer: Hamaspik Choice Inc Medicaid	$23.70
Rate for Payer: Hamaspik Choice Inc Medicare	$23.70
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$30.80

OLANZAPINE 10 MG IM SOLR [38263]

Facility

$60.31

Service Code	NDC 00002759701
Hospital Charge Code	00002759701
Hospital Revenue Code	250
Min. Negotiated Rate	$21.11
Max. Negotiated Rate	$48.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$33.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$30.16
Rate for Payer: Aetna Government	$30.16
Rate for Payer: Brighton Health Commercial	$45.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$48.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$41.01
Rate for Payer: Group Health Inc Commercial	$30.16
Rate for Payer: Group Health Inc Medicare	$21.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$30.16
Rate for Payer: Hamaspik Choice Inc Medicare	$30.16
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$39.20

Know your out-of-pocket cost for care.

All Charges