St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

OLANZAPINE 10 MG PO TABS [17937]

Facility

$19.92

Service Code	NDC 43598016630
Hospital Charge Code	43598016630
Hospital Revenue Code	250
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$15.93
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.96
Rate for Payer: Aetna Government	$9.96
Rate for Payer: Brighton Health Commercial	$14.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$15.93
Rate for Payer: Cigna LocalPlus Benefit Plan	$13.54
Rate for Payer: Group Health Inc Commercial	$9.96
Rate for Payer: Group Health Inc Medicare	$6.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.96
Rate for Payer: Hamaspik Choice Inc Medicare	$9.96
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12.94

OLANZAPINE 10 MG PO TABS [17937]

Facility

$19.92

Service Code	NDC 60505311300
Hospital Charge Code	60505311300
Hospital Revenue Code	250
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$15.93
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.96
Rate for Payer: Aetna Government	$9.96
Rate for Payer: Brighton Health Commercial	$14.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$15.93
Rate for Payer: Cigna LocalPlus Benefit Plan	$13.54
Rate for Payer: Group Health Inc Commercial	$9.96
Rate for Payer: Group Health Inc Medicare	$6.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.96
Rate for Payer: Hamaspik Choice Inc Medicare	$9.96
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12.95

OLANZAPINE 10 MG PO TABS [17937]

Facility

$13.22

Service Code	NDC 00904637661
Hospital Charge Code	00904637661
Hospital Revenue Code	250
Min. Negotiated Rate	$4.63
Max. Negotiated Rate	$10.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.27
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.61
Rate for Payer: Aetna Government	$6.61
Rate for Payer: Brighton Health Commercial	$9.91
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.99
Rate for Payer: Group Health Inc Commercial	$6.61
Rate for Payer: Group Health Inc Medicare	$4.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.61
Rate for Payer: Hamaspik Choice Inc Medicare	$6.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.59

OLANZAPINE 10 MG PO TABS [17937]

Facility

$19.92

Service Code	NDC 43598016605
Hospital Charge Code	43598016605
Hospital Revenue Code	250
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$15.93
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.96
Rate for Payer: Aetna Government	$9.96
Rate for Payer: Brighton Health Commercial	$14.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$15.93
Rate for Payer: Cigna LocalPlus Benefit Plan	$13.54
Rate for Payer: Group Health Inc Commercial	$9.96
Rate for Payer: Group Health Inc Medicare	$6.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.96
Rate for Payer: Hamaspik Choice Inc Medicare	$9.96
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12.94

OLANZAPINE 10 MG PO TBDP [28160]

Facility

$20.97

Service Code	NDC 60505327600
Hospital Charge Code	60505327600
Hospital Revenue Code	250
Min. Negotiated Rate	$7.34
Max. Negotiated Rate	$16.78
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.54
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.49
Rate for Payer: Aetna Government	$10.49
Rate for Payer: Brighton Health Commercial	$15.73
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$16.78
Rate for Payer: Cigna LocalPlus Benefit Plan	$14.26
Rate for Payer: Group Health Inc Commercial	$10.49
Rate for Payer: Group Health Inc Medicare	$7.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.49
Rate for Payer: Hamaspik Choice Inc Medicare	$10.49
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.63

OLANZAPINE 10 MG PO TBDP [28160]

Facility

$3.05

Service Code	NDC 55111026379
Hospital Charge Code	55111026379
Hospital Revenue Code	250
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$2.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.68
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.52
Rate for Payer: Aetna Government	$1.52
Rate for Payer: Brighton Health Commercial	$2.29
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.07
Rate for Payer: Group Health Inc Commercial	$1.52
Rate for Payer: Group Health Inc Medicare	$1.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.52
Rate for Payer: Hamaspik Choice Inc Medicare	$1.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.98

OLANZAPINE 10 MG PO TBDP [28160]

Facility

$3.05

Service Code	NDC 55111026381
Hospital Charge Code	55111026381
Hospital Revenue Code	250
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$2.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.68
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.52
Rate for Payer: Aetna Government	$1.52
Rate for Payer: Brighton Health Commercial	$2.29
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.07
Rate for Payer: Group Health Inc Commercial	$1.52
Rate for Payer: Group Health Inc Medicare	$1.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.52
Rate for Payer: Hamaspik Choice Inc Medicare	$1.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.98

OLANZAPINE 10 MG TAB

Facility

$0.84

Hospital Charge Code	41651568
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.67
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.42
Rate for Payer: Aetna Government	$0.42
Rate for Payer: Brighton Health Commercial	$0.63
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.67
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.57
Rate for Payer: Group Health Inc Commercial	$0.42
Rate for Payer: Group Health Inc Medicare	$0.29
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.42
Rate for Payer: Hamaspik Choice Inc Medicare	$0.42
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.55

OLANZAPINE 10 MG TAB

Facility

$0.84

Hospital Charge Code	41641568
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.67
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.42
Rate for Payer: Aetna Government	$0.42
Rate for Payer: Brighton Health Commercial	$0.63
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.67
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.57
Rate for Payer: Group Health Inc Commercial	$0.42
Rate for Payer: Group Health Inc Medicare	$0.29
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.42
Rate for Payer: Hamaspik Choice Inc Medicare	$0.42
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.55

OLANZAPINE 20 MG PO TABS [28158]

Facility

$0.95

Service Code	NDC 00904628761
Hospital Charge Code	00904628761
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.52
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.48
Rate for Payer: Aetna Government	$0.48
Rate for Payer: Brighton Health Commercial	$0.72
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.65
Rate for Payer: Group Health Inc Commercial	$0.48
Rate for Payer: Group Health Inc Medicare	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.48
Rate for Payer: Hamaspik Choice Inc Medicare	$0.48
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.62

OLANZAPINE 20 MG PO TABS [28158]

Facility

$39.83

Service Code	NDC 60505314003
Hospital Charge Code	60505314003
Hospital Revenue Code	250
Min. Negotiated Rate	$13.94
Max. Negotiated Rate	$31.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$21.91
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$19.92
Rate for Payer: Aetna Government	$19.92
Rate for Payer: Brighton Health Commercial	$29.87
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$31.86
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.08
Rate for Payer: Group Health Inc Commercial	$19.92
Rate for Payer: Group Health Inc Medicare	$13.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.92
Rate for Payer: Hamaspik Choice Inc Medicare	$19.92
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$25.89

OLANZAPINE 20 MG PO TABS [28158]

Facility

$39.83

Service Code	NDC 55111016830
Hospital Charge Code	55111016830
Hospital Revenue Code	250
Min. Negotiated Rate	$13.94
Max. Negotiated Rate	$31.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$21.91
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$19.92
Rate for Payer: Aetna Government	$19.92
Rate for Payer: Brighton Health Commercial	$29.87
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$31.86
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.08
Rate for Payer: Group Health Inc Commercial	$19.92
Rate for Payer: Group Health Inc Medicare	$13.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.92
Rate for Payer: Hamaspik Choice Inc Medicare	$19.92
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$25.89

OLANZAPINE 20 MG PO TBDP [28162]

Facility

$40.89

Service Code	NDC 60505327800
Hospital Charge Code	60505327800
Hospital Revenue Code	250
Min. Negotiated Rate	$14.31
Max. Negotiated Rate	$32.71
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$22.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.44
Rate for Payer: Aetna Government	$20.44
Rate for Payer: Brighton Health Commercial	$30.67
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$32.71
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.80
Rate for Payer: Group Health Inc Commercial	$20.44
Rate for Payer: Group Health Inc Medicare	$14.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$20.44
Rate for Payer: Hamaspik Choice Inc Medicare	$20.44
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$26.58

OLANZAPINE 20 MG TAB

Facility

$6.96

Hospital Charge Code	41655230
Hospital Revenue Code	250
Min. Negotiated Rate	$2.44
Max. Negotiated Rate	$5.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.83
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.48
Rate for Payer: Aetna Government	$3.48
Rate for Payer: Brighton Health Commercial	$5.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.73
Rate for Payer: Group Health Inc Commercial	$3.48
Rate for Payer: Group Health Inc Medicare	$2.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.48
Rate for Payer: Hamaspik Choice Inc Medicare	$3.48
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.52

OLANZAPINE 20 MG TAB

Facility

$6.96

Hospital Charge Code	41645230
Hospital Revenue Code	250
Min. Negotiated Rate	$2.44
Max. Negotiated Rate	$5.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.83
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.48
Rate for Payer: Aetna Government	$3.48
Rate for Payer: Brighton Health Commercial	$5.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.73
Rate for Payer: Group Health Inc Commercial	$3.48
Rate for Payer: Group Health Inc Medicare	$2.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.48
Rate for Payer: Hamaspik Choice Inc Medicare	$3.48
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.52

OLANZAPINE 2.5 MG PO TABS [21057]

Facility

$11.20

Service Code	NDC 55111016330
Hospital Charge Code	55111016330
Hospital Revenue Code	250
Min. Negotiated Rate	$3.92
Max. Negotiated Rate	$8.96
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5.60
Rate for Payer: Aetna Government	$5.60
Rate for Payer: Brighton Health Commercial	$8.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.96
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.61
Rate for Payer: Group Health Inc Commercial	$5.60
Rate for Payer: Group Health Inc Medicare	$3.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.60
Rate for Payer: Hamaspik Choice Inc Medicare	$5.60
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.28

OLANZAPINE 2.5 MG PO TABS [21057]

Facility

$11.20

Service Code	NDC 60505311000
Hospital Charge Code	60505311000
Hospital Revenue Code	250
Min. Negotiated Rate	$3.92
Max. Negotiated Rate	$8.96
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5.60
Rate for Payer: Aetna Government	$5.60
Rate for Payer: Brighton Health Commercial	$8.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.96
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.61
Rate for Payer: Group Health Inc Commercial	$5.60
Rate for Payer: Group Health Inc Medicare	$3.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.60
Rate for Payer: Hamaspik Choice Inc Medicare	$5.60
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.28

OLANZAPINE 2.5 MG PO TABS [21057]

Facility

$11.20

Service Code	NDC 00904628361
Hospital Charge Code	00904628361
Hospital Revenue Code	250
Min. Negotiated Rate	$3.92
Max. Negotiated Rate	$8.96
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5.60
Rate for Payer: Aetna Government	$5.60
Rate for Payer: Brighton Health Commercial	$8.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.96
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.61
Rate for Payer: Group Health Inc Commercial	$5.60
Rate for Payer: Group Health Inc Medicare	$3.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.60
Rate for Payer: Hamaspik Choice Inc Medicare	$5.60
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.28

OLANZAPINE 2.5 MG TAB

Facility

$12.34

Hospital Charge Code	41652494
Hospital Revenue Code	250
Min. Negotiated Rate	$4.32
Max. Negotiated Rate	$9.87
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.79
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.17
Rate for Payer: Aetna Government	$6.17
Rate for Payer: Brighton Health Commercial	$9.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.87
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.39
Rate for Payer: Group Health Inc Commercial	$6.17
Rate for Payer: Group Health Inc Medicare	$4.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.17
Rate for Payer: Hamaspik Choice Inc Medicare	$6.17
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.02

OLANZAPINE 2.5 MG TAB

Facility

$12.34

Hospital Charge Code	41642494
Hospital Revenue Code	250
Min. Negotiated Rate	$4.32
Max. Negotiated Rate	$9.87
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.79
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.17
Rate for Payer: Aetna Government	$6.17
Rate for Payer: Brighton Health Commercial	$9.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.87
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.39
Rate for Payer: Group Health Inc Commercial	$6.17
Rate for Payer: Group Health Inc Medicare	$4.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.17
Rate for Payer: Hamaspik Choice Inc Medicare	$6.17
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.02

OLANZAPINE 5 MG PO TABS [17936]

Facility

$13.22

Service Code	NDC 43598016405
Hospital Charge Code	43598016405
Hospital Revenue Code	250
Min. Negotiated Rate	$4.63
Max. Negotiated Rate	$10.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.27
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.61
Rate for Payer: Aetna Government	$6.61
Rate for Payer: Brighton Health Commercial	$9.91
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.99
Rate for Payer: Group Health Inc Commercial	$6.61
Rate for Payer: Group Health Inc Medicare	$4.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.61
Rate for Payer: Hamaspik Choice Inc Medicare	$6.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.59

OLANZAPINE 5 MG PO TABS [17936]

Facility

$13.22

Service Code	NDC 00904637761
Hospital Charge Code	00904637761
Hospital Revenue Code	250
Min. Negotiated Rate	$4.63
Max. Negotiated Rate	$10.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.27
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.61
Rate for Payer: Aetna Government	$6.61
Rate for Payer: Brighton Health Commercial	$9.91
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.99
Rate for Payer: Group Health Inc Commercial	$6.61
Rate for Payer: Group Health Inc Medicare	$4.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.61
Rate for Payer: Hamaspik Choice Inc Medicare	$6.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.59

OLANZAPINE 5 MG PO TABS [17936]

Facility

$13.22

Service Code	NDC 60505311100
Hospital Charge Code	60505311100
Hospital Revenue Code	250
Min. Negotiated Rate	$4.63
Max. Negotiated Rate	$10.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.27
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.61
Rate for Payer: Aetna Government	$6.61
Rate for Payer: Brighton Health Commercial	$9.91
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.99
Rate for Payer: Group Health Inc Commercial	$6.61
Rate for Payer: Group Health Inc Medicare	$4.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.61
Rate for Payer: Hamaspik Choice Inc Medicare	$6.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.59

OLANZAPINE 5 MG PO TABS [17936]

Facility

$12.29

Service Code	NDC 69543038130
Hospital Charge Code	69543038130
Hospital Revenue Code	250
Min. Negotiated Rate	$4.30
Max. Negotiated Rate	$9.83
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$6.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.14
Rate for Payer: Aetna Government	$6.14
Rate for Payer: Brighton Health Commercial	$9.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.83
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.36
Rate for Payer: Group Health Inc Commercial	$6.14
Rate for Payer: Group Health Inc Medicare	$4.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.14
Rate for Payer: Hamaspik Choice Inc Medicare	$6.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$7.99

OLANZAPINE 5 MG PO TBDP [28159]

Facility

$20.08

Service Code	NDC 00002445385
Hospital Charge Code	00002445385
Hospital Revenue Code	250
Min. Negotiated Rate	$7.03
Max. Negotiated Rate	$16.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.04
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.04
Rate for Payer: Aetna Government	$10.04
Rate for Payer: Brighton Health Commercial	$15.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$16.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$13.65
Rate for Payer: Group Health Inc Commercial	$10.04
Rate for Payer: Group Health Inc Medicare	$7.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.04
Rate for Payer: Hamaspik Choice Inc Medicare	$10.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.05

Know your out-of-pocket cost for care.

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