St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

OLANZAPINE 5 MG PO TBDP [28159]

Facility

$2.08

Service Code	NDC 55111026281
Hospital Charge Code	55111026281
Hospital Revenue Code	250
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.04
Rate for Payer: Aetna Government	$1.04
Rate for Payer: Brighton Health Commercial	$1.56
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.41
Rate for Payer: Group Health Inc Commercial	$1.04
Rate for Payer: Group Health Inc Medicare	$0.73
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.04
Rate for Payer: Hamaspik Choice Inc Medicare	$1.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.35

OLANZAPINE 5 MG PO TBDP [28159]

Facility

$14.27

Service Code	NDC 49884032055
Hospital Charge Code	49884032055
Hospital Revenue Code	250
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$11.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.14
Rate for Payer: Aetna Government	$7.14
Rate for Payer: Brighton Health Commercial	$10.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.42
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.71
Rate for Payer: Group Health Inc Commercial	$7.14
Rate for Payer: Group Health Inc Medicare	$5.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.14
Rate for Payer: Hamaspik Choice Inc Medicare	$7.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.28

OLANZAPINE 5 MG PO TBDP [28159]

Facility

$2.08

Service Code	NDC 55111026279
Hospital Charge Code	55111026279
Hospital Revenue Code	250
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.04
Rate for Payer: Aetna Government	$1.04
Rate for Payer: Brighton Health Commercial	$1.56
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.41
Rate for Payer: Group Health Inc Commercial	$1.04
Rate for Payer: Group Health Inc Medicare	$0.73
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.04
Rate for Payer: Hamaspik Choice Inc Medicare	$1.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.35

OLANZAPINE 5 MG PO TBDP [28159]

Facility

$14.27

Service Code	NDC 60505327500
Hospital Charge Code	60505327500
Hospital Revenue Code	250
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$11.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.14
Rate for Payer: Aetna Government	$7.14
Rate for Payer: Brighton Health Commercial	$10.71
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.42
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.71
Rate for Payer: Group Health Inc Commercial	$7.14
Rate for Payer: Group Health Inc Medicare	$5.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.14
Rate for Payer: Hamaspik Choice Inc Medicare	$7.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.28

OLANZAPINE 5 MG PO TBDP [28159]

Facility

$14.27

Service Code	NDC 49884032052
Hospital Charge Code	49884032052
Hospital Revenue Code	250
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$11.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.14
Rate for Payer: Aetna Government	$7.14
Rate for Payer: Brighton Health Commercial	$10.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.42
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.71
Rate for Payer: Group Health Inc Commercial	$7.14
Rate for Payer: Group Health Inc Medicare	$5.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.14
Rate for Payer: Hamaspik Choice Inc Medicare	$7.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.28

OLANZAPINE 5 MG TAB

Facility

$12.91

Hospital Charge Code	41651872
Hospital Revenue Code	250
Min. Negotiated Rate	$4.52
Max. Negotiated Rate	$10.33
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.46
Rate for Payer: Aetna Government	$6.46
Rate for Payer: Brighton Health Commercial	$9.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.33
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.78
Rate for Payer: Group Health Inc Commercial	$6.46
Rate for Payer: Group Health Inc Medicare	$4.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.46
Rate for Payer: Hamaspik Choice Inc Medicare	$6.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.39

OLANZAPINE 5 MG TAB

Facility

$12.91

Hospital Charge Code	41641872
Hospital Revenue Code	250
Min. Negotiated Rate	$4.52
Max. Negotiated Rate	$10.33
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.46
Rate for Payer: Aetna Government	$6.46
Rate for Payer: Brighton Health Commercial	$9.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$10.33
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.78
Rate for Payer: Group Health Inc Commercial	$6.46
Rate for Payer: Group Health Inc Medicare	$4.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.46
Rate for Payer: Hamaspik Choice Inc Medicare	$6.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.39

OLANZAPINE 7.5 MG PO TABS [17938]

Facility

$16.08

Service Code	NDC 60505311200
Hospital Charge Code	60505311200
Hospital Revenue Code	250
Min. Negotiated Rate	$5.63
Max. Negotiated Rate	$12.87
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8.04
Rate for Payer: Aetna Government	$8.04
Rate for Payer: Brighton Health Commercial	$12.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.87
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.94
Rate for Payer: Group Health Inc Commercial	$8.04
Rate for Payer: Group Health Inc Medicare	$5.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.04
Rate for Payer: Hamaspik Choice Inc Medicare	$8.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10.45

OLANZAPINE 7.5 MG PO TABS [17938]

Facility

$16.08

Service Code	NDC 43598016530
Hospital Charge Code	43598016530
Hospital Revenue Code	250
Min. Negotiated Rate	$5.63
Max. Negotiated Rate	$12.87
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8.04
Rate for Payer: Aetna Government	$8.04
Rate for Payer: Brighton Health Commercial	$12.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.87
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.94
Rate for Payer: Group Health Inc Commercial	$8.04
Rate for Payer: Group Health Inc Medicare	$5.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.04
Rate for Payer: Hamaspik Choice Inc Medicare	$8.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10.45

OLANZAPINE 7.5 MG TAB

Facility

$15.71

Hospital Charge Code	41651567
Hospital Revenue Code	250
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$12.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.86
Rate for Payer: Aetna Government	$7.86
Rate for Payer: Brighton Health Commercial	$11.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.68
Rate for Payer: Group Health Inc Commercial	$7.86
Rate for Payer: Group Health Inc Medicare	$5.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.86
Rate for Payer: Hamaspik Choice Inc Medicare	$7.86
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10.21

OLANZAPINE 7.5 MG TAB

Facility

$15.71

Hospital Charge Code	41641567
Hospital Revenue Code	250
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$12.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.86
Rate for Payer: Aetna Government	$7.86
Rate for Payer: Brighton Health Commercial	$11.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.68
Rate for Payer: Group Health Inc Commercial	$7.86
Rate for Payer: Group Health Inc Medicare	$5.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.86
Rate for Payer: Hamaspik Choice Inc Medicare	$7.86
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10.21

OLANZAPINE INJECTION

Facility

$41.50

Service Code	HCPCS J3490
Hospital Charge Code	41650275
Hospital Revenue Code	636
Min. Negotiated Rate	$14.52
Max. Negotiated Rate	$26.98
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	$24.90
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$20.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$23.86
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 INJECTION

Facility

$41.50

Service Code	HCPCS J3490
Hospital Charge Code	41650275
Hospital Revenue Code	636
Min. Negotiated Rate	$20.75
Max. Negotiated Rate	$20.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$20.75
Rate for Payer: Hamaspik Choice Inc Medicare	$20.75

OLANZAPINE INJECTION

Facility

$41.50

Service Code	HCPCS J3490
Hospital Charge Code	41640275
Hospital Revenue Code	636
Min. Negotiated Rate	$20.75
Max. Negotiated Rate	$20.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$20.75
Rate for Payer: Hamaspik Choice Inc Medicare	$20.75

OLANZAPINE INJECTION

Facility

$41.50

Service Code	HCPCS J3490
Hospital Charge Code	41640275
Hospital Revenue Code	636
Min. Negotiated Rate	$14.52
Max. Negotiated Rate	$26.98
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	$24.90
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$20.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$23.86
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

OLIGOCLONAL BANDING

Facility

$68.48

Service Code	HCPCS 83916
Hospital Charge Code	40609102
Hospital Revenue Code	300
Min. Negotiated Rate	$19.17
Max. Negotiated Rate	$51.36
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$37.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$27.39
Rate for Payer: Aetna Government	$27.39
Rate for Payer: Affinity Essential Plan 1&2	$19.17
Rate for Payer: Affinity Essential Plan 3&4	$19.17
Rate for Payer: Affinity Medicaid/CHP/HARP	$19.17
Rate for Payer: Brighton Health Commercial	$51.36
Rate for Payer: Cash Price	$27.39
Rate for Payer: Cash Price	$27.39
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$27.39
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$31.98
Rate for Payer: Cigna LocalPlus Benefit Plan	$27.06
Rate for Payer: Elderplan Medicare Advantage	$27.39
Rate for Payer: EmblemHealth Commercial	$27.39
Rate for Payer: Fidelis Essential Plan Aliesa	$23.28
Rate for Payer: Fidelis Essential Plan QHP	$24.38
Rate for Payer: Fidelis Medicare Advantage	$27.39
Rate for Payer: Fidelis Qualified Health Plan	$24.38
Rate for Payer: Group Health Inc Commercial	$27.39
Rate for Payer: Group Health Inc Medicare	$27.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$34.24
Rate for Payer: Hamaspik Choice Inc Medicare	$27.39
Rate for Payer: Healthfirst Medicare Advantage	$27.39
Rate for Payer: Healthfirst QHP	$27.39
Rate for Payer: Humana Medicare	$27.94
Rate for Payer: Senior Whole Health Medicare Advantage	$27.39
Rate for Payer: United Healthcare Commercial	$25.47
Rate for Payer: United Healthcare Medicare Advantage	$27.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$27.39
Rate for Payer: Wellcare CHP/FHP/Medicaid	$21.91
Rate for Payer: Wellcare Medicare	$24.65

OLIGOCLONAL BANDING

Facility

$68.48

Service Code	HCPCS 83916
Hospital Charge Code	40609102
Hospital Revenue Code	300
Rate for Payer: Cash Price	$27.39

OLIVE WIRES

Facility

$575.00

Hospital Charge Code	64906019
Hospital Revenue Code	270
Min. Negotiated Rate	$201.25
Max. Negotiated Rate	$460.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$316.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$287.50
Rate for Payer: Aetna Government	$287.50
Rate for Payer: Brighton Health Commercial	$431.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$460.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$391.00
Rate for Payer: Group Health Inc Commercial	$287.50
Rate for Payer: Group Health Inc Medicare	$201.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$287.50
Rate for Payer: Hamaspik Choice Inc Medicare	$287.50

OLOPATADINE 0.1% OPHTHALMIC SOLN - NF

Facility

$230.78

Hospital Charge Code	41643857
Hospital Revenue Code	250
Min. Negotiated Rate	$80.77
Max. Negotiated Rate	$184.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$126.93
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$115.39
Rate for Payer: Aetna Government	$115.39
Rate for Payer: Brighton Health Commercial	$173.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$184.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$156.93
Rate for Payer: Group Health Inc Commercial	$115.39
Rate for Payer: Group Health Inc Medicare	$80.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$115.39
Rate for Payer: Hamaspik Choice Inc Medicare	$115.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$150.01

OLOPATADINE 0.1% OPHTHALMIC SOLN - NF

Facility

$230.78

Hospital Charge Code	41653857
Hospital Revenue Code	250
Min. Negotiated Rate	$80.77
Max. Negotiated Rate	$184.62
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$126.93
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$115.39
Rate for Payer: Aetna Government	$115.39
Rate for Payer: Brighton Health Commercial	$173.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$184.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$156.93
Rate for Payer: Group Health Inc Commercial	$115.39
Rate for Payer: Group Health Inc Medicare	$80.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$115.39
Rate for Payer: Hamaspik Choice Inc Medicare	$115.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$150.01

OLOPATADINE HCL 0.1 % OP SOLN [19452]

Facility

$3.65

Service Code	NDC 00536130840
Hospital Charge Code	00536130840
Hospital Revenue Code	250
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$2.92
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.82
Rate for Payer: Aetna Government	$1.82
Rate for Payer: Brighton Health Commercial	$2.74
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.92
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.48
Rate for Payer: Group Health Inc Commercial	$1.82
Rate for Payer: Group Health Inc Medicare	$1.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.82
Rate for Payer: Hamaspik Choice Inc Medicare	$1.82
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.37

OLOPATADINE HCL 0.1 % OP SOLN [19452]

Facility

$6.25

Service Code	NDC 70069000701
Hospital Charge Code	70069000701
Hospital Revenue Code	250
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$5.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.12
Rate for Payer: Aetna Government	$3.12
Rate for Payer: Brighton Health Commercial	$4.69
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.25
Rate for Payer: Group Health Inc Commercial	$3.12
Rate for Payer: Group Health Inc Medicare	$2.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.12
Rate for Payer: Hamaspik Choice Inc Medicare	$3.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.06

OLYMPUS THUNDERBEAT 5MM

Facility

$1,050.00

Hospital Charge Code	40005322
Hospital Revenue Code	270
Min. Negotiated Rate	$367.50
Max. Negotiated Rate	$840.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$577.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$525.00
Rate for Payer: Aetna Government	$525.00
Rate for Payer: Brighton Health Commercial	$787.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$840.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$714.00
Rate for Payer: Group Health Inc Commercial	$525.00
Rate for Payer: Group Health Inc Medicare	$367.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$525.00
Rate for Payer: Hamaspik Choice Inc Medicare	$525.00

OLYMPUS WATER CONTAINER

Facility

$509.98

Hospital Charge Code	64905415
Hospital Revenue Code	270
Min. Negotiated Rate	$178.49
Max. Negotiated Rate	$407.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$280.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$254.99
Rate for Payer: Aetna Government	$254.99
Rate for Payer: Brighton Health Commercial	$382.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$407.98
Rate for Payer: Cigna LocalPlus Benefit Plan	$346.79
Rate for Payer: Group Health Inc Commercial	$254.99
Rate for Payer: Group Health Inc Medicare	$178.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$254.99
Rate for Payer: Hamaspik Choice Inc Medicare	$254.99

OLYM THUND OPEN EXTENDED JAW

Facility

$914.00

Hospital Charge Code	40005323
Hospital Revenue Code	272
Min. Negotiated Rate	$319.90
Max. Negotiated Rate	$731.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$502.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$457.00
Rate for Payer: Aetna Government	$457.00
Rate for Payer: Brighton Health Commercial	$685.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$731.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$621.52
Rate for Payer: Group Health Inc Commercial	$457.00
Rate for Payer: Group Health Inc Medicare	$319.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$457.00
Rate for Payer: Hamaspik Choice Inc Medicare	$457.00

Know your out-of-pocket cost for care.

All Charges