St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

LEVETIRACETAM 100 MG/ML INJ

Facility

$0.39

Service Code	HCPCS J1953
Hospital Charge Code	41654576
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.22
Rate for Payer: Group Health Inc Commercial	$0.20
Rate for Payer: Group Health Inc Medicare	$0.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.20
Rate for Payer: Hamaspik Choice Inc Medicare	$0.20
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.07
Rate for Payer: SOMOS Essential	$0.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.25

LEVETIRACETAM 100 MG/ML INJ

Facility

$0.39

Service Code	HCPCS J1953
Hospital Charge Code	41654576
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.20
Rate for Payer: Hamaspik Choice Inc Medicare	$0.20

LEVETIRACETAM 100 MG/ML LIQUID

Facility

$0.15

Hospital Charge Code	41654673
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.08
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.08
Rate for Payer: Aetna Government	$0.08
Rate for Payer: Brighton Health Commercial	$0.11
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.10
Rate for Payer: Group Health Inc Commercial	$0.08
Rate for Payer: Group Health Inc Medicare	$0.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.08
Rate for Payer: Hamaspik Choice Inc Medicare	$0.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.10

LEVETIRACETAM 100 MG/ML LIQUID

Facility

$0.15

Hospital Charge Code	41644673
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.08
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.08
Rate for Payer: Aetna Government	$0.08
Rate for Payer: Brighton Health Commercial	$0.11
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.10
Rate for Payer: Group Health Inc Commercial	$0.08
Rate for Payer: Group Health Inc Medicare	$0.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.08
Rate for Payer: Hamaspik Choice Inc Medicare	$0.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.10

LEVETIRACETAM 100 MG/ML PO SOLN [36590]

Facility

$0.88

Service Code	NDC 00904706092
Hospital Charge Code	00904706092
Hospital Revenue Code	250
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.44
Rate for Payer: Aetna Government	$0.44
Rate for Payer: Brighton Health Commercial	$0.66
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.60
Rate for Payer: Group Health Inc Commercial	$0.44
Rate for Payer: Group Health Inc Medicare	$0.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.44
Rate for Payer: Hamaspik Choice Inc Medicare	$0.44
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.57

LEVETIRACETAM 100 MG/ML PO SOLN [36590]

Facility

$0.65

Service Code	NDC 00121079916
Hospital Charge Code	00121079916
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.33
Rate for Payer: Aetna Government	$0.33
Rate for Payer: Brighton Health Commercial	$0.49
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.44
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.42

LEVETIRACETAM 100 MG/ML PO SOLN [36590]

Facility

$0.61

Service Code	NDC 54838054880
Hospital Charge Code	54838054880
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.34
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.31
Rate for Payer: Aetna Government	$0.31
Rate for Payer: Brighton Health Commercial	$0.46
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.49
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.42
Rate for Payer: Group Health Inc Commercial	$0.31
Rate for Payer: Group Health Inc Medicare	$0.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.31
Rate for Payer: Hamaspik Choice Inc Medicare	$0.31
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.40

LEVETIRACETAM 100 MG/ML PO SOLN [36590]

Facility

$0.87

Service Code	NDC 00904706093
Hospital Charge Code	00904706093
Hospital Revenue Code	250
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.43
Rate for Payer: Aetna Government	$0.43
Rate for Payer: Brighton Health Commercial	$0.65
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.59
Rate for Payer: Group Health Inc Commercial	$0.43
Rate for Payer: Group Health Inc Medicare	$0.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.43
Rate for Payer: Hamaspik Choice Inc Medicare	$0.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.56

LEVETIRACETAM 100 MG/ML PO SOLN [36590]

Facility

$1.38

Service Code	NDC 50383024106
Hospital Charge Code	50383024106
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$1.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.69
Rate for Payer: Aetna Government	$0.69
Rate for Payer: Brighton Health Commercial	$1.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.94
Rate for Payer: Group Health Inc Commercial	$0.69
Rate for Payer: Group Health Inc Medicare	$0.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.69
Rate for Payer: Hamaspik Choice Inc Medicare	$0.69
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.89

LEVETIRACETAM 100 MG/ML PO SOLN [36590]

Facility

$0.76

Service Code	NDC 00904726594
Hospital Charge Code	00904726594
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.61
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.42
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.38
Rate for Payer: Aetna Government	$0.38
Rate for Payer: Brighton Health Commercial	$0.57
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.61
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.52
Rate for Payer: Group Health Inc Commercial	$0.38
Rate for Payer: Group Health Inc Medicare	$0.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.38
Rate for Payer: Hamaspik Choice Inc Medicare	$0.38
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.49

LEVETIRACETAM 100 MG/ML PO SOLN [36590]

Facility

$0.66

Service Code	NDC 63739001971
Hospital Charge Code	63739001971
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.33
Rate for Payer: Aetna Government	$0.33
Rate for Payer: Brighton Health Commercial	$0.49
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.45
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.43

LEVETIRACETAM 100 MG/ML PO SOLN [36590]

Facility

$1.87

Service Code	NDC 00121479940
Hospital Charge Code	00121479940
Hospital Revenue Code	250
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$1.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.93
Rate for Payer: Aetna Government	$0.93
Rate for Payer: Brighton Health Commercial	$1.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.27
Rate for Payer: Group Health Inc Commercial	$0.93
Rate for Payer: Group Health Inc Medicare	$0.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.93
Rate for Payer: Hamaspik Choice Inc Medicare	$0.93
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.21

LEVETIRACETAM 100 MG/ML PO SOLN [36590]

Facility

$1.38

Service Code	NDC 50268047013
Hospital Charge Code	50268047013
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$1.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.69
Rate for Payer: Aetna Government	$0.69
Rate for Payer: Brighton Health Commercial	$1.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.94
Rate for Payer: Group Health Inc Commercial	$0.69
Rate for Payer: Group Health Inc Medicare	$0.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.69
Rate for Payer: Hamaspik Choice Inc Medicare	$0.69
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.89

LEVETIRACETAM 100 MG/ML PO SOLN [36590]

Facility

$0.65

Service Code	NDC 65862025047
Hospital Charge Code	65862025047
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.33
Rate for Payer: Aetna Government	$0.33
Rate for Payer: Brighton Health Commercial	$0.49
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.44
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.42

LEVETIRACETAM 1500MG/100ML PREMIX

Facility

$0.46

Service Code	HCPCS J1953
Hospital Charge Code	41647937
Hospital Revenue Code	636
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.23
Rate for Payer: Hamaspik Choice Inc Medicare	$0.23

LEVETIRACETAM 1500MG/100ML PREMIX

Facility

$0.46

Service Code	HCPCS J1953
Hospital Charge Code	41657937
Hospital Revenue Code	636
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.23
Rate for Payer: Hamaspik Choice Inc Medicare	$0.23

LEVETIRACETAM 1500MG/100ML PREMIX

Facility

$0.46

Service Code	HCPCS J1953
Hospital Charge Code	41657937
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.28
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.23
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.26
Rate for Payer: Group Health Inc Commercial	$0.23
Rate for Payer: Group Health Inc Medicare	$0.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.23
Rate for Payer: Hamaspik Choice Inc Medicare	$0.23
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.07
Rate for Payer: SOMOS Essential	$0.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.30

LEVETIRACETAM 1500MG/100ML PREMIX

Facility

$0.46

Service Code	HCPCS J1953
Hospital Charge Code	41647937
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.28
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.23
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.26
Rate for Payer: Group Health Inc Commercial	$0.23
Rate for Payer: Group Health Inc Medicare	$0.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.23
Rate for Payer: Hamaspik Choice Inc Medicare	$0.23
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.07
Rate for Payer: SOMOS Essential	$0.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.30

LEVETIRACETAM 250 MG PO TABS [26816]

Facility

$0.60

Service Code	NDC 68084085911
Hospital Charge Code	68084085911
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.48
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.30
Rate for Payer: Aetna Government	$0.30
Rate for Payer: Brighton Health Commercial	$0.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.48
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.41
Rate for Payer: Group Health Inc Commercial	$0.30
Rate for Payer: Group Health Inc Medicare	$0.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.30
Rate for Payer: Hamaspik Choice Inc Medicare	$0.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.39

LEVETIRACETAM 250 MG PO TABS [26816]

Facility

$2.88

Service Code	NDC 65862024508
Hospital Charge Code	65862024508
Hospital Revenue Code	250
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$2.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.58
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.44
Rate for Payer: Aetna Government	$1.44
Rate for Payer: Brighton Health Commercial	$2.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.96
Rate for Payer: Group Health Inc Commercial	$1.44
Rate for Payer: Group Health Inc Medicare	$1.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.44
Rate for Payer: Hamaspik Choice Inc Medicare	$1.44
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.87

LEVETIRACETAM 250 MG PO TABS [26816]

Facility

$0.60

Service Code	NDC 68084085901
Hospital Charge Code	68084085901
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.48
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.30
Rate for Payer: Aetna Government	$0.30
Rate for Payer: Brighton Health Commercial	$0.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.48
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.41
Rate for Payer: Group Health Inc Commercial	$0.30
Rate for Payer: Group Health Inc Medicare	$0.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.30
Rate for Payer: Hamaspik Choice Inc Medicare	$0.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.39

LEVETIRACETAM 250MG TAB

Facility

$0.12

Hospital Charge Code	41648435
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.06
Rate for Payer: Aetna Government	$0.06
Rate for Payer: Brighton Health Commercial	$0.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.08
Rate for Payer: Group Health Inc Commercial	$0.06
Rate for Payer: Group Health Inc Medicare	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.06
Rate for Payer: Hamaspik Choice Inc Medicare	$0.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.08

LEVETIRACETAM 250MG TAB

Facility

$0.12

Hospital Charge Code	41658435
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.06
Rate for Payer: Aetna Government	$0.06
Rate for Payer: Brighton Health Commercial	$0.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.08
Rate for Payer: Group Health Inc Commercial	$0.06
Rate for Payer: Group Health Inc Medicare	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.06
Rate for Payer: Hamaspik Choice Inc Medicare	$0.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.08

LEVETIRACETAM 500MG/100ML PREMIX

Facility

$0.65

Service Code	HCPCS J1953
Hospital Charge Code	41647939
Hospital Revenue Code	636
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33

LEVETIRACETAM 500MG/100ML PREMIX

Facility

$0.65

Service Code	HCPCS J1953
Hospital Charge Code	41657939
Hospital Revenue Code	636
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33

Know your out-of-pocket cost for care.

All Charges