St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

LEVETIRACETAM 750 MG PO TABS [26818]

Facility

$4.76

Service Code	NDC 31722053805
Hospital Charge Code	31722053805
Hospital Revenue Code	250
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$3.81
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.38
Rate for Payer: Aetna Government	$2.38
Rate for Payer: Brighton Health Commercial	$3.57
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.81
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.24
Rate for Payer: Group Health Inc Commercial	$2.38
Rate for Payer: Group Health Inc Medicare	$1.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.38
Rate for Payer: Hamaspik Choice Inc Medicare	$2.38
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.09

LEVETIRACETAM 750MG TAB

Facility

$0.54

Hospital Charge Code	41648437
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.43
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.27
Rate for Payer: Aetna Government	$0.27
Rate for Payer: Brighton Health Commercial	$0.41
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.43
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.37
Rate for Payer: Group Health Inc Commercial	$0.27
Rate for Payer: Group Health Inc Medicare	$0.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.27
Rate for Payer: Hamaspik Choice Inc Medicare	$0.27
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.35

LEVETIRACETAM 750MG TAB

Facility

$0.54

Hospital Charge Code	41658437
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.43
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.27
Rate for Payer: Aetna Government	$0.27
Rate for Payer: Brighton Health Commercial	$0.41
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.43
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.37
Rate for Payer: Group Health Inc Commercial	$0.27
Rate for Payer: Group Health Inc Medicare	$0.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.27
Rate for Payer: Hamaspik Choice Inc Medicare	$0.27
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.35

LEVETIRACETAM 750 MG TAB CR

Facility

$1.37

Hospital Charge Code	41645226
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$1.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.75
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	$0.93
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 750 MG TAB CR

Facility

$1.37

Hospital Charge Code	41655226
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$1.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.75
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	$0.93
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 IN NACL 1000 MG/100ML IV SOLN [113476]

Facility

$0.13

Service Code	HCPCS J1953
Hospital Charge Code	44567050201
Hospital Revenue Code	278
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.07
Rate for Payer: Hamaspik Choice Inc Medicare	$0.07

LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN [113476]

Facility

$0.13

Service Code	HCPCS J1953
Hospital Charge Code	44567050210
Hospital Revenue Code	278
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.07
Rate for Payer: Hamaspik Choice Inc Medicare	$0.07

LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN [113476]

Facility

$0.26

Service Code	HCPCS J1953
Hospital Charge Code	14789022010
Hospital Revenue Code	278
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.27
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.15
Rate for Payer: EmblemHealth Commercial	$0.13
Rate for Payer: Fidelis Medicare Advantage	$0.27
Rate for Payer: Group Health Inc Commercial	$0.13
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.17

LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN [113476]

Facility

$0.26

Service Code	HCPCS J1953
Hospital Charge Code	14789022010
Hospital Revenue Code	278
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13

LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN [113476]

Facility

$0.13

Service Code	HCPCS J1953
Hospital Charge Code	44567050201
Hospital Revenue Code	278
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.08
Rate for Payer: EmblemHealth Commercial	$0.07
Rate for Payer: Fidelis Medicare Advantage	$0.14
Rate for Payer: Group Health Inc Commercial	$0.07
Rate for Payer: Group Health Inc Medicare	$0.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.07
Rate for Payer: Hamaspik Choice Inc Medicare	$0.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.09

LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN [113476]

Facility

$0.26

Service Code	HCPCS J1953
Hospital Charge Code	67457026510
Hospital Revenue Code	278
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13

LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN [113476]

Facility

$0.67

Service Code	HCPCS J1953
Hospital Charge Code	70860060382
Hospital Revenue Code	278
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.71
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.37
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.39
Rate for Payer: EmblemHealth Commercial	$0.34
Rate for Payer: Fidelis Medicare Advantage	$0.71
Rate for Payer: Group Health Inc Commercial	$0.34
Rate for Payer: Group Health Inc Medicare	$0.24
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.34
Rate for Payer: Hamaspik Choice Inc Medicare	$0.34
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.44

LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN [113476]

Facility

$0.54

Service Code	HCPCS J1953
Hospital Charge Code	55150024747
Hospital Revenue Code	278
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.32
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.27
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.31
Rate for Payer: EmblemHealth Commercial	$0.27
Rate for Payer: Fidelis Medicare Advantage	$0.57
Rate for Payer: Group Health Inc Commercial	$0.27
Rate for Payer: Group Health Inc Medicare	$0.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.27
Rate for Payer: Hamaspik Choice Inc Medicare	$0.27
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.35

LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN [113476]

Facility

$0.13

Service Code	HCPCS J1953
Hospital Charge Code	44567050210
Hospital Revenue Code	278
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.08
Rate for Payer: EmblemHealth Commercial	$0.07
Rate for Payer: Fidelis Medicare Advantage	$0.14
Rate for Payer: Group Health Inc Commercial	$0.07
Rate for Payer: Group Health Inc Medicare	$0.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.07
Rate for Payer: Hamaspik Choice Inc Medicare	$0.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.09

LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN [113476]

Facility

$0.67

Service Code	HCPCS J1953
Hospital Charge Code	70860060382
Hospital Revenue Code	278
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.34
Rate for Payer: Hamaspik Choice Inc Medicare	$0.34

LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN [113476]

Facility

$0.26

Service Code	HCPCS J1953
Hospital Charge Code	67457026510
Hospital Revenue Code	278
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.27
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.15
Rate for Payer: EmblemHealth Commercial	$0.13
Rate for Payer: Fidelis Medicare Advantage	$0.27
Rate for Payer: Group Health Inc Commercial	$0.13
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.17

LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN [113476]

Facility

$0.54

Service Code	HCPCS J1953
Hospital Charge Code	55150024747
Hospital Revenue Code	278
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.27
Rate for Payer: Hamaspik Choice Inc Medicare	$0.27

LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN [113477]

Facility

$0.18

Service Code	HCPCS J1953
Hospital Charge Code	44567050301
Hospital Revenue Code	278
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.19
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.11
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.09
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.10
Rate for Payer: EmblemHealth Commercial	$0.09
Rate for Payer: Fidelis Medicare Advantage	$0.19
Rate for Payer: Group Health Inc Commercial	$0.09
Rate for Payer: Group Health Inc Medicare	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.09
Rate for Payer: Hamaspik Choice Inc Medicare	$0.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.12

LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN [113477]

Facility

$0.72

Service Code	HCPCS J1953
Hospital Charge Code	55150024847
Hospital Revenue Code	278
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.36
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.36
Rate for Payer: Hamaspik Choice Inc Medicare	$0.36

LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN [113477]

Facility

$0.18

Service Code	HCPCS J1953
Hospital Charge Code	44567050310
Hospital Revenue Code	278
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.19
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.11
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.09
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.10
Rate for Payer: EmblemHealth Commercial	$0.09
Rate for Payer: Fidelis Medicare Advantage	$0.19
Rate for Payer: Group Health Inc Commercial	$0.09
Rate for Payer: Group Health Inc Medicare	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.09
Rate for Payer: Hamaspik Choice Inc Medicare	$0.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.12

LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN [113477]

Facility

$0.72

Service Code	HCPCS J1953
Hospital Charge Code	55150024847
Hospital Revenue Code	278
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.43
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.41
Rate for Payer: EmblemHealth Commercial	$0.36
Rate for Payer: Fidelis Medicare Advantage	$0.76
Rate for Payer: Group Health Inc Commercial	$0.36
Rate for Payer: Group Health Inc Medicare	$0.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.36
Rate for Payer: Hamaspik Choice Inc Medicare	$0.36
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.47

LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN [113477]

Facility

$0.18

Service Code	HCPCS J1953
Hospital Charge Code	44567050310
Hospital Revenue Code	278
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.09
Rate for Payer: Hamaspik Choice Inc Medicare	$0.09

LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN [113477]

Facility

$0.18

Service Code	HCPCS J1953
Hospital Charge Code	44567050301
Hospital Revenue Code	278
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.09
Rate for Payer: Hamaspik Choice Inc Medicare	$0.09

LEVETIRACETAM IN NACL 500 MG/100ML IV SOLN [113475]

Facility

$0.33

Service Code	HCPCS J1953
Hospital Charge Code	55150024647
Hospital Revenue Code	278
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.17
Rate for Payer: Hamaspik Choice Inc Medicare	$0.17

LEVETIRACETAM IN NACL 500 MG/100ML IV SOLN [113475]

Facility

$0.33

Service Code	HCPCS J1953
Hospital Charge Code	55150024647
Hospital Revenue Code	278
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.19
Rate for Payer: EmblemHealth Commercial	$0.17
Rate for Payer: Fidelis Medicare Advantage	$0.35
Rate for Payer: Group Health Inc Commercial	$0.17
Rate for Payer: Group Health Inc Medicare	$0.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.17
Rate for Payer: Hamaspik Choice Inc Medicare	$0.17
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.22

Know your out-of-pocket cost for care.

All Charges