St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

LEVOCARNITINE IV 1000MG/5ML

Facility

$82.60

Service Code	HCPCS J1955
Hospital Charge Code	41656647
Hospital Revenue Code	636
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$41.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$41.30
Rate for Payer: Hamaspik Choice Inc Medicare	$41.30

LEVOFLOXACIN 250 MG/D5W 50 ML IVPB PREMI

Facility

$14.00

Service Code	HCPCS J1956
Hospital Charge Code	41651700
Hospital Revenue Code	636
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$7.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00

LEVOFLOXACIN 250 MG/D5W 50 ML IVPB PREMI

Facility

$14.00

Service Code	HCPCS J1956
Hospital Charge Code	41651700
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$9.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.91
Rate for Payer: Aetna Government	$0.91
Rate for Payer: Brighton Health Commercial	$8.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.05
Rate for Payer: Group Health Inc Commercial	$7.00
Rate for Payer: Group Health Inc Medicare	$4.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1.02
Rate for Payer: SOMOS Essential	$1.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.10

LEVOFLOXACIN 250 MG/D5W 50 ML IVPB PREMI

Facility

$14.00

Service Code	HCPCS J1956
Hospital Charge Code	41641700
Hospital Revenue Code	636
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$7.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00

LEVOFLOXACIN 250 MG/D5W 50 ML IVPB PREMI

Facility

$14.00

Service Code	HCPCS J1956
Hospital Charge Code	41641700
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$9.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.91
Rate for Payer: Aetna Government	$0.91
Rate for Payer: Brighton Health Commercial	$8.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.05
Rate for Payer: Group Health Inc Commercial	$7.00
Rate for Payer: Group Health Inc Medicare	$4.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1.02
Rate for Payer: SOMOS Essential	$1.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.10

LEVOFLOXACIN 250 MG PO TABS [18918]

Facility

$14.73

Service Code	NDC 00904635161
Hospital Charge Code	00904635161
Hospital Revenue Code	250
Min. Negotiated Rate	$5.15
Max. Negotiated Rate	$11.78
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.36
Rate for Payer: Aetna Government	$7.36
Rate for Payer: Brighton Health Commercial	$11.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.78
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.01
Rate for Payer: Group Health Inc Commercial	$7.36
Rate for Payer: Group Health Inc Medicare	$5.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.36
Rate for Payer: Hamaspik Choice Inc Medicare	$7.36
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.57

LEVOFLOXACIN 250 MG TAB

Facility

$0.26

Hospital Charge Code	41651651
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.18
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

LEVOFLOXACIN 250 MG TAB

Facility

$0.26

Hospital Charge Code	41641651
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.21
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.18
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

LEVOFLOXACIN 25 MG/ML INJ

Facility

$0.26

Service Code	HCPCS J1956
Hospital Charge Code	41652102
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$1.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.91
Rate for Payer: Aetna Government	$0.91
Rate for Payer: Brighton Health Commercial	$0.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.15
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: SOMOS CHP/HARP/Medicaid	$1.02
Rate for Payer: SOMOS Essential	$1.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.17

LEVOFLOXACIN 25 MG/ML INJ

Facility

$0.26

Hospital Charge Code	41642102
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.17
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.15
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

LEVOFLOXACIN 25 MG/ML INJ

Facility

$0.26

Hospital Charge Code	41642102
Hospital Revenue Code	636
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

LEVOFLOXACIN 25 MG/ML INJ

Facility

$0.26

Service Code	HCPCS J1956
Hospital Charge Code	41652102
Hospital Revenue Code	636
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

LEVOFLOXACIN 500 MG/D5W 100 ML IVPB PREM

Facility

$13.14

Service Code	HCPCS J1956
Hospital Charge Code	41641701
Hospital Revenue Code	636
Min. Negotiated Rate	$6.57
Max. Negotiated Rate	$6.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.57
Rate for Payer: Hamaspik Choice Inc Medicare	$6.57

LEVOFLOXACIN 500 MG/D5W 100 ML IVPB PREM

Facility

$13.14

Service Code	HCPCS J1956
Hospital Charge Code	41651701
Hospital Revenue Code	636
Min. Negotiated Rate	$6.57
Max. Negotiated Rate	$6.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.57
Rate for Payer: Hamaspik Choice Inc Medicare	$6.57

LEVOFLOXACIN 500 MG/D5W 100 ML IVPB PREM

Facility

$13.14

Service Code	HCPCS J1956
Hospital Charge Code	41651701
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$8.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.23
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.91
Rate for Payer: Aetna Government	$0.91
Rate for Payer: Brighton Health Commercial	$7.88
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.56
Rate for Payer: Group Health Inc Commercial	$6.57
Rate for Payer: Group Health Inc Medicare	$4.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.57
Rate for Payer: Hamaspik Choice Inc Medicare	$6.57
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1.02
Rate for Payer: SOMOS Essential	$1.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.54

LEVOFLOXACIN 500 MG/D5W 100 ML IVPB PREM

Facility

$13.14

Service Code	HCPCS J1956
Hospital Charge Code	41641701
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$8.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.23
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.91
Rate for Payer: Aetna Government	$0.91
Rate for Payer: Brighton Health Commercial	$7.88
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$7.56
Rate for Payer: Group Health Inc Commercial	$6.57
Rate for Payer: Group Health Inc Medicare	$4.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$6.57
Rate for Payer: Hamaspik Choice Inc Medicare	$6.57
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1.02
Rate for Payer: SOMOS Essential	$1.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$8.54

LEVOFLOXACIN 500 MG PO TABS [18919]

Facility

$20.09

Service Code	NDC 55111028050
Hospital Charge Code	55111028050
Hospital Revenue Code	250
Min. Negotiated Rate	$7.03
Max. Negotiated Rate	$16.07
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.04
Rate for Payer: Aetna Government	$10.04
Rate for Payer: Brighton Health Commercial	$15.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$16.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$13.66
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	$13.06

LEVOFLOXACIN 500 MG PO TABS [18919]

Facility

$16.82

Service Code	NDC 00904635261
Hospital Charge Code	00904635261
Hospital Revenue Code	250
Min. Negotiated Rate	$5.89
Max. Negotiated Rate	$13.46
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$8.41
Rate for Payer: Aetna Government	$8.41
Rate for Payer: Brighton Health Commercial	$12.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$13.46
Rate for Payer: Cigna LocalPlus Benefit Plan	$11.44
Rate for Payer: Group Health Inc Commercial	$8.41
Rate for Payer: Group Health Inc Medicare	$5.89
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.41
Rate for Payer: Hamaspik Choice Inc Medicare	$8.41
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10.93

LEVOFLOXACIN 500 MG TAB

Facility

$1.00

Hospital Charge Code	41641825
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

LEVOFLOXACIN 500 MG TAB

Facility

$1.00

Hospital Charge Code	41651825
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

LEVOFLOXACIN 750 MG/D5W 150 ML IVPB PREM

Facility

$8.23

Service Code	HCPCS J1956
Hospital Charge Code	41652930
Hospital Revenue Code	636
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$4.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.12
Rate for Payer: Hamaspik Choice Inc Medicare	$4.12

LEVOFLOXACIN 750 MG/D5W 150 ML IVPB PREM

Facility

$8.23

Service Code	HCPCS J1956
Hospital Charge Code	41642930
Hospital Revenue Code	636
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$4.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.12
Rate for Payer: Hamaspik Choice Inc Medicare	$4.12

LEVOFLOXACIN 750 MG/D5W 150 ML IVPB PREM

Facility

$8.23

Service Code	HCPCS J1956
Hospital Charge Code	41642930
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$5.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.53
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.91
Rate for Payer: Aetna Government	$0.91
Rate for Payer: Brighton Health Commercial	$4.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.73
Rate for Payer: Group Health Inc Commercial	$4.12
Rate for Payer: Group Health Inc Medicare	$2.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.12
Rate for Payer: Hamaspik Choice Inc Medicare	$4.12
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1.02
Rate for Payer: SOMOS Essential	$1.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.35

LEVOFLOXACIN 750 MG/D5W 150 ML IVPB PREM

Facility

$8.23

Service Code	HCPCS J1956
Hospital Charge Code	41652930
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$5.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.53
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.91
Rate for Payer: Aetna Government	$0.91
Rate for Payer: Brighton Health Commercial	$4.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.73
Rate for Payer: Group Health Inc Commercial	$4.12
Rate for Payer: Group Health Inc Medicare	$2.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.12
Rate for Payer: Hamaspik Choice Inc Medicare	$4.12
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1.02
Rate for Payer: SOMOS Essential	$1.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.35

LEVOFLOXACIN 750 MG PO TABS [28964]

Facility

$36.12

Service Code	NDC 31722072320
Hospital Charge Code	31722072320
Hospital Revenue Code	250
Min. Negotiated Rate	$12.64
Max. Negotiated Rate	$28.89
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$19.86
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$18.06
Rate for Payer: Aetna Government	$18.06
Rate for Payer: Brighton Health Commercial	$27.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$28.89
Rate for Payer: Cigna LocalPlus Benefit Plan	$24.56
Rate for Payer: Group Health Inc Commercial	$18.06
Rate for Payer: Group Health Inc Medicare	$12.64
Rate for Payer: Hamaspik Choice Inc Medicaid	$18.06
Rate for Payer: Hamaspik Choice Inc Medicare	$18.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$23.48

Know your out-of-pocket cost for care.

All Charges