St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

LEVONORGESTREL 1.5MG TAB

Facility

$20.00

Hospital Charge Code	41655981
Hospital Revenue Code	250
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$16.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.00
Rate for Payer: Aetna Government	$10.00
Rate for Payer: Brighton Health Commercial	$15.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$16.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$13.60
Rate for Payer: Group Health Inc Commercial	$10.00
Rate for Payer: Group Health Inc Medicare	$7.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.00
Rate for Payer: Hamaspik Choice Inc Medicare	$10.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.00

LEVONORGESTREL 1.5MG TAB

Facility

$20.00

Hospital Charge Code	41645981
Hospital Revenue Code	250
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$16.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.00
Rate for Payer: Aetna Government	$10.00
Rate for Payer: Brighton Health Commercial	$15.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$16.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$13.60
Rate for Payer: Group Health Inc Commercial	$10.00
Rate for Payer: Group Health Inc Medicare	$7.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.00
Rate for Payer: Hamaspik Choice Inc Medicare	$10.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.00

LEVONORGESTREL 20.1 MCG/DAY IU IUD [184276]

Facility

$1,064.83

Service Code	HCPCS J7297
Hospital Charge Code	00023585801
Hospital Revenue Code	250
Min. Negotiated Rate	$372.69
Max. Negotiated Rate	$851.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$585.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$845.10
Rate for Payer: Aetna Government	$845.10
Rate for Payer: Brighton Health Commercial	$798.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$851.86
Rate for Payer: Cigna LocalPlus Benefit Plan	$724.08
Rate for Payer: Group Health Inc Commercial	$532.42
Rate for Payer: Group Health Inc Medicare	$372.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$532.42
Rate for Payer: Hamaspik Choice Inc Medicare	$532.42
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$692.14

LEVONORGESTREL 20 MCG/DAY IU IUD [184275]

Facility

$1,388.15

Service Code	HCPCS J7298
Hospital Charge Code	50419042301
Hospital Revenue Code	250
Min. Negotiated Rate	$485.85
Max. Negotiated Rate	$1,110.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$763.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$999.28
Rate for Payer: Aetna Government	$999.28
Rate for Payer: Brighton Health Commercial	$1,041.11
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,110.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$943.94
Rate for Payer: Group Health Inc Commercial	$694.08
Rate for Payer: Group Health Inc Medicare	$485.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$694.08
Rate for Payer: Hamaspik Choice Inc Medicare	$694.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$902.30

LEVONORGESTREL-ETHINYL ESTRAD 0.15-30 MG-MCG PO TABS [10401]

Facility

$1.11

Service Code	NDC 69238155406
Hospital Charge Code	69238155406
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.55
Rate for Payer: Aetna Government	$0.55
Rate for Payer: Brighton Health Commercial	$0.83
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.75
Rate for Payer: Group Health Inc Commercial	$0.55
Rate for Payer: Group Health Inc Medicare	$0.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.55
Rate for Payer: Hamaspik Choice Inc Medicare	$0.55
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.72

LEVONORGESTREL IU 52MG

Facility

$1,437.50

Service Code	HCPCS J7297
Hospital Charge Code	41656550
Hospital Revenue Code	636
Min. Negotiated Rate	$718.75
Max. Negotiated Rate	$718.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$718.75
Rate for Payer: Hamaspik Choice Inc Medicare	$718.75

LEVONORGESTREL IU 52MG

Facility

$1,437.50

Service Code	HCPCS J7297
Hospital Charge Code	41646550
Hospital Revenue Code	636
Min. Negotiated Rate	$503.12
Max. Negotiated Rate	$934.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$790.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$845.10
Rate for Payer: Aetna Government	$845.10
Rate for Payer: Brighton Health Commercial	$862.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$718.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$826.56
Rate for Payer: Group Health Inc Commercial	$718.75
Rate for Payer: Group Health Inc Medicare	$503.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$718.75
Rate for Payer: Hamaspik Choice Inc Medicare	$718.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$934.38

LEVONORGESTREL IU 52MG

Facility

$322.25

Service Code	HCPCS J7298
Hospital Charge Code	41647891
Hospital Revenue Code	636
Min. Negotiated Rate	$112.79
Max. Negotiated Rate	$999.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$177.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$999.28
Rate for Payer: Aetna Government	$999.28
Rate for Payer: Brighton Health Commercial	$193.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$161.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$185.29
Rate for Payer: Group Health Inc Commercial	$161.12
Rate for Payer: Group Health Inc Medicare	$112.79
Rate for Payer: Hamaspik Choice Inc Medicaid	$161.12
Rate for Payer: Hamaspik Choice Inc Medicare	$161.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$209.46

LEVONORGESTREL IU 52MG

Facility

$1,437.50

Service Code	HCPCS J7297
Hospital Charge Code	41656550
Hospital Revenue Code	636
Min. Negotiated Rate	$503.12
Max. Negotiated Rate	$934.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$790.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$845.10
Rate for Payer: Aetna Government	$845.10
Rate for Payer: Brighton Health Commercial	$862.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$718.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$826.56
Rate for Payer: Group Health Inc Commercial	$718.75
Rate for Payer: Group Health Inc Medicare	$503.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$718.75
Rate for Payer: Hamaspik Choice Inc Medicare	$718.75
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$934.38

LEVONORGESTREL IU 52MG

Facility

$322.25

Service Code	HCPCS J7298
Hospital Charge Code	41657891
Hospital Revenue Code	636
Min. Negotiated Rate	$161.12
Max. Negotiated Rate	$161.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$161.12
Rate for Payer: Hamaspik Choice Inc Medicare	$161.12

LEVONORGESTREL IU 52MG

Facility

$322.25

Service Code	HCPCS J7298
Hospital Charge Code	41657891
Hospital Revenue Code	636
Min. Negotiated Rate	$112.79
Max. Negotiated Rate	$999.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$177.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$999.28
Rate for Payer: Aetna Government	$999.28
Rate for Payer: Brighton Health Commercial	$193.35
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$161.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$185.29
Rate for Payer: Group Health Inc Commercial	$161.12
Rate for Payer: Group Health Inc Medicare	$112.79
Rate for Payer: Hamaspik Choice Inc Medicaid	$161.12
Rate for Payer: Hamaspik Choice Inc Medicare	$161.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$209.46

LEVONORGESTREL IU 52MG

Facility

$322.25

Service Code	HCPCS J7298
Hospital Charge Code	41647891
Hospital Revenue Code	636
Min. Negotiated Rate	$161.12
Max. Negotiated Rate	$161.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$161.12
Rate for Payer: Hamaspik Choice Inc Medicare	$161.12

LEVONORGESTREL IU 52MG

Facility

$1,437.50

Service Code	HCPCS J7297
Hospital Charge Code	41646550
Hospital Revenue Code	636
Min. Negotiated Rate	$718.75
Max. Negotiated Rate	$718.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$718.75
Rate for Payer: Hamaspik Choice Inc Medicare	$718.75

LEVOTHYROXINE 100MCG

Facility

$110.14

Service Code	HCPCS J3490
Hospital Charge Code	41650368
Hospital Revenue Code	636
Min. Negotiated Rate	$55.07
Max. Negotiated Rate	$55.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$55.07
Rate for Payer: Hamaspik Choice Inc Medicare	$55.07

LEVOTHYROXINE 100MCG

Facility

$110.14

Service Code	HCPCS J3490
Hospital Charge Code	41640368
Hospital Revenue Code	636
Min. Negotiated Rate	$55.07
Max. Negotiated Rate	$55.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$55.07
Rate for Payer: Hamaspik Choice Inc Medicare	$55.07

LEVOTHYROXINE 100MCG

Facility

$394.90

Service Code	HCPCS J3490
Hospital Charge Code	41640195
Hospital Revenue Code	636
Min. Negotiated Rate	$138.22
Max. Negotiated Rate	$256.68
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$217.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$197.45
Rate for Payer: Aetna Government	$197.45
Rate for Payer: Brighton Health Commercial	$236.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$197.45
Rate for Payer: Cigna LocalPlus Benefit Plan	$227.07
Rate for Payer: Group Health Inc Commercial	$197.45
Rate for Payer: Group Health Inc Medicare	$138.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$197.45
Rate for Payer: Hamaspik Choice Inc Medicare	$197.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$256.68

LEVOTHYROXINE 100MCG

Facility

$394.90

Service Code	HCPCS J3490
Hospital Charge Code	41640195
Hospital Revenue Code	636
Min. Negotiated Rate	$197.45
Max. Negotiated Rate	$197.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$197.45
Rate for Payer: Hamaspik Choice Inc Medicare	$197.45

LEVOTHYROXINE 100MCG

Facility

$394.90

Service Code	HCPCS J3490
Hospital Charge Code	41650195
Hospital Revenue Code	636
Min. Negotiated Rate	$197.45
Max. Negotiated Rate	$197.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$197.45
Rate for Payer: Hamaspik Choice Inc Medicare	$197.45

LEVOTHYROXINE 100MCG

Facility

$110.14

Service Code	HCPCS J3490
Hospital Charge Code	41640368
Hospital Revenue Code	636
Min. Negotiated Rate	$38.55
Max. Negotiated Rate	$71.59
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$60.58
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$55.07
Rate for Payer: Aetna Government	$55.07
Rate for Payer: Brighton Health Commercial	$66.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$55.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$63.33
Rate for Payer: Group Health Inc Commercial	$55.07
Rate for Payer: Group Health Inc Medicare	$38.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$55.07
Rate for Payer: Hamaspik Choice Inc Medicare	$55.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$71.59

LEVOTHYROXINE 100MCG

Facility

$394.90

Service Code	HCPCS J3490
Hospital Charge Code	41650195
Hospital Revenue Code	636
Min. Negotiated Rate	$138.22
Max. Negotiated Rate	$256.68
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$217.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$197.45
Rate for Payer: Aetna Government	$197.45
Rate for Payer: Brighton Health Commercial	$236.94
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$197.45
Rate for Payer: Cigna LocalPlus Benefit Plan	$227.07
Rate for Payer: Group Health Inc Commercial	$197.45
Rate for Payer: Group Health Inc Medicare	$138.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$197.45
Rate for Payer: Hamaspik Choice Inc Medicare	$197.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$256.68

LEVOTHYROXINE 100MCG

Facility

$110.14

Service Code	HCPCS J3490
Hospital Charge Code	41650368
Hospital Revenue Code	636
Min. Negotiated Rate	$38.55
Max. Negotiated Rate	$71.59
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$60.58
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$55.07
Rate for Payer: Aetna Government	$55.07
Rate for Payer: Brighton Health Commercial	$66.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$55.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$63.33
Rate for Payer: Group Health Inc Commercial	$55.07
Rate for Payer: Group Health Inc Medicare	$38.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$55.07
Rate for Payer: Hamaspik Choice Inc Medicare	$55.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$71.59

LEVOTHYROXINE 100 MCG TAB

Facility

$0.30

Hospital Charge Code	41643966
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.15
Rate for Payer: Aetna Government	$0.15
Rate for Payer: Brighton Health Commercial	$0.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.20
Rate for Payer: Group Health Inc Commercial	$0.15
Rate for Payer: Group Health Inc Medicare	$0.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.20

LEVOTHYROXINE 100 MCG TAB

Facility

$0.30

Hospital Charge Code	41653966
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.15
Rate for Payer: Aetna Government	$0.15
Rate for Payer: Brighton Health Commercial	$0.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.20
Rate for Payer: Group Health Inc Commercial	$0.15
Rate for Payer: Group Health Inc Medicare	$0.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.20

LEVOTHYROXINE 100 MCG VIAL

Facility

$105.88

Hospital Charge Code	41646094
Hospital Revenue Code	250
Min. Negotiated Rate	$37.06
Max. Negotiated Rate	$84.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$58.23
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$52.94
Rate for Payer: Aetna Government	$52.94
Rate for Payer: Brighton Health Commercial	$79.41
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$84.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$72.00
Rate for Payer: Group Health Inc Commercial	$52.94
Rate for Payer: Group Health Inc Medicare	$37.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$52.94
Rate for Payer: Hamaspik Choice Inc Medicare	$52.94
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$68.82

LEVOTHYROXINE 100 MCG VIAL

Facility

$105.88

Hospital Charge Code	41656094
Hospital Revenue Code	250
Min. Negotiated Rate	$37.06
Max. Negotiated Rate	$84.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$58.23
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$52.94
Rate for Payer: Aetna Government	$52.94
Rate for Payer: Brighton Health Commercial	$79.41
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$84.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$72.00
Rate for Payer: Group Health Inc Commercial	$52.94
Rate for Payer: Group Health Inc Medicare	$37.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$52.94
Rate for Payer: Hamaspik Choice Inc Medicare	$52.94
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$68.82

Know your out-of-pocket cost for care.

All Charges