St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

TERBUTALINE SULFATE 1 MG/ML IJ SOLN

Facility

$4.80

Service Code	HCPCS J3105
Hospital Charge Code	0143974601
Hospital Revenue Code	250
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$2.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.40

TERBUTALINE SULFATE 1 MG/ML IJ SOLN

Facility

$23.64

Service Code	HCPCS J3105
Hospital Charge Code	6332366501
Hospital Revenue Code	250
Min. Negotiated Rate	$11.82
Max. Negotiated Rate	$11.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.82

TERBUTALINE SULFATE 2.5 MG PO TABS

Facility

$5.44

Service Code	NDC 0527131801
Hospital Charge Code	0527131801
Hospital Revenue Code	250
Min. Negotiated Rate	$1.90
Max. Negotiated Rate	$4.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.99
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.72
Rate for Payer: Aetna Government	$2.72
Rate for Payer: Brighton Health Commercial	$4.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.70
Rate for Payer: EmblemHealth Commercial	$2.72
Rate for Payer: Group Health Inc Commercial	$2.72
Rate for Payer: Group Health Inc Medicare	$1.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.72
Rate for Payer: Hamaspik Choice Inc Medicare	$2.72
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.54

TERBUTALINE SULFATE 2.5 MG PO TABS

Facility

$5.44

Service Code	NDC 0527131801
Hospital Charge Code	0527131801
Hospital Revenue Code	250
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$2.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.72

TERBUTALINE SULFATE 2.5 MG PO TABS

Facility

$5.44

Service Code	NDC 0115261101
Hospital Charge Code	0115261101
Hospital Revenue Code	250
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$2.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.72

TERBUTALINE SULFATE 2.5 MG PO TABS

Facility

$5.44

Service Code	NDC 0115261101
Hospital Charge Code	0115261101
Hospital Revenue Code	250
Min. Negotiated Rate	$1.90
Max. Negotiated Rate	$4.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.99
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.72
Rate for Payer: Aetna Government	$2.72
Rate for Payer: Brighton Health Commercial	$4.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.70
Rate for Payer: EmblemHealth Commercial	$2.72
Rate for Payer: Group Health Inc Commercial	$2.72
Rate for Payer: Group Health Inc Medicare	$1.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.72
Rate for Payer: Hamaspik Choice Inc Medicare	$2.72
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.54

Testes & scrotal procedures

Facility

$54,546.21

Service Code	APR-DRG 4832
Min. Negotiated Rate	$12,335.00
Max. Negotiated Rate	$54,546.21
Rate for Payer: Affinity Essential Plan 1&2	$54,546.21
Rate for Payer: Affinity Essential Plan 3&4	$54,546.21
Rate for Payer: Affinity Medicaid/CHP/HARP	$24,242.76
Rate for Payer: Amida Care Medicaid	$24,242.76
Rate for Payer: EmblemHealth Essential Plan 1&2	$54,546.21
Rate for Payer: EmblemHealth Essential Plan 3&4	$24,242.76
Rate for Payer: Fidelis CHP/HARP/Medicaid	$24,242.76
Rate for Payer: Fidelis Qualified Health Plan	$29,091.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$24,242.76
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$24,242.76
Rate for Payer: Healthfirst Commercial	$21,929.00
Rate for Payer: Healthfirst Essential Plan	$54,546.21
Rate for Payer: Healthfirst QHP	$12,335.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$24,242.76
Rate for Payer: SOMOS Essential	$54,546.21
Rate for Payer: United Healthcare Essential Plan 1&2	$54,546.21
Rate for Payer: United Healthcare Essential Plan 3&4	$54,546.21
Rate for Payer: United Healthcare Medicaid	$24,242.76
Rate for Payer: Wellcare CHP/FHP/Medicaid	$24,242.76

Testes & scrotal procedures

Facility

$43,126.67

Service Code	APR-DRG 4831
Min. Negotiated Rate	$6,880.00
Max. Negotiated Rate	$43,126.67
Rate for Payer: Affinity Essential Plan 1&2	$43,126.67
Rate for Payer: Affinity Essential Plan 3&4	$43,126.67
Rate for Payer: Affinity Medicaid/CHP/HARP	$19,167.41
Rate for Payer: Amida Care Medicaid	$19,167.41
Rate for Payer: EmblemHealth Essential Plan 1&2	$43,126.67
Rate for Payer: EmblemHealth Essential Plan 3&4	$19,167.41
Rate for Payer: Fidelis CHP/HARP/Medicaid	$19,167.41
Rate for Payer: Fidelis Qualified Health Plan	$23,000.89
Rate for Payer: Hamaspik Choice Inc Medicaid	$19,167.41
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$19,167.41
Rate for Payer: Healthfirst Commercial	$11,840.00
Rate for Payer: Healthfirst Essential Plan	$43,126.67
Rate for Payer: Healthfirst QHP	$6,880.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$19,167.41
Rate for Payer: SOMOS Essential	$43,126.67
Rate for Payer: United Healthcare Essential Plan 1&2	$43,126.67
Rate for Payer: United Healthcare Essential Plan 3&4	$43,126.67
Rate for Payer: United Healthcare Medicaid	$19,167.41
Rate for Payer: Wellcare CHP/FHP/Medicaid	$19,167.41

Testes & scrotal procedures

Facility

$87,971.18

Service Code	APR-DRG 4833
Min. Negotiated Rate	$25,398.00
Max. Negotiated Rate	$87,971.18
Rate for Payer: Affinity Essential Plan 1&2	$87,971.18
Rate for Payer: Affinity Essential Plan 3&4	$87,971.18
Rate for Payer: Affinity Medicaid/CHP/HARP	$39,098.30
Rate for Payer: Amida Care Medicaid	$39,098.30
Rate for Payer: EmblemHealth Essential Plan 1&2	$87,971.18
Rate for Payer: EmblemHealth Essential Plan 3&4	$39,098.30
Rate for Payer: Fidelis CHP/HARP/Medicaid	$39,098.30
Rate for Payer: Fidelis Qualified Health Plan	$46,917.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$39,098.30
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$39,098.30
Rate for Payer: Healthfirst Commercial	$45,797.00
Rate for Payer: Healthfirst Essential Plan	$87,971.18
Rate for Payer: Healthfirst QHP	$25,398.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$39,098.30
Rate for Payer: SOMOS Essential	$87,971.18
Rate for Payer: United Healthcare Essential Plan 1&2	$87,971.18
Rate for Payer: United Healthcare Essential Plan 3&4	$87,971.18
Rate for Payer: United Healthcare Medicaid	$39,098.30
Rate for Payer: Wellcare CHP/FHP/Medicaid	$39,098.30

Testes & scrotal procedures

Facility

$107,255.84

Service Code	APR-DRG 4834
Min. Negotiated Rate	$35,867.00
Max. Negotiated Rate	$107,255.84
Rate for Payer: Affinity Essential Plan 1&2	$107,255.84
Rate for Payer: Affinity Essential Plan 3&4	$107,255.84
Rate for Payer: Affinity Medicaid/CHP/HARP	$47,669.26
Rate for Payer: Amida Care Medicaid	$47,669.26
Rate for Payer: EmblemHealth Essential Plan 1&2	$107,255.84
Rate for Payer: EmblemHealth Essential Plan 3&4	$47,669.26
Rate for Payer: Fidelis CHP/HARP/Medicaid	$47,669.26
Rate for Payer: Fidelis Qualified Health Plan	$57,203.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$47,669.26
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$47,669.26
Rate for Payer: Healthfirst Commercial	$48,352.00
Rate for Payer: Healthfirst Essential Plan	$107,255.84
Rate for Payer: Healthfirst QHP	$35,867.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$47,669.26
Rate for Payer: SOMOS Essential	$107,255.84
Rate for Payer: United Healthcare Essential Plan 1&2	$107,255.84
Rate for Payer: United Healthcare Essential Plan 3&4	$107,255.84
Rate for Payer: United Healthcare Medicaid	$47,669.26
Rate for Payer: Wellcare CHP/FHP/Medicaid	$47,669.26

TESTICULAR AND EPIDIDYMAL PROCEDURES

Facility

$2,262.24

Service Code	EAPG 00180
Min. Negotiated Rate	$1,643.15
Max. Negotiated Rate	$2,262.24
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1,643.15
Rate for Payer: Healthfirst Commercial	$2,262.24

TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN

Facility

$25.96

Service Code	HCPCS J1071
Hospital Charge Code	0009041701
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$20.77
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$14.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.03
Rate for Payer: Aetna Government	$0.03
Rate for Payer: Brighton Health Commercial	$19.47
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$20.77
Rate for Payer: Cigna LocalPlus Benefit Plan	$17.65
Rate for Payer: EmblemHealth Commercial	$12.98
Rate for Payer: Group Health Inc Commercial	$12.98
Rate for Payer: Group Health Inc Medicare	$9.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$12.98
Rate for Payer: Hamaspik Choice Inc Medicare	$12.98
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$16.87

TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN

Facility

$25.96

Service Code	HCPCS J1071
Hospital Charge Code	0009041701
Hospital Revenue Code	250
Min. Negotiated Rate	$12.98
Max. Negotiated Rate	$12.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$12.98

TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN

Facility

$23.15

Service Code	HCPCS J1071
Hospital Charge Code	6275601540
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$18.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$12.73
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.03
Rate for Payer: Aetna Government	$0.03
Rate for Payer: Brighton Health Commercial	$17.36
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$15.74
Rate for Payer: EmblemHealth Commercial	$11.57
Rate for Payer: Group Health Inc Commercial	$11.57
Rate for Payer: Group Health Inc Medicare	$8.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.57
Rate for Payer: Hamaspik Choice Inc Medicare	$11.57
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$15.05

TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN

Facility

$23.15

Service Code	HCPCS J1071
Hospital Charge Code	6275601540
Hospital Revenue Code	250
Min. Negotiated Rate	$11.57
Max. Negotiated Rate	$11.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$11.57

TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP

Facility

$113.90

Service Code	HCPCS 90715
Hospital Charge Code	4928140020
Hospital Revenue Code	250
Min. Negotiated Rate	$35.80
Max. Negotiated Rate	$91.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$62.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.80
Rate for Payer: Aetna Government	$35.80
Rate for Payer: Brighton Health Commercial	$85.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$91.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$77.45
Rate for Payer: EmblemHealth Commercial	$56.95
Rate for Payer: Group Health Inc Commercial	$56.95
Rate for Payer: Group Health Inc Medicare	$39.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$56.95
Rate for Payer: Hamaspik Choice Inc Medicare	$56.95
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$39.81
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$74.03

TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP

Facility

$113.89

Service Code	HCPCS 90715
Hospital Charge Code	4928140010
Hospital Revenue Code	250
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$56.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$56.95

TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP

Facility

$113.89

Service Code	HCPCS 90715
Hospital Charge Code	4928140010
Hospital Revenue Code	250
Min. Negotiated Rate	$35.80
Max. Negotiated Rate	$91.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$62.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.80
Rate for Payer: Aetna Government	$35.80
Rate for Payer: Brighton Health Commercial	$85.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$91.11
Rate for Payer: Cigna LocalPlus Benefit Plan	$77.45
Rate for Payer: EmblemHealth Commercial	$56.95
Rate for Payer: Group Health Inc Commercial	$56.95
Rate for Payer: Group Health Inc Medicare	$39.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$56.95
Rate for Payer: Hamaspik Choice Inc Medicare	$56.95
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$39.81
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$74.03

TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP

Facility

$113.90

Service Code	HCPCS 90715
Hospital Charge Code	4928140020
Hospital Revenue Code	250
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$56.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$56.95

TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSY

Facility

$112.84

Service Code	HCPCS 90715
Hospital Charge Code	5816084252
Hospital Revenue Code	250
Min. Negotiated Rate	$35.80
Max. Negotiated Rate	$90.27
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$62.06
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.80
Rate for Payer: Aetna Government	$35.80
Rate for Payer: Brighton Health Commercial	$84.63
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$90.27
Rate for Payer: Cigna LocalPlus Benefit Plan	$76.73
Rate for Payer: EmblemHealth Commercial	$56.42
Rate for Payer: Group Health Inc Commercial	$56.42
Rate for Payer: Group Health Inc Medicare	$39.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$56.42
Rate for Payer: Hamaspik Choice Inc Medicare	$56.42
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$39.81
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$73.35

TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSY

Facility

$112.84

Service Code	HCPCS 90715
Hospital Charge Code	5816084252
Hospital Revenue Code	250
Min. Negotiated Rate	$56.42
Max. Negotiated Rate	$56.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$56.42

TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSY

Facility

$112.84

Service Code	HCPCS 90715
Hospital Charge Code	5816084243
Hospital Revenue Code	250
Min. Negotiated Rate	$35.80
Max. Negotiated Rate	$90.27
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$62.06
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.80
Rate for Payer: Aetna Government	$35.80
Rate for Payer: Brighton Health Commercial	$84.63
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$90.27
Rate for Payer: Cigna LocalPlus Benefit Plan	$76.73
Rate for Payer: EmblemHealth Commercial	$56.42
Rate for Payer: Group Health Inc Commercial	$56.42
Rate for Payer: Group Health Inc Medicare	$39.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$56.42
Rate for Payer: Hamaspik Choice Inc Medicare	$56.42
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$39.81
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$73.35

TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSY

Facility

$112.84

Service Code	HCPCS 90715
Hospital Charge Code	5816084243
Hospital Revenue Code	250
Min. Negotiated Rate	$56.42
Max. Negotiated Rate	$56.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$56.42

TETANUS-DIPHTHERIA TOXOIDS TD 2-2 LF/0.5ML IM SUSP

Facility

$67.16

Service Code	HCPCS 90714
Hospital Charge Code	1353313101
Hospital Revenue Code	250
Min. Negotiated Rate	$23.51
Max. Negotiated Rate	$53.73
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$36.94
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$26.22
Rate for Payer: Aetna Government	$26.22
Rate for Payer: Brighton Health Commercial	$50.37
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$53.73
Rate for Payer: Cigna LocalPlus Benefit Plan	$45.67
Rate for Payer: EmblemHealth Commercial	$33.58
Rate for Payer: Group Health Inc Commercial	$33.58
Rate for Payer: Group Health Inc Medicare	$23.51
Rate for Payer: Hamaspik Choice Inc Medicaid	$33.58
Rate for Payer: Hamaspik Choice Inc Medicare	$33.58
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$37.37
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$43.66

TETANUS-DIPHTHERIA TOXOIDS TD 2-2 LF/0.5ML IM SUSP

Facility

$67.16

Service Code	HCPCS 90714
Hospital Charge Code	1353313101
Hospital Revenue Code	250
Min. Negotiated Rate	$33.58
Max. Negotiated Rate	$33.58
Rate for Payer: Hamaspik Choice Inc Medicaid	$33.58

Know your out-of-pocket cost for care.

All Charges