St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

TETRACYCLINE HCL 500 MG PO CAPS

Facility

$15.75

Service Code	NDC 2315576701
Hospital Charge Code	2315576701
Hospital Revenue Code	250
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$7.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.88

TETRACYCLINE HCL 500 MG PO CAPS

Facility

$15.75

Service Code	NDC 2315576701
Hospital Charge Code	2315576701
Hospital Revenue Code	250
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$12.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.88
Rate for Payer: Aetna Government	$7.88
Rate for Payer: Brighton Health Commercial	$11.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.71
Rate for Payer: EmblemHealth Commercial	$7.88
Rate for Payer: Group Health Inc Commercial	$7.88
Rate for Payer: Group Health Inc Medicare	$5.51
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.88
Rate for Payer: Hamaspik Choice Inc Medicare	$7.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10.24

TETRACYCLINE HCL 500 MG PO CAPS

Facility

$15.75

Service Code	NDC 5199190701
Hospital Charge Code	5199190701
Hospital Revenue Code	250
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$12.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.88
Rate for Payer: Aetna Government	$7.88
Rate for Payer: Brighton Health Commercial	$11.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.71
Rate for Payer: EmblemHealth Commercial	$7.88
Rate for Payer: Group Health Inc Commercial	$7.88
Rate for Payer: Group Health Inc Medicare	$5.51
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.88
Rate for Payer: Hamaspik Choice Inc Medicare	$7.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10.24

TETRAHYDROZOLINE HCL 0.05 % OP SOLN

Facility

$0.13

Service Code	NDC 0536121794
Hospital Charge Code	0536121794
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.06

TETRAHYDROZOLINE HCL 0.05 % OP SOLN

Facility

$0.13

Service Code	NDC 0536121794
Hospital Charge Code	0536121794
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	$0.10
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.09
Rate for Payer: EmblemHealth Commercial	$0.06
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

TEZEPELUMAB-EKKO 210 MG/1.91ML SC SOAJ

Facility

$2.00

Service Code	NDC 5551312301
Hospital Charge Code	5551312301
Hospital Revenue Code	250
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.00
Rate for Payer: Aetna Government	$1.00
Rate for Payer: Brighton Health Commercial	$1.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.36
Rate for Payer: EmblemHealth Commercial	$1.00
Rate for Payer: Group Health Inc Commercial	$1.00
Rate for Payer: Group Health Inc Medicare	$0.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30

TEZEPELUMAB-EKKO 210 MG/1.91ML SC SOAJ

Facility

$2.00

Service Code	NDC 5551312301
Hospital Charge Code	5551312301
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00

TEZEPELUMAB-EKKO 210 MG/1.91ML SC SOSY

Facility

$2.00

Service Code	HCPCS J2356
Hospital Charge Code	5551311201
Hospital Revenue Code	250
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$18.37
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$18.01
Rate for Payer: Aetna Government	$18.01
Rate for Payer: Affinity Essential Plan 1&2	$12.61
Rate for Payer: Affinity Essential Plan 3&4	$12.61
Rate for Payer: Affinity Medicaid/CHP/HARP	$12.61
Rate for Payer: Brighton Health Commercial	$1.50
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$18.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.36
Rate for Payer: Elderplan Medicare Advantage	$18.01
Rate for Payer: EmblemHealth Commercial	$18.01
Rate for Payer: Fidelis CHP/HARP/Medicaid	$16.21
Rate for Payer: Fidelis Essential Plan Aliesa	$15.31
Rate for Payer: Fidelis Essential Plan QHP	$16.03
Rate for Payer: Fidelis Medicare Advantage	$18.01
Rate for Payer: Fidelis Qualified Health Plan	$16.03
Rate for Payer: Group Health Inc Commercial	$18.01
Rate for Payer: Group Health Inc Medicare	$18.01
Rate for Payer: Hamaspik Choice Inc Medicaid	$18.01
Rate for Payer: Hamaspik Choice Inc Medicare	$18.01
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$18.01
Rate for Payer: Healthfirst Medicare Advantage	$15.31
Rate for Payer: Healthfirst QHP	$18.01
Rate for Payer: Humana Medicare	$18.37
Rate for Payer: Senior Whole Health Medicare Advantage	$18.01
Rate for Payer: United Healthcare Medicare Advantage	$18.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30
Rate for Payer: Wellcare CHP/FHP/Medicaid	$17.11
Rate for Payer: Wellcare Medicare	$17.11

TEZEPELUMAB-EKKO 210 MG/1.91ML SC SOSY

Facility

$2.00

Service Code	HCPCS J2356
Hospital Charge Code	5551311201
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00

THEOPHYLLINE 80 MG/15ML PO ELIX

Facility

$0.84

Service Code	NDC 0121482015
Hospital Charge Code	0121482015
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.67
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.42
Rate for Payer: Aetna Government	$0.42
Rate for Payer: Brighton Health Commercial	$0.63
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.67
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.57
Rate for Payer: EmblemHealth Commercial	$0.42
Rate for Payer: Group Health Inc Commercial	$0.42
Rate for Payer: Group Health Inc Medicare	$0.29
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.42
Rate for Payer: Hamaspik Choice Inc Medicare	$0.42
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.54

THEOPHYLLINE 80 MG/15ML PO ELIX

Facility

$0.33

Service Code	NDC 1785664401
Hospital Charge Code	1785664401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.16

THEOPHYLLINE 80 MG/15ML PO ELIX

Facility

$0.84

Service Code	NDC 0121482015
Hospital Charge Code	0121482015
Hospital Revenue Code	250
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.42

THEOPHYLLINE 80 MG/15ML PO ELIX

Facility

$0.33

Service Code	NDC 1785664401
Hospital Charge Code	1785664401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.16
Rate for Payer: Aetna Government	$0.16
Rate for Payer: Brighton Health Commercial	$0.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.22
Rate for Payer: EmblemHealth Commercial	$0.16
Rate for Payer: Group Health Inc Commercial	$0.16
Rate for Payer: Group Health Inc Medicare	$0.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.16
Rate for Payer: Hamaspik Choice Inc Medicare	$0.16
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.21

THEOPHYLLINE ER 100 MG PO CP24

Facility

$4.23

Service Code	NDC 5224410010
Hospital Charge Code	5224410010
Hospital Revenue Code	250
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$2.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.11

THEOPHYLLINE ER 100 MG PO CP24

Facility

$4.23

Service Code	NDC 5224410010
Hospital Charge Code	5224410010
Hospital Revenue Code	250
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$3.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.32
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.11
Rate for Payer: Aetna Government	$2.11
Rate for Payer: Brighton Health Commercial	$3.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.87
Rate for Payer: EmblemHealth Commercial	$2.11
Rate for Payer: Group Health Inc Commercial	$2.11
Rate for Payer: Group Health Inc Medicare	$1.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.11
Rate for Payer: Hamaspik Choice Inc Medicare	$2.11
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.75

THEOPHYLLINE ER 200 MG PO CP24

Facility

$6.28

Service Code	NDC 5224420010
Hospital Charge Code	5224420010
Hospital Revenue Code	250
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$5.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.14
Rate for Payer: Aetna Government	$3.14
Rate for Payer: Brighton Health Commercial	$4.71
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.27
Rate for Payer: EmblemHealth Commercial	$3.14
Rate for Payer: Group Health Inc Commercial	$3.14
Rate for Payer: Group Health Inc Medicare	$2.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.14
Rate for Payer: Hamaspik Choice Inc Medicare	$3.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.08

THEOPHYLLINE ER 200 MG PO CP24

Facility

$6.28

Service Code	NDC 5224420010
Hospital Charge Code	5224420010
Hospital Revenue Code	250
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$3.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.14

THEOPHYLLINE ER 300 MG PO CP24

Facility

$7.72

Service Code	NDC 5224430010
Hospital Charge Code	5224430010
Hospital Revenue Code	250
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$6.17
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.86
Rate for Payer: Aetna Government	$3.86
Rate for Payer: Brighton Health Commercial	$5.79
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.25
Rate for Payer: EmblemHealth Commercial	$3.86
Rate for Payer: Group Health Inc Commercial	$3.86
Rate for Payer: Group Health Inc Medicare	$2.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.86
Rate for Payer: Hamaspik Choice Inc Medicare	$3.86
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.02

THEOPHYLLINE ER 300 MG PO CP24

Facility

$7.72

Service Code	NDC 5224430010
Hospital Charge Code	5224430010
Hospital Revenue Code	250
Min. Negotiated Rate	$3.86
Max. Negotiated Rate	$3.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.86

THEOPHYLLINE ER 300 MG PO TB12

Facility

$4.30

Service Code	NDC 6233202531
Hospital Charge Code	6233202531
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$3.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.15
Rate for Payer: Aetna Government	$2.15
Rate for Payer: Brighton Health Commercial	$3.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.92
Rate for Payer: EmblemHealth Commercial	$2.15
Rate for Payer: Group Health Inc Commercial	$2.15
Rate for Payer: Group Health Inc Medicare	$1.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.15
Rate for Payer: Hamaspik Choice Inc Medicare	$2.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.79

THEOPHYLLINE ER 300 MG PO TB12

Facility

$4.30

Service Code	NDC 6233202531
Hospital Charge Code	6233202531
Hospital Revenue Code	250
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$2.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.15

THERA M PLUS PO TABS

Facility

$2.19

Service Code	NDC 7733386125
Hospital Charge Code	7733386125
Hospital Revenue Code	250
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.09

THERA M PLUS PO TABS

Facility

$0.05

Service Code	NDC 5789662101
Hospital Charge Code	5789662101
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.02
Rate for Payer: Aetna Government	$0.02
Rate for Payer: Brighton Health Commercial	$0.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.03
Rate for Payer: EmblemHealth Commercial	$0.02
Rate for Payer: Group Health Inc Commercial	$0.02
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.02
Rate for Payer: Hamaspik Choice Inc Medicare	$0.02
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

THERA M PLUS PO TABS

Facility

$0.05

Service Code	NDC 5789662101
Hospital Charge Code	5789662101
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.02

THERA M PLUS PO TABS

Facility

$2.19

Service Code	NDC 7733386125
Hospital Charge Code	7733386125
Hospital Revenue Code	250
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.09
Rate for Payer: Aetna Government	$1.09
Rate for Payer: Brighton Health Commercial	$1.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.49
Rate for Payer: EmblemHealth Commercial	$1.09
Rate for Payer: Group Health Inc Commercial	$1.09
Rate for Payer: Group Health Inc Medicare	$0.77
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.09
Rate for Payer: Hamaspik Choice Inc Medicare	$1.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.42

Know your out-of-pocket cost for care.

All Charges