St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

ACYCLOVIR 800 MG PO TABS

Facility

$4.22

Service Code	NDC 3172277801
Hospital Charge Code	3172277801
Hospital Revenue Code	250
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$2.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.11

ACYCLOVIR IV SYRINGE 5 MG/ML (NEO/PED)

Facility

$39.38

Service Code	NDC 9999123454
Hospital Charge Code	9999123454
Hospital Revenue Code	258
Min. Negotiated Rate	$19.69
Max. Negotiated Rate	$19.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.69

ACYCLOVIR IV SYRINGE 5 MG/ML (NEO/PED)

Facility

$39.38

Service Code	NDC 9999123454
Hospital Charge Code	9999123454
Hospital Revenue Code	258
Min. Negotiated Rate	$13.78
Max. Negotiated Rate	$31.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$21.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$19.69
Rate for Payer: Aetna Government	$19.69
Rate for Payer: Brighton Health Commercial	$29.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$31.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$26.78
Rate for Payer: EmblemHealth Commercial	$19.69
Rate for Payer: Group Health Inc Commercial	$19.69
Rate for Payer: Group Health Inc Medicare	$13.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.69
Rate for Payer: Hamaspik Choice Inc Medicare	$19.69
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$25.60

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$2.26

Service Code	HCPCS J0133
Hospital Charge Code	6332332510
Hospital Revenue Code	258
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.13

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$0.52

Service Code	HCPCS J0133
Hospital Charge Code	6332332514
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.41
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$0.39
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.41
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.35
Rate for Payer: EmblemHealth Commercial	$0.26
Rate for Payer: Group Health Inc Commercial	$0.26
Rate for Payer: Group Health Inc Medicare	$0.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.26
Rate for Payer: Hamaspik Choice Inc Medicare	$0.26
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.34

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$1.72

Service Code	HCPCS J0133
Hospital Charge Code	6521962420
Hospital Revenue Code	258
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$0.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.86

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$0.52

Service Code	HCPCS J0133
Hospital Charge Code	6332332524
Hospital Revenue Code	258
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.26

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$2.10

Service Code	HCPCS J0133
Hospital Charge Code	6332332520
Hospital Revenue Code	258
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.05

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$1.50

Service Code	HCPCS J0133
Hospital Charge Code	5515015520
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$1.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.83
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$1.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.02
Rate for Payer: EmblemHealth Commercial	$0.75
Rate for Payer: Group Health Inc Commercial	$0.75
Rate for Payer: Group Health Inc Medicare	$0.53
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.75
Rate for Payer: Hamaspik Choice Inc Medicare	$0.75
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.98

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$2.26

Service Code	HCPCS J0133
Hospital Charge Code	6332332503
Hospital Revenue Code	258
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.13

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$1.60

Service Code	HCPCS J0133
Hospital Charge Code	5515015410
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$1.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$1.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.09
Rate for Payer: EmblemHealth Commercial	$0.80
Rate for Payer: Group Health Inc Commercial	$0.80
Rate for Payer: Group Health Inc Medicare	$0.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.80
Rate for Payer: Hamaspik Choice Inc Medicare	$0.80
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.04

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$2.10

Service Code	HCPCS J0133
Hospital Charge Code	6332332509
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$1.68
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$1.57
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.68
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.43
Rate for Payer: EmblemHealth Commercial	$1.05
Rate for Payer: Group Health Inc Commercial	$1.05
Rate for Payer: Group Health Inc Medicare	$0.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.05
Rate for Payer: Hamaspik Choice Inc Medicare	$1.05
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.36

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$1.72

Service Code	HCPCS J0133
Hospital Charge Code	6521962404
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$1.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$1.29
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.17
Rate for Payer: EmblemHealth Commercial	$0.86
Rate for Payer: Group Health Inc Commercial	$0.86
Rate for Payer: Group Health Inc Medicare	$0.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.86
Rate for Payer: Hamaspik Choice Inc Medicare	$0.86
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.12

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$1.72

Service Code	HCPCS J0133
Hospital Charge Code	6521962404
Hospital Revenue Code	258
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$0.86
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.86

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$1.60

Service Code	HCPCS J0133
Hospital Charge Code	5515015410
Hospital Revenue Code	258
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$0.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.80

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$2.26

Service Code	HCPCS J0133
Hospital Charge Code	6332332510
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$1.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$1.69
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.53
Rate for Payer: EmblemHealth Commercial	$1.13
Rate for Payer: Group Health Inc Commercial	$1.13
Rate for Payer: Group Health Inc Medicare	$0.79
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.13
Rate for Payer: Hamaspik Choice Inc Medicare	$1.13
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.47

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$1.87

Service Code	HCPCS J0133
Hospital Charge Code	6521962202
Hospital Revenue Code	258
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$0.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.94

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$1.50

Service Code	HCPCS J0133
Hospital Charge Code	5515015520
Hospital Revenue Code	258
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.75

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$1.87

Service Code	HCPCS J0133
Hospital Charge Code	6521962202
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$1.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$1.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.27
Rate for Payer: EmblemHealth Commercial	$0.94
Rate for Payer: Group Health Inc Commercial	$0.94
Rate for Payer: Group Health Inc Medicare	$0.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.94
Rate for Payer: Hamaspik Choice Inc Medicare	$0.94
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.22

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$2.26

Service Code	HCPCS J0133
Hospital Charge Code	6332332503
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$1.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$1.69
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.53
Rate for Payer: EmblemHealth Commercial	$1.13
Rate for Payer: Group Health Inc Commercial	$1.13
Rate for Payer: Group Health Inc Medicare	$0.79
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.13
Rate for Payer: Hamaspik Choice Inc Medicare	$1.13
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.47

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$0.52

Service Code	HCPCS J0133
Hospital Charge Code	6332332514
Hospital Revenue Code	258
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.26

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$0.52

Service Code	HCPCS J0133
Hospital Charge Code	6332332524
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.41
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$0.39
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.41
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.35
Rate for Payer: EmblemHealth Commercial	$0.26
Rate for Payer: Group Health Inc Commercial	$0.26
Rate for Payer: Group Health Inc Medicare	$0.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.26
Rate for Payer: Hamaspik Choice Inc Medicare	$0.26
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.34

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$2.10

Service Code	HCPCS J0133
Hospital Charge Code	6332332520
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$1.68
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$1.57
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.68
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.43
Rate for Payer: EmblemHealth Commercial	$1.05
Rate for Payer: Group Health Inc Commercial	$1.05
Rate for Payer: Group Health Inc Medicare	$0.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.05
Rate for Payer: Hamaspik Choice Inc Medicare	$1.05
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.36

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$1.72

Service Code	HCPCS J0133
Hospital Charge Code	6521962420
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$1.38
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$1.29
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.38
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.17
Rate for Payer: EmblemHealth Commercial	$0.86
Rate for Payer: Group Health Inc Commercial	$0.86
Rate for Payer: Group Health Inc Medicare	$0.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.86
Rate for Payer: Hamaspik Choice Inc Medicare	$0.86
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.12

ACYCLOVIR SODIUM 50 MG/ML IV SOLN

Facility

$2.10

Service Code	HCPCS J0133
Hospital Charge Code	6332332509
Hospital Revenue Code	258
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.05

Know your out-of-pocket cost for care.

All Charges