St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PR IMG RETINA DETCJ/MNTR DS REM PHYS/QHP I&R UNI/BI

Professional

Both

$65.80

Service Code	HCPCS 92228 26
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$49.35
Rate for Payer: Cash Price	$18.07
Rate for Payer: SOMOS CHP/HARP/Medicaid	$49.35
Rate for Payer: SOMOS Essential	$49.35

PR IMG RETINA DETCJ/MNTR DS REM PHYS/QHP I&R UNI/BI

Professional

Both

$55.93

Service Code	HCPCS 92228 TC
Min. Negotiated Rate	$41.95
Max. Negotiated Rate	$41.95
Rate for Payer: Cash Price	$15.95
Rate for Payer: SOMOS CHP/HARP/Medicaid	$41.95
Rate for Payer: SOMOS Essential	$41.95

PR IMG RETINA DETCJ/MNTR DS REM PHYS/QHP I&R UNI/BI

Professional

Both

$121.73

Service Code	HCPCS 92228
Min. Negotiated Rate	$91.30
Max. Negotiated Rate	$91.30
Rate for Payer: Cash Price	$34.02
Rate for Payer: SOMOS CHP/HARP/Medicaid	$91.30
Rate for Payer: SOMOS Essential	$91.30

PRIMIDONE 250 MG PO TABS [6544]

Facility

$1.05

Service Code	NDC 68084020301
Hospital Charge Code	68084020301
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.84
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.58
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.52
Rate for Payer: Aetna Government	$0.52
Rate for Payer: Brighton Health Commercial	$0.79
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.84
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.71
Rate for Payer: Group Health Inc Commercial	$0.52
Rate for Payer: Group Health Inc Medicare	$0.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.52
Rate for Payer: Hamaspik Choice Inc Medicare	$0.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.68

PRIMIDONE 250 MG TAB

Facility

$1.00

Hospital Charge Code	41652929
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

PRIMIDONE 250 MG TAB

Facility

$1.00

Hospital Charge Code	41642929
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

PRIMIDONE 50 MG PO TABS [11129]

Facility

$0.95

Service Code	NDC 50268068611
Hospital Charge Code	50268068611
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.52
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.48
Rate for Payer: Aetna Government	$0.48
Rate for Payer: Brighton Health Commercial	$0.72
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.65
Rate for Payer: Group Health Inc Commercial	$0.48
Rate for Payer: Group Health Inc Medicare	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.48
Rate for Payer: Hamaspik Choice Inc Medicare	$0.48
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.62

PRIMIDONE 50 MG PO TABS [11129]

Facility

$0.50

Service Code	NDC 72888004501
Hospital Charge Code	72888004501
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.25
Rate for Payer: Aetna Government	$0.25
Rate for Payer: Brighton Health Commercial	$0.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.34
Rate for Payer: Group Health Inc Commercial	$0.25
Rate for Payer: Group Health Inc Medicare	$0.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.25
Rate for Payer: Hamaspik Choice Inc Medicare	$0.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.33

PRIMIDONE 50 MG PO TABS [11129]

Facility

$0.95

Service Code	NDC 50268068615
Hospital Charge Code	50268068615
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.52
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.48
Rate for Payer: Aetna Government	$0.48
Rate for Payer: Brighton Health Commercial	$0.72
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.65
Rate for Payer: Group Health Inc Commercial	$0.48
Rate for Payer: Group Health Inc Medicare	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.48
Rate for Payer: Hamaspik Choice Inc Medicare	$0.48
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.62

PRIMIDONE 50 MG TAB

Facility

$0.16

Hospital Charge Code	41643024
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.13
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.09
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.08
Rate for Payer: Aetna Government	$0.08
Rate for Payer: Brighton Health Commercial	$0.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.11
Rate for Payer: Group Health Inc Commercial	$0.08
Rate for Payer: Group Health Inc Medicare	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.08
Rate for Payer: Hamaspik Choice Inc Medicare	$0.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.10

PRIMIDONE 50 MG TAB

Facility

$0.16

Hospital Charge Code	41653024
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.13
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.09
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.08
Rate for Payer: Aetna Government	$0.08
Rate for Payer: Brighton Health Commercial	$0.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.11
Rate for Payer: Group Health Inc Commercial	$0.08
Rate for Payer: Group Health Inc Medicare	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.08
Rate for Payer: Hamaspik Choice Inc Medicare	$0.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.10

PRIMIDONE (MYSOLINE(R)), SERUM

Facility

$41.48

Service Code	HCPCS 80188
Hospital Charge Code	40609831
Hospital Revenue Code	301
Rate for Payer: Cash Price	$16.59

PRIMIDONE (MYSOLINE(R)), SERUM

Facility

$41.48

Service Code	HCPCS 80188
Hospital Charge Code	40609831
Hospital Revenue Code	301
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$31.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$22.81
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.59
Rate for Payer: Aetna Government	$16.59
Rate for Payer: Affinity Essential Plan 1&2	$11.61
Rate for Payer: Affinity Essential Plan 3&4	$11.61
Rate for Payer: Affinity Medicaid/CHP/HARP	$11.61
Rate for Payer: Brighton Health Commercial	$31.11
Rate for Payer: Cash Price	$16.59
Rate for Payer: Cash Price	$16.59
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$16.59
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$26.39
Rate for Payer: Cigna LocalPlus Benefit Plan	$22.33
Rate for Payer: Elderplan Medicare Advantage	$16.59
Rate for Payer: EmblemHealth Commercial	$16.59
Rate for Payer: Fidelis Essential Plan Aliesa	$14.10
Rate for Payer: Fidelis Essential Plan QHP	$14.77
Rate for Payer: Fidelis Medicare Advantage	$16.59
Rate for Payer: Fidelis Qualified Health Plan	$14.77
Rate for Payer: Group Health Inc Commercial	$16.59
Rate for Payer: Group Health Inc Medicare	$16.59
Rate for Payer: Hamaspik Choice Inc Medicaid	$20.74
Rate for Payer: Hamaspik Choice Inc Medicare	$16.59
Rate for Payer: Healthfirst Medicare Advantage	$16.59
Rate for Payer: Healthfirst QHP	$16.59
Rate for Payer: Humana Medicare	$16.92
Rate for Payer: Senior Whole Health Medicare Advantage	$16.59
Rate for Payer: United Healthcare Commercial	$21.02
Rate for Payer: United Healthcare Medicare Advantage	$16.59
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$16.59
Rate for Payer: Wellcare CHP/FHP/Medicaid	$13.27
Rate for Payer: Wellcare Medicare	$14.93

PR IMM ADMN SARSCOV2 100 MCG/0.5 ML 3RD DOSE

Professional

Both

$100.00

Service Code	HCPCS 0013A
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$75.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$75.00
Rate for Payer: SOMOS Essential	$75.00

PR IMM ADMN SARSCOV2 10MCG/0.2ML TRIS-SUCROSE 1ST

Professional

Both

$100.00

Service Code	HCPCS 0071A
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$75.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$75.00
Rate for Payer: SOMOS Essential	$75.00

PR IMM ADMN SARSCOV2 10MCG/0.2ML TRIS-SUCROSE 2ND

Professional

Both

$100.00

Service Code	HCPCS 0072A
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$75.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$75.00
Rate for Payer: SOMOS Essential	$75.00

PR IMM ADMN SARSCOV2 25 MCG/0.25 ML 1ST DOSE

Professional

Both

$100.00

Service Code	HCPCS 0111A
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$75.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$75.00
Rate for Payer: SOMOS Essential	$75.00

PR IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2

Professional

Both

$60.34

Service Code	HCPCS 90480
Min. Negotiated Rate	$45.26
Max. Negotiated Rate	$45.26
Rate for Payer: SOMOS CHP/HARP/Medicaid	$45.26
Rate for Payer: SOMOS Essential	$45.26

PR IMPL ABSRB MESH/PRSTH DLYD CLSR DFCT INFCTJ/TRMA

Professional

Both

$1,716.65

Service Code	HCPCS 15778
Min. Negotiated Rate	$1,287.49
Max. Negotiated Rate	$1,287.49
Rate for Payer: Cash Price	$458.03
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1,287.49
Rate for Payer: SOMOS Essential	$1,287.49

PR IMPLANTATION INTRASTROMAL CORNEAL RING SEGMENTS

Professional

Both

$1,829.45

Service Code	HCPCS 65785
Min. Negotiated Rate	$1,372.09
Max. Negotiated Rate	$1,372.09
Rate for Payer: Cash Price	$505.01
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1,372.09
Rate for Payer: SOMOS Essential	$1,372.09

PR IMPLANTATION NERVE END BONE/MUSCLE

Professional

Both

$1,018.96

Service Code	HCPCS 64787
Min. Negotiated Rate	$764.22
Max. Negotiated Rate	$764.22
Rate for Payer: Cash Price	$270.96
Rate for Payer: SOMOS CHP/HARP/Medicaid	$764.22
Rate for Payer: SOMOS Essential	$764.22

PR IMPLNT BIO IMPLNT FOR SOFT TISSUE REINFORCEMENT

Professional

Both

$937.76

Service Code	HCPCS 15777
Min. Negotiated Rate	$703.32
Max. Negotiated Rate	$703.32
Rate for Payer: Cash Price	$250.69
Rate for Payer: SOMOS CHP/HARP/Medicaid	$703.32
Rate for Payer: SOMOS Essential	$703.32

PR IMPL OI IMPLT SKULL MAG TC ATTACHMENT ESP<100

Professional

Both

$2,677.22

Service Code	HCPCS 69716
Min. Negotiated Rate	$2,007.92
Max. Negotiated Rate	$2,007.92
Rate for Payer: Cash Price	$724.58
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,007.92
Rate for Payer: SOMOS Essential	$2,007.92

PR IMPL OI IMPLT SKULL MAG TC ATTACHMENT ESP>=100

Professional

Both

$2,901.99

Service Code	HCPCS 69729
Min. Negotiated Rate	$2,176.49
Max. Negotiated Rate	$2,176.49
Rate for Payer: Cash Price	$786.69
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2,176.49
Rate for Payer: SOMOS Essential	$2,176.49

PR IMPLTJ BRAIN INTRACAVITARY CHEMOTHERAPY AGENT

Professional

Both

$419.65

Service Code	HCPCS 61517
Min. Negotiated Rate	$314.74
Max. Negotiated Rate	$314.74
Rate for Payer: Cash Price	$110.12
Rate for Payer: SOMOS CHP/HARP/Medicaid	$314.74
Rate for Payer: SOMOS Essential	$314.74

Know your out-of-pocket cost for care.

All Charges