St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

PR XTRNL PT ACTIVTD ECG DWNLD W/R&I </30 DAYS

Professional

Both

$95.03

Service Code	HCPCS 93272
Min. Negotiated Rate	$71.27
Max. Negotiated Rate	$71.27
Rate for Payer: Cash Price	$26.07
Rate for Payer: SOMOS CHP/HARP/Medicaid	$71.27
Rate for Payer: SOMOS Essential	$71.27

PR XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBLNGL

Professional

Both

$1,251.95

Service Code	HCPCS 41015
Min. Negotiated Rate	$938.96
Max. Negotiated Rate	$938.96
Rate for Payer: Cash Price	$344.13
Rate for Payer: SOMOS CHP/HARP/Medicaid	$938.96
Rate for Payer: SOMOS Essential	$938.96

PR XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMENT

Professional

Both

$1,463.11

Service Code	HCPCS 41016
Min. Negotiated Rate	$1,097.33
Max. Negotiated Rate	$1,097.33
Rate for Payer: Cash Price	$399.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1,097.33
Rate for Payer: SOMOS Essential	$1,097.33

PR XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMNDB

Professional

Both

$1,457.37

Service Code	HCPCS 41017
Min. Negotiated Rate	$1,093.03
Max. Negotiated Rate	$1,093.03
Rate for Payer: Cash Price	$396.67
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1,093.03
Rate for Payer: SOMOS Essential	$1,093.03

PR XTRORAL I&D FLOOR MASTICATOR SPACE

Professional

Both

$1,695.40

Service Code	HCPCS 41018
Min. Negotiated Rate	$1,271.55
Max. Negotiated Rate	$1,271.55
Rate for Payer: Cash Price	$462.57
Rate for Payer: SOMOS CHP/HARP/Medicaid	$1,271.55
Rate for Payer: SOMOS Essential	$1,271.55

PR YELLOW FEVER VACCINE LIVE SUBQ

Professional

Both

$630.00

Service Code	HCPCS 90717
Min. Negotiated Rate	$472.50
Max. Negotiated Rate	$472.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$472.50
Rate for Payer: SOMOS Essential	$472.50

PR ZOSTER VACCINE HZV LIVE FOR SUBCUTANEOUS USE

Professional

Both

$654.29

Service Code	HCPCS 90736
Min. Negotiated Rate	$490.72
Max. Negotiated Rate	$490.72
Rate for Payer: SOMOS CHP/HARP/Medicaid	$490.72
Rate for Payer: SOMOS Essential	$490.72

PSA

Facility

$547.75

Hospital Charge Code	64902742
Hospital Revenue Code	270
Min. Negotiated Rate	$191.71
Max. Negotiated Rate	$438.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$301.26
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$273.88
Rate for Payer: Aetna Government	$273.88
Rate for Payer: Brighton Health Commercial	$410.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$438.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$372.47
Rate for Payer: Group Health Inc Commercial	$273.88
Rate for Payer: Group Health Inc Medicare	$191.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$273.88
Rate for Payer: Hamaspik Choice Inc Medicare	$273.88

PSA TOTAL+% FREE

Facility

$45.98

Service Code	HCPCS 84153
Hospital Charge Code	40609859
Hospital Revenue Code	301
Min. Negotiated Rate	$12.87
Max. Negotiated Rate	$34.48
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$25.29
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$18.39
Rate for Payer: Aetna Government	$18.39
Rate for Payer: Affinity Essential Plan 1&2	$12.87
Rate for Payer: Affinity Essential Plan 3&4	$12.87
Rate for Payer: Affinity Medicaid/CHP/HARP	$12.87
Rate for Payer: Brighton Health Commercial	$34.48
Rate for Payer: Cash Price	$18.39
Rate for Payer: Cash Price	$18.39
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$18.39
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$29.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$24.75
Rate for Payer: Elderplan Medicare Advantage	$18.39
Rate for Payer: EmblemHealth Commercial	$18.39
Rate for Payer: Fidelis Essential Plan Aliesa	$15.63
Rate for Payer: Fidelis Essential Plan QHP	$16.37
Rate for Payer: Fidelis Medicare Advantage	$18.39
Rate for Payer: Fidelis Qualified Health Plan	$16.37
Rate for Payer: Group Health Inc Commercial	$18.39
Rate for Payer: Group Health Inc Medicare	$18.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.99
Rate for Payer: Hamaspik Choice Inc Medicare	$18.39
Rate for Payer: Healthfirst Medicare Advantage	$18.39
Rate for Payer: Healthfirst QHP	$18.39
Rate for Payer: Humana Medicare	$18.76
Rate for Payer: Senior Whole Health Medicare Advantage	$18.39
Rate for Payer: United Healthcare Commercial	$23.30
Rate for Payer: United Healthcare Medicare Advantage	$18.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$18.39
Rate for Payer: Wellcare CHP/FHP/Medicaid	$14.71
Rate for Payer: Wellcare Medicare	$16.55

PSA TOTAL+% FREE

Facility

$45.98

Service Code	HCPCS 84153
Hospital Charge Code	40609859
Hospital Revenue Code	301
Rate for Payer: Cash Price	$18.39

PSD APEX PROCESSING USSC

Facility

$1,620.00

Hospital Charge Code	40202059
Hospital Revenue Code	270
Min. Negotiated Rate	$567.00
Max. Negotiated Rate	$1,296.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$891.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$810.00
Rate for Payer: Aetna Government	$810.00
Rate for Payer: Brighton Health Commercial	$1,215.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,296.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,101.60
Rate for Payer: Group Health Inc Commercial	$810.00
Rate for Payer: Group Health Inc Medicare	$567.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$810.00
Rate for Payer: Hamaspik Choice Inc Medicare	$810.00

PSD GEL (PERI STRIPS DRY)

Facility

$90.00

Hospital Charge Code	40202058
Hospital Revenue Code	272
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$72.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$49.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$45.00
Rate for Payer: Aetna Government	$45.00
Rate for Payer: Brighton Health Commercial	$67.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$72.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$61.20
Rate for Payer: Group Health Inc Commercial	$45.00
Rate for Payer: Group Health Inc Medicare	$31.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$45.00
Rate for Payer: Hamaspik Choice Inc Medicare	$45.00

PSEUDOEPHEDRINE 30 MG TAB

Facility

$1.00

Hospital Charge Code	41644788
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

PSEUDOEPHEDRINE 30 MG TAB

Facility

$1.00

Hospital Charge Code	41654788
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

PSEUDOEPHEDRINE 60 MG TAB

Facility

$0.05

Hospital Charge Code	41644528
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	$0.03
Rate for Payer: Aetna Government	$0.03
Rate for Payer: Brighton Health Commercial	$0.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.03
Rate for Payer: Group Health Inc Commercial	$0.03
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

PSEUDOEPHEDRINE 60 MG TAB

Facility

$0.05

Hospital Charge Code	41654528
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	$0.03
Rate for Payer: Aetna Government	$0.03
Rate for Payer: Brighton Health Commercial	$0.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.03
Rate for Payer: Group Health Inc Commercial	$0.03
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

PSEUDOEPHEDRINE 6 MG/ML SYRUP 120 ML

Facility

$0.03

Hospital Charge Code	41641098
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.02
Rate for Payer: Aetna Government	$0.02
Rate for Payer: Brighton Health Commercial	$0.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.02
Rate for Payer: Group Health Inc Commercial	$0.02
Rate for Payer: Group Health Inc Medicare	$0.01
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	$0.02

PSEUDOEPHEDRINE 6 MG/ML SYRUP 120 ML

Facility

$0.03

Hospital Charge Code	41651098
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.02
Rate for Payer: Aetna Government	$0.02
Rate for Payer: Brighton Health Commercial	$0.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.02
Rate for Payer: Group Health Inc Commercial	$0.02
Rate for Payer: Group Health Inc Medicare	$0.01
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	$0.02

PSEUDOEPHEDRINE HCL 15 MG/5ML PO LIQD [11184]

Facility

$0.06

Service Code	NDC 50580053604
Hospital Charge Code	50580053604
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.05
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.03
Rate for Payer: Aetna Government	$0.03
Rate for Payer: Brighton Health Commercial	$0.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.05
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.04
Rate for Payer: Group Health Inc Commercial	$0.03
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.04

PSEUDOEPHEDRINE HCL 30 MG PO TABS [6714]

Facility

$0.05

Service Code	NDC 00904633724
Hospital Charge Code	00904633724
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	$0.03
Rate for Payer: Aetna Government	$0.03
Rate for Payer: Brighton Health Commercial	$0.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.04
Rate for Payer: Group Health Inc Commercial	$0.03
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

PSEUDOEPHEDRINE HCL 30 MG PO TABS [6714]

Facility

$0.10

Service Code	NDC 45802043262
Hospital Charge Code	45802043262
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.08
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.06
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.05
Rate for Payer: Aetna Government	$0.05
Rate for Payer: Brighton Health Commercial	$0.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.08
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.07
Rate for Payer: Group Health Inc Commercial	$0.05
Rate for Payer: Group Health Inc Medicare	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.05
Rate for Payer: Hamaspik Choice Inc Medicare	$0.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.07

PSEUDOEPHEDRINE HCL 30 MG PO TABS [6714]

Facility

$0.04

Service Code	NDC 00904699061
Hospital Charge Code	00904699061
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.02
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: 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

PSEUDOEPHEDRINE HCL 30 MG PO TABS [6714]

Facility

$0.03

Service Code	NDC 00904505359
Hospital Charge Code	00904505359
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.02
Rate for Payer: Aetna Government	$0.02
Rate for Payer: Brighton Health Commercial	$0.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.03
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.02
Rate for Payer: Group Health Inc Commercial	$0.02
Rate for Payer: Group Health Inc Medicare	$0.01
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	$0.02

PSEUDOEPHEDRINE HCL 60 MG PO TABS [6715]

Facility

$0.07

Service Code	NDC 00904690706
Hospital Charge Code	00904690706
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.04
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.03
Rate for Payer: Aetna Government	$0.03
Rate for Payer: Brighton Health Commercial	$0.05
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.05
Rate for Payer: Group Health Inc Commercial	$0.03
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.04

PSEUDOEPHEDRINE HCL 60 MG PO TABS [6715]

Facility

$0.09

Service Code	NDC 00904672846
Hospital Charge Code	00904672846
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.07
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$0.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.06
Rate for Payer: Group Health Inc Commercial	$0.04
Rate for Payer: Group Health Inc Medicare	$0.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.04
Rate for Payer: Hamaspik Choice Inc Medicare	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.06

Know your out-of-pocket cost for care.

All Charges