St. Barnabas Hospital

All Charges

Charge

Type

Price

BUPIVACAINE 0.75% INJ 30 ML

Facility OP

$5.24

Service Code	HCPCS J3490
Hospital Charge Code	41641497
Hospital Revenue Code	636
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$3.41
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.88
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.62
Rate for Payer: Aetna Government	$2.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.62
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.01
Rate for Payer: Group Health Inc Commercial	$2.62
Rate for Payer: Group Health Inc Medicare	$1.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.62
Rate for Payer: Hamaspik Choice Inc Medicare	$2.62
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.41

BUPIVACAINE 0.75% INJ 30 ML

Facility IP

$5.24

Service Code	HCPCS J3490
Hospital Charge Code	41651497
Hospital Revenue Code	636
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$2.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.62
Rate for Payer: Hamaspik Choice Inc Medicare	$2.62

BUPIVACAINE PF 0.5% 10ML INJ

Facility IP

$0.33

Service Code	HCPCS J3490
Hospital Charge Code	41647821
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.17
Rate for Payer: Hamaspik Choice Inc Medicare	$0.17

BUPIVACAINE PF 0.5% 10ML INJ

Facility OP

$0.33

Service Code	HCPCS J3490
Hospital Charge Code	41647821
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.17
Rate for Payer: Aetna Government	$0.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.19
Rate for Payer: Group Health Inc Commercial	$0.17
Rate for Payer: Group Health Inc Medicare	$0.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.17
Rate for Payer: Hamaspik Choice Inc Medicare	$0.17
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.21

BUPIVACAINE PF 0.5% 10ML INJ

Facility IP

$0.33

Service Code	HCPCS J3490
Hospital Charge Code	41657821
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.17
Rate for Payer: Hamaspik Choice Inc Medicare	$0.17

BUPIVACAINE PF 0.5% 10ML INJ

Facility OP

$0.33

Service Code	HCPCS J3490
Hospital Charge Code	41657821
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.21
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.17
Rate for Payer: Aetna Government	$0.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.19
Rate for Payer: Group Health Inc Commercial	$0.17
Rate for Payer: Group Health Inc Medicare	$0.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.17
Rate for Payer: Hamaspik Choice Inc Medicare	$0.17
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.21

BUPIVACAINE PF 7.5MG IN DEX 2ML I

Facility OP

$5.10

Service Code	HCPCS J3490
Hospital Charge Code	41647830
Hospital Revenue Code	636
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$3.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.55
Rate for Payer: Aetna Government	$2.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.55
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.93
Rate for Payer: Group Health Inc Commercial	$2.55
Rate for Payer: Group Health Inc Medicare	$1.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.55
Rate for Payer: Hamaspik Choice Inc Medicare	$2.55
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.32

BUPIVACAINE PF 7.5MG IN DEX 2ML I

Facility IP

$5.10

Service Code	HCPCS J3490
Hospital Charge Code	41647830
Hospital Revenue Code	636
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.55
Rate for Payer: Hamaspik Choice Inc Medicare	$2.55

BUPIVACAINE PF 7.5ML IN DEX 2ML I

Facility IP

$5.10

Service Code	HCPCS J3490
Hospital Charge Code	41657830
Hospital Revenue Code	636
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.55
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.55
Rate for Payer: Hamaspik Choice Inc Medicare	$2.55

BUPIVACAINE PF 7.5ML IN DEX 2ML I

Facility OP

$5.10

Service Code	HCPCS J3490
Hospital Charge Code	41657830
Hospital Revenue Code	636
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$3.32
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.80
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.55
Rate for Payer: Aetna Government	$2.55
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.55
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.93
Rate for Payer: Group Health Inc Commercial	$2.55
Rate for Payer: Group Health Inc Medicare	$1.78
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.55
Rate for Payer: Hamaspik Choice Inc Medicare	$2.55
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.32

BUPRENORPHINE/NALOX 12-3MG DETOX

Facility IP

$18.00

Service Code	HCPCS J0575
Hospital Charge Code	41649003
Hospital Revenue Code	636
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$9.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.00
Rate for Payer: Hamaspik Choice Inc Medicare	$9.00

BUPRENORPHINE/NALOX 12-3MG DETOX

Facility OP

$18.00

Service Code	HCPCS J0575
Hospital Charge Code	41659003
Hospital Revenue Code	636
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$12.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12.85
Rate for Payer: Aetna Government	$12.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.35
Rate for Payer: Group Health Inc Commercial	$9.00
Rate for Payer: Group Health Inc Medicare	$6.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.00
Rate for Payer: Hamaspik Choice Inc Medicare	$9.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.70

BUPRENORPHINE/NALOX 12-3MG DETOX

Facility OP

$18.00

Service Code	HCPCS J0575
Hospital Charge Code	41649003
Hospital Revenue Code	636
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$12.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9.90
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12.85
Rate for Payer: Aetna Government	$12.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$9.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.35
Rate for Payer: Group Health Inc Commercial	$9.00
Rate for Payer: Group Health Inc Medicare	$6.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.00
Rate for Payer: Hamaspik Choice Inc Medicare	$9.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.70

BUPRENORPHINE/NALOX 12-3MG DETOX

Facility IP

$18.00

Service Code	HCPCS J0575
Hospital Charge Code	41659003
Hospital Revenue Code	636
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$9.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.00
Rate for Payer: Hamaspik Choice Inc Medicare	$9.00

BUPRENORPHINE/NALOX 2-0.5MG DETOX

Facility IP

$5.00

Service Code	HCPCS J0592
Hospital Charge Code	41659000
Hospital Revenue Code	636
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$2.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2.50

BUPRENORPHINE/NALOX 2-0.5MG DETOX

Facility OP

$5.00

Service Code	HCPCS J0592
Hospital Charge Code	41659000
Hospital Revenue Code	636
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$4.37
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.37
Rate for Payer: Aetna Government	$4.37
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.88
Rate for Payer: Group Health Inc Commercial	$2.50
Rate for Payer: Group Health Inc Medicare	$1.75
Rate for Payer: Hamaspik Choice Inc Medicare	$2.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.25

BUPRENORPHINE/NALOX 2-0.5MG DETOX

Facility OP

$5.00

Service Code	HCPCS J0592
Hospital Charge Code	41649000
Hospital Revenue Code	636
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$4.37
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.37
Rate for Payer: Aetna Government	$4.37
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.88
Rate for Payer: Group Health Inc Commercial	$2.50
Rate for Payer: Group Health Inc Medicare	$1.75
Rate for Payer: Hamaspik Choice Inc Medicare	$2.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.25

BUPRENORPHINE/NALOX 2-0.5MG DETOX

Facility IP

$5.00

Service Code	HCPCS J0592
Hospital Charge Code	41649000
Hospital Revenue Code	636
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$2.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2.50

BUPRENORPHINE + NALOXONE 2 MG-0.5 MG TAB

Facility OP

$8.06

Hospital Charge Code	41644955
Hospital Revenue Code	250
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$6.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.43
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.03
Rate for Payer: Aetna Government	$4.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.45
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.48
Rate for Payer: Group Health Inc Commercial	$4.03
Rate for Payer: Group Health Inc Medicare	$2.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.03
Rate for Payer: Hamaspik Choice Inc Medicare	$4.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.24

BUPRENORPHINE + NALOXONE 2 MG-0.5 MG TAB

Facility OP

$8.06

Hospital Charge Code	41654955
Hospital Revenue Code	250
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$6.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.43
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.03
Rate for Payer: Aetna Government	$4.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.45
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.48
Rate for Payer: Group Health Inc Commercial	$4.03
Rate for Payer: Group Health Inc Medicare	$2.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.03
Rate for Payer: Hamaspik Choice Inc Medicare	$4.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.24

BUPRENORPHINE/NALOXONE 4-1MGDETOX

Facility OP

$9.00

Service Code	HCPCS J0592
Hospital Charge Code	41659001
Hospital Revenue Code	636
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$5.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.37
Rate for Payer: Aetna Government	$4.37
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.18
Rate for Payer: Group Health Inc Commercial	$4.50
Rate for Payer: Group Health Inc Medicare	$3.15
Rate for Payer: Hamaspik Choice Inc Medicare	$4.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.85

BUPRENORPHINE/NALOXONE 4-1MGDETOX

Facility IP

$9.00

Service Code	HCPCS J0592
Hospital Charge Code	41659001
Hospital Revenue Code	636
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.50
Rate for Payer: Hamaspik Choice Inc Medicare	$4.50

BUPRENORPHINE/NALOXONE 4-1MGDETOX

Facility OP

$9.00

Service Code	HCPCS J0592
Hospital Charge Code	41649001
Hospital Revenue Code	636
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$5.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.37
Rate for Payer: Aetna Government	$4.37
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.18
Rate for Payer: Group Health Inc Commercial	$4.50
Rate for Payer: Group Health Inc Medicare	$3.15
Rate for Payer: Hamaspik Choice Inc Medicare	$4.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.85

BUPRENORPHINE/NALOXONE 4-1MGDETOX

Facility IP

$9.00

Service Code	HCPCS J0592
Hospital Charge Code	41649001
Hospital Revenue Code	636
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.50
Rate for Payer: Hamaspik Choice Inc Medicare	$4.50

BUPRENORPHINE/NALOXONE 8-2MGDETOX

Facility OP

$9.00

Service Code	HCPCS J0574
Hospital Charge Code	41649002
Hospital Revenue Code	636
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$708.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$6.42
Rate for Payer: Aetna Government	$6.42
Rate for Payer: Amida Care Medicaid	$7.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.18
Rate for Payer: Fidelis CHP/HARP/Medicaid	$708.00
Rate for Payer: Fidelis Essential Plan Aliesa	$7.08
Rate for Payer: Fidelis Essential Plan QHP	$7.08
Rate for Payer: Fidelis Qualified Health Plan	$7.43
Rate for Payer: Group Health Inc Commercial	$4.50
Rate for Payer: Group Health Inc Medicare	$3.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.08
Rate for Payer: Hamaspik Choice Inc Medicare	$4.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$7.08
Rate for Payer: Healthfirst Essential Plan	$7.08
Rate for Payer: Healthfirst QHP	$7.08
Rate for Payer: SOMOS CHP/HARP/Medicaid	$7.08
Rate for Payer: SOMOS Essential	$7.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.85
Rate for Payer: Wellcare CHP/FHP/Medicaid	$7.08

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