St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

ACYCLOVIR 200 MG CAP

Facility

$0.07

Hospital Charge Code	41643514
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	$0.04
Rate for Payer: Aetna Government	$0.04
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	$0.04
Rate for Payer: Group Health Inc Medicare	$0.02
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	$0.05

ACYCLOVIR 200 MG PO CAPS [8969]

Facility

$0.13

Service Code	NDC 75834012401
Hospital Charge Code	75834012401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.07
Rate for Payer: Aetna Government	$0.07
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: Group Health Inc Commercial	$0.07
Rate for Payer: Group Health Inc Medicare	$0.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.07
Rate for Payer: Hamaspik Choice Inc Medicare	$0.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.09

ACYCLOVIR 200 MG PO CAPS [8969]

Facility

$1.53

Service Code	NDC 00904578961
Hospital Charge Code	00904578961
Hospital Revenue Code	250
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$1.22
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.84
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.76
Rate for Payer: Aetna Government	$0.76
Rate for Payer: Brighton Health Commercial	$1.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.04
Rate for Payer: Group Health Inc Commercial	$0.76
Rate for Payer: Group Health Inc Medicare	$0.54
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.76
Rate for Payer: Hamaspik Choice Inc Medicare	$0.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.99

ACYCLOVIR 400 MG PO TABS [8971]

Facility

$2.17

Service Code	NDC 31722077701
Hospital Charge Code	31722077701
Hospital Revenue Code	250
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.73
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.08
Rate for Payer: Aetna Government	$1.08
Rate for Payer: Brighton Health Commercial	$1.63
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.73
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.47
Rate for Payer: Group Health Inc Commercial	$1.08
Rate for Payer: Group Health Inc Medicare	$0.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.08
Rate for Payer: Hamaspik Choice Inc Medicare	$1.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.41

ACYCLOVIR 400 MG PO TABS [8971]

Facility

$3.75

Service Code	NDC 50268006115
Hospital Charge Code	50268006115
Hospital Revenue Code	250
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$3.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.06
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.87
Rate for Payer: Aetna Government	$1.87
Rate for Payer: Brighton Health Commercial	$2.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.55
Rate for Payer: Group Health Inc Commercial	$1.87
Rate for Payer: Group Health Inc Medicare	$1.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.87
Rate for Payer: Hamaspik Choice Inc Medicare	$1.87
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.43

ACYCLOVIR 400 MG TAB

Facility

$1.08

Service Code	HCPCS J8499
Hospital Charge Code	41641746
Hospital Revenue Code	636
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.59
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.54
Rate for Payer: Aetna Government	$0.54
Rate for Payer: Brighton Health Commercial	$0.65
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.54
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.62
Rate for Payer: Group Health Inc Commercial	$0.54
Rate for Payer: Group Health Inc Medicare	$0.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.54
Rate for Payer: Hamaspik Choice Inc Medicare	$0.54
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.70

ACYCLOVIR 400 MG TAB

Facility

$1.08

Service Code	HCPCS J8499
Hospital Charge Code	41641746
Hospital Revenue Code	636
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.54
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.54
Rate for Payer: Hamaspik Choice Inc Medicare	$0.54

ACYCLOVIR 400 MG TAB

Facility

$1.08

Service Code	HCPCS J8499
Hospital Charge Code	41651746
Hospital Revenue Code	636
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.59
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.54
Rate for Payer: Aetna Government	$0.54
Rate for Payer: Brighton Health Commercial	$0.65
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.54
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.62
Rate for Payer: Group Health Inc Commercial	$0.54
Rate for Payer: Group Health Inc Medicare	$0.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.54
Rate for Payer: Hamaspik Choice Inc Medicare	$0.54
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.70

ACYCLOVIR 400 MG TAB

Facility

$1.08

Service Code	HCPCS J8499
Hospital Charge Code	41651746
Hospital Revenue Code	636
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.54
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.54
Rate for Payer: Hamaspik Choice Inc Medicare	$0.54

ACYCLOVIR 40 MG/ML SUSP

Facility

$0.25

Service Code	HCPCS J8499
Hospital Charge Code	41651595
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.14
Rate for Payer: Group Health Inc Commercial	$0.13
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.16

ACYCLOVIR 40 MG/ML SUSP

Facility

$0.25

Service Code	HCPCS J8499
Hospital Charge Code	41641595
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13

ACYCLOVIR 40 MG/ML SUSP

Facility

$0.25

Service Code	HCPCS J8499
Hospital Charge Code	41641595
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.13
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.14
Rate for Payer: Group Health Inc Commercial	$0.13
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.16

ACYCLOVIR 40 MG/ML SUSP

Facility

$0.25

Service Code	HCPCS J8499
Hospital Charge Code	41651595
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13

ACYCLOVIR 500 MG/10 ML INJ

Facility

$0.08

Hospital Charge Code	41653579
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.04
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	$0.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.05
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	$0.05

ACYCLOVIR 500 MG/10 ML INJ

Facility

$0.08

Hospital Charge Code	41643579
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.06
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.04
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	$0.06
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.05
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	$0.05

ACYCLOVIR 5 MG/ML INJ PEDIATRIC

Facility

$1.00

Hospital Charge Code	41644573
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

ACYCLOVIR 5 MG/ML INJ PEDIATRIC

Facility

$1.00

Hospital Charge Code	41654573
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

ACYCLOVIR 5MG/ML NS

Facility

$5.64

Service Code	HCPCS J0133
Hospital Charge Code	41650328
Hospital Revenue Code	636
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$2.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.82
Rate for Payer: Hamaspik Choice Inc Medicare	$2.82

ACYCLOVIR 5MG/ML NS

Facility

$5.64

Service Code	HCPCS J0133
Hospital Charge Code	41640328
Hospital Revenue Code	636
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$2.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.82
Rate for Payer: Hamaspik Choice Inc Medicare	$2.82

ACYCLOVIR 5MG/ML NS

Facility

$5.64

Service Code	HCPCS J0133
Hospital Charge Code	41640328
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$3.67
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$3.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.82
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.24
Rate for Payer: Group Health Inc Commercial	$2.82
Rate for Payer: Group Health Inc Medicare	$1.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.82
Rate for Payer: Hamaspik Choice Inc Medicare	$2.82
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.06
Rate for Payer: SOMOS Essential	$0.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.67

ACYCLOVIR 5MG/ML NS

Facility

$5.64

Service Code	HCPCS J0133
Hospital Charge Code	41650328
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$3.67
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.04
Rate for Payer: Aetna Government	$0.04
Rate for Payer: Brighton Health Commercial	$3.38
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.82
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.24
Rate for Payer: Group Health Inc Commercial	$2.82
Rate for Payer: Group Health Inc Medicare	$1.97
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.82
Rate for Payer: Hamaspik Choice Inc Medicare	$2.82
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.06
Rate for Payer: SOMOS Essential	$0.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.67

ACYCLOVIR 800 MG PO TABS [8972]

Facility

$4.22

Service Code	NDC 50268006211
Hospital Charge Code	50268006211
Hospital Revenue Code	250
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$3.37
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	$3.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.37
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.87
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	$2.74

ACYCLOVIR 800 MG PO TABS [8972]

Facility

$4.22

Service Code	NDC 50268006215
Hospital Charge Code	50268006215
Hospital Revenue Code	250
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$3.37
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	$3.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.37
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.87
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	$2.74

ACYCLOVIR 800 MG PO TABS [8972]

Facility

$4.22

Service Code	NDC 31722077801
Hospital Charge Code	31722077801
Hospital Revenue Code	250
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$3.37
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	$3.16
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.37
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.87
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	$2.74

ACYCLOVIR 800 MG TAB

Facility

$0.29

Service Code	HCPCS J8499
Hospital Charge Code	41643578
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15

Know your out-of-pocket cost for care.

All Charges