St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

CYCLOSPORINE(SANDIMMUNE)100MG/ML

Facility

$14.00

Service Code	HCPCS J7502
Hospital Charge Code	41641148
Hospital Revenue Code	636
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$7.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00

CYCLOSPORINE(SANDIMMUNE)100MG/ML

Facility

$14.00

Service Code	HCPCS J7502
Hospital Charge Code	41651148
Hospital Revenue Code	636
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$9.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.42
Rate for Payer: Aetna Government	$2.42
Rate for Payer: Brighton Health Commercial	$8.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.05
Rate for Payer: Group Health Inc Commercial	$7.00
Rate for Payer: Group Health Inc Medicare	$4.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.43
Rate for Payer: SOMOS Essential	$2.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.10

CYCLOSPORINE(SANDIMMUNE)100MG/ML

Facility

$14.00

Service Code	HCPCS J7502
Hospital Charge Code	41641148
Hospital Revenue Code	636
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$9.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.42
Rate for Payer: Aetna Government	$2.42
Rate for Payer: Brighton Health Commercial	$8.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$8.05
Rate for Payer: Group Health Inc Commercial	$7.00
Rate for Payer: Group Health Inc Medicare	$4.90
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$2.43
Rate for Payer: SOMOS Essential	$2.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.10

CYCLOSPORINE (SANDIMMUNE) 25 MG CAP

Facility

$5.00

Service Code	HCPCS J7515
Hospital Charge Code	41651147
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

CYCLOSPORINE (SANDIMMUNE) 25 MG CAP

Facility

$5.00

Service Code	HCPCS J7515
Hospital Charge Code	41641147
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

CYCLOSPORINE (SANDIMMUNE) 25 MG CAP

Facility

$5.00

Service Code	HCPCS J7515
Hospital Charge Code	41651147
Hospital Revenue Code	636
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$3.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.82
Rate for Payer: Aetna Government	$0.82
Rate for Payer: Brighton Health Commercial	$3.00
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 Medicaid	$2.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.98
Rate for Payer: SOMOS Essential	$0.98
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.25

CYCLOSPORINE (SANDIMMUNE) 25 MG CAP

Facility

$5.00

Service Code	HCPCS J7515
Hospital Charge Code	41641147
Hospital Revenue Code	636
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$3.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.82
Rate for Payer: Aetna Government	$0.82
Rate for Payer: Brighton Health Commercial	$3.00
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 Medicaid	$2.50
Rate for Payer: Hamaspik Choice Inc Medicare	$2.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.98
Rate for Payer: SOMOS Essential	$0.98
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.25

CYLINDER SET W/PUMP - 16CM

Facility

$14,840.00

Service Code	HCPCS C1813
Hospital Charge Code	40203033
Hospital Revenue Code	278
Min. Negotiated Rate	$3,775.00
Max. Negotiated Rate	$15,582.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8,162.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,775.00
Rate for Payer: Aetna Government	$3,775.00
Rate for Payer: Brighton Health Commercial	$8,904.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7,420.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$8,533.00
Rate for Payer: EmblemHealth Commercial	$7,420.00
Rate for Payer: Fidelis Medicare Advantage	$15,582.00
Rate for Payer: Group Health Inc Commercial	$7,420.00
Rate for Payer: Group Health Inc Medicare	$5,194.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,420.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7,420.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9,646.00

CYLINDER SET W/PUMP - 16CM

Facility

$14,840.00

Service Code	HCPCS C1813
Hospital Charge Code	40203033
Hospital Revenue Code	278
Min. Negotiated Rate	$7,420.00
Max. Negotiated Rate	$7,420.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,420.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7,420.00

CYLINDER SET W/PUMP - 20CM

Facility

$14,840.00

Service Code	HCPCS C1813
Hospital Charge Code	40203034
Hospital Revenue Code	278
Min. Negotiated Rate	$3,775.00
Max. Negotiated Rate	$15,582.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8,162.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,775.00
Rate for Payer: Aetna Government	$3,775.00
Rate for Payer: Brighton Health Commercial	$8,904.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7,420.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$8,533.00
Rate for Payer: EmblemHealth Commercial	$7,420.00
Rate for Payer: Fidelis Medicare Advantage	$15,582.00
Rate for Payer: Group Health Inc Commercial	$7,420.00
Rate for Payer: Group Health Inc Medicare	$5,194.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,420.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7,420.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9,646.00

CYLINDER SET W/PUMP - 20CM

Facility

$14,840.00

Service Code	HCPCS C1813
Hospital Charge Code	40203034
Hospital Revenue Code	278
Min. Negotiated Rate	$7,420.00
Max. Negotiated Rate	$7,420.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,420.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7,420.00

CYLINDER SET W/PUMP - 22CM

Facility

$14,840.00

Service Code	HCPCS C1813
Hospital Charge Code	40203035
Hospital Revenue Code	278
Min. Negotiated Rate	$3,775.00
Max. Negotiated Rate	$15,582.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8,162.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3,775.00
Rate for Payer: Aetna Government	$3,775.00
Rate for Payer: Brighton Health Commercial	$8,904.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7,420.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$8,533.00
Rate for Payer: EmblemHealth Commercial	$7,420.00
Rate for Payer: Fidelis Medicare Advantage	$15,582.00
Rate for Payer: Group Health Inc Commercial	$7,420.00
Rate for Payer: Group Health Inc Medicare	$5,194.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,420.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7,420.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9,646.00

CYLINDER SET W/PUMP - 22CM

Facility

$14,840.00

Service Code	HCPCS C1813
Hospital Charge Code	40203035
Hospital Revenue Code	278
Min. Negotiated Rate	$7,420.00
Max. Negotiated Rate	$7,420.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7,420.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7,420.00

CYLINDER SET ZERO ANGLE

Facility

$10,450.00

Hospital Charge Code	64906032
Hospital Revenue Code	270
Min. Negotiated Rate	$3,657.50
Max. Negotiated Rate	$8,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5,747.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$5,225.00
Rate for Payer: Aetna Government	$5,225.00
Rate for Payer: Brighton Health Commercial	$7,837.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8,360.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$7,106.00
Rate for Payer: Group Health Inc Commercial	$5,225.00
Rate for Payer: Group Health Inc Medicare	$3,657.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$5,225.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5,225.00

CYMETRA INJECTABLE 1 CC

Facility

$602.85

Service Code	HCPCS Q4112
Hospital Charge Code	40205800
Hospital Revenue Code	636
Min. Negotiated Rate	$301.42
Max. Negotiated Rate	$301.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$301.42
Rate for Payer: Hamaspik Choice Inc Medicare	$301.42

CYMETRA INJECTABLE 1 CC

Facility

$602.85

Service Code	HCPCS Q4112
Hospital Charge Code	40205800
Hospital Revenue Code	636
Min. Negotiated Rate	$211.00
Max. Negotiated Rate	$872.08
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$331.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$872.08
Rate for Payer: Aetna Government	$872.08
Rate for Payer: Brighton Health Commercial	$361.71
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$301.42
Rate for Payer: Cigna LocalPlus Benefit Plan	$346.64
Rate for Payer: Group Health Inc Commercial	$301.42
Rate for Payer: Group Health Inc Medicare	$211.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$301.42
Rate for Payer: Hamaspik Choice Inc Medicare	$301.42
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$391.85

CYPROHEPTADINE 2 MG/5 ML LIQUID

Facility

$0.20

Hospital Charge Code	41653415
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.10
Rate for Payer: Aetna Government	$0.10
Rate for Payer: Brighton Health Commercial	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.14
Rate for Payer: Group Health Inc Commercial	$0.10
Rate for Payer: Group Health Inc Medicare	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10
Rate for Payer: Hamaspik Choice Inc Medicare	$0.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.13

CYPROHEPTADINE 2 MG/5 ML LIQUID

Facility

$0.20

Hospital Charge Code	41643415
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.10
Rate for Payer: Aetna Government	$0.10
Rate for Payer: Brighton Health Commercial	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.14
Rate for Payer: Group Health Inc Commercial	$0.10
Rate for Payer: Group Health Inc Medicare	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10
Rate for Payer: Hamaspik Choice Inc Medicare	$0.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.13

CYPROHEPTADINE 4 MG TAB

Facility

$1.00

Hospital Charge Code	41640915
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

CYPROHEPTADINE 4 MG TAB

Facility

$1.00

Hospital Charge Code	41650915
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

CYPROHEPTADINE HCL 2 MG/5ML PO SYRP [2032]

Facility

$0.14

Service Code	NDC 64980050448
Hospital Charge Code	64980050448
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.11
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	$0.11
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

CYPROHEPTADINE HCL 4 MG PO TABS [2033]

Facility

$1.07

Service Code	NDC 50268018915
Hospital Charge Code	50268018915
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.86
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	$0.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.86
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.73
Rate for Payer: Group Health Inc Commercial	$0.54
Rate for Payer: Group Health Inc Medicare	$0.37
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

CYPROHEPTADINE HCL 4 MG PO TABS [2033]

Facility

$1.07

Service Code	NDC 70710111001
Hospital Charge Code	70710111001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.59
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.53
Rate for Payer: Aetna Government	$0.53
Rate for Payer: Brighton Health Commercial	$0.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.85
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.73
Rate for Payer: Group Health Inc Commercial	$0.53
Rate for Payer: Group Health Inc Medicare	$0.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.53
Rate for Payer: Hamaspik Choice Inc Medicare	$0.53
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.69

CYPROHEPTADINE HCL 4 MG PO TABS [2033]

Facility

$1.07

Service Code	NDC 50742019001
Hospital Charge Code	50742019001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.59
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.53
Rate for Payer: Aetna Government	$0.53
Rate for Payer: Brighton Health Commercial	$0.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.85
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.73
Rate for Payer: Group Health Inc Commercial	$0.53
Rate for Payer: Group Health Inc Medicare	$0.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.53
Rate for Payer: Hamaspik Choice Inc Medicare	$0.53
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.69

CYPROHEPTADINE HCL 4 MG PO TABS [2033]

Facility

$1.07

Service Code	NDC 50268018911
Hospital Charge Code	50268018911
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.86
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	$0.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.86
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.73
Rate for Payer: Group Health Inc Commercial	$0.54
Rate for Payer: Group Health Inc Medicare	$0.37
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

Know your out-of-pocket cost for care.

All Charges