St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

LEVETIRACETAM 500 MG/5ML IV SOLN

Facility

$3.00

Service Code	HCPCS J1953
Hospital Charge Code	5515017705
Hospital Revenue Code	258
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$1.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50

LEVETIRACETAM 500 MG/5ML IV SOLN

Facility

$0.60

Service Code	HCPCS J1953
Hospital Charge Code	7248510610
Hospital Revenue Code	258
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.30

LEVETIRACETAM 500 MG/5ML IV SOLN

Facility

$0.60

Service Code	HCPCS J1953
Hospital Charge Code	7220512025
Hospital Revenue Code	258
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.30

LEVETIRACETAM 500 MG/5ML IV SOLN

Facility

$0.93

Service Code	HCPCS J1953
Hospital Charge Code	0409188602
Hospital Revenue Code	258
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.47

LEVETIRACETAM 500 MG/5ML IV SOLN

Facility

$1.38

Service Code	HCPCS J1953
Hospital Charge Code	5122401325
Hospital Revenue Code	258
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$0.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.69

LEVETIRACETAM 500 MG/5ML IV SOLN

Facility

$2.52

Service Code	HCPCS J1953
Hospital Charge Code	6745779005
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$2.02
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$1.89
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.02
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.71
Rate for Payer: EmblemHealth Commercial	$1.26
Rate for Payer: Group Health Inc Commercial	$1.26
Rate for Payer: Group Health Inc Medicare	$0.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.26
Rate for Payer: Hamaspik Choice Inc Medicare	$1.26
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.64

LEVETIRACETAM 500 MG/5ML IV SOLN

Facility

$0.72

Service Code	HCPCS J1953
Hospital Charge Code	7220512007
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.58
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.49
Rate for Payer: EmblemHealth Commercial	$0.36
Rate for Payer: Group Health Inc Commercial	$0.36
Rate for Payer: Group Health Inc Medicare	$0.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.36
Rate for Payer: Hamaspik Choice Inc Medicare	$0.36
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.47

LEVETIRACETAM 500 MG/5ML IV SOLN

Facility

$2.10

Service Code	HCPCS J1953
Hospital Charge Code	0143967301
Hospital Revenue Code	258
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.05

LEVETIRACETAM 500 MG/5ML IV SOLN

Facility

$3.00

Service Code	HCPCS J1953
Hospital Charge Code	5515017705
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$2.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$2.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.04
Rate for Payer: EmblemHealth Commercial	$1.50
Rate for Payer: Group Health Inc Commercial	$1.50
Rate for Payer: Group Health Inc Medicare	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.95

LEVETIRACETAM 500 MG/5ML IV SOLN

Facility

$2.10

Service Code	HCPCS J1953
Hospital Charge Code	0143967301
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$1.68
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$1.57
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.68
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.43
Rate for Payer: EmblemHealth Commercial	$1.05
Rate for Payer: Group Health Inc Commercial	$1.05
Rate for Payer: Group Health Inc Medicare	$0.74
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.05
Rate for Payer: Hamaspik Choice Inc Medicare	$1.05
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.36

LEVETIRACETAM 500 MG/5ML IV SOLN

Facility

$0.93

Service Code	HCPCS J1953
Hospital Charge Code	0409188602
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.75
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.75
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.63
Rate for Payer: EmblemHealth Commercial	$0.47
Rate for Payer: Group Health Inc Commercial	$0.47
Rate for Payer: Group Health Inc Medicare	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.47
Rate for Payer: Hamaspik Choice Inc Medicare	$0.47
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.61

LEVETIRACETAM 500 MG/5ML IV SOLN

Facility

$0.60

Service Code	HCPCS J1953
Hospital Charge Code	7248510610
Hospital Revenue Code	258
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.48
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.48
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.41
Rate for Payer: EmblemHealth Commercial	$0.30
Rate for Payer: Group Health Inc Commercial	$0.30
Rate for Payer: Group Health Inc Medicare	$0.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.30
Rate for Payer: Hamaspik Choice Inc Medicare	$0.30
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.39

LEVETIRACETAM 500 MG/5ML IV SOLN

Facility

$0.72

Service Code	HCPCS J1953
Hospital Charge Code	7220512007
Hospital Revenue Code	258
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.36
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.36

LEVETIRACETAM 500 MG PO TABS

Facility

$0.25

Service Code	NDC 0904712461
Hospital Charge Code	0904712461
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.20
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	$0.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.17
Rate for Payer: EmblemHealth Commercial	$0.13
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

LEVETIRACETAM 500 MG PO TABS

Facility

$3.51

Service Code	NDC 3172253712
Hospital Charge Code	3172253712
Hospital Revenue Code	250
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$2.81
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.93
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.76
Rate for Payer: Aetna Government	$1.76
Rate for Payer: Brighton Health Commercial	$2.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.81
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.39
Rate for Payer: EmblemHealth Commercial	$1.76
Rate for Payer: Group Health Inc Commercial	$1.76
Rate for Payer: Group Health Inc Medicare	$1.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.76
Rate for Payer: Hamaspik Choice Inc Medicare	$1.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.28

LEVETIRACETAM 500 MG PO TABS

Facility

$3.51

Service Code	NDC 3172253705
Hospital Charge Code	3172253705
Hospital Revenue Code	250
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$2.81
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.93
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.76
Rate for Payer: Aetna Government	$1.76
Rate for Payer: Brighton Health Commercial	$2.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.81
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.39
Rate for Payer: EmblemHealth Commercial	$1.76
Rate for Payer: Group Health Inc Commercial	$1.76
Rate for Payer: Group Health Inc Medicare	$1.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.76
Rate for Payer: Hamaspik Choice Inc Medicare	$1.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.28

LEVETIRACETAM 500 MG PO TABS

Facility

$0.25

Service Code	NDC 0904712461
Hospital Charge Code	0904712461
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13

LEVETIRACETAM 500 MG PO TABS

Facility

$3.51

Service Code	NDC 3172253705
Hospital Charge Code	3172253705
Hospital Revenue Code	250
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$1.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.76

LEVETIRACETAM 500 MG PO TABS

Facility

$3.51

Service Code	NDC 6818011302
Hospital Charge Code	6818011302
Hospital Revenue Code	250
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$1.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.76

LEVETIRACETAM 500 MG PO TABS

Facility

$3.51

Service Code	NDC 6818011302
Hospital Charge Code	6818011302
Hospital Revenue Code	250
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$2.81
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.93
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.76
Rate for Payer: Aetna Government	$1.76
Rate for Payer: Brighton Health Commercial	$2.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.81
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.39
Rate for Payer: EmblemHealth Commercial	$1.76
Rate for Payer: Group Health Inc Commercial	$1.76
Rate for Payer: Group Health Inc Medicare	$1.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.76
Rate for Payer: Hamaspik Choice Inc Medicare	$1.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.28

LEVETIRACETAM 500 MG PO TABS

Facility

$3.51

Service Code	NDC 3172253712
Hospital Charge Code	3172253712
Hospital Revenue Code	250
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$1.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.76

LEVETIRACETAM 750 MG PO TABS

Facility

$0.34

Service Code	NDC 0904712561
Hospital Charge Code	0904712561
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.17

LEVETIRACETAM 750 MG PO TABS

Facility

$4.76

Service Code	NDC 3172253805
Hospital Charge Code	3172253805
Hospital Revenue Code	250
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$3.81
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.38
Rate for Payer: Aetna Government	$2.38
Rate for Payer: Brighton Health Commercial	$3.57
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.81
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.24
Rate for Payer: EmblemHealth Commercial	$2.38
Rate for Payer: Group Health Inc Commercial	$2.38
Rate for Payer: Group Health Inc Medicare	$1.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.38
Rate for Payer: Hamaspik Choice Inc Medicare	$2.38
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.09

LEVETIRACETAM 750 MG PO TABS

Facility

$4.76

Service Code	NDC 3172253805
Hospital Charge Code	3172253805
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$2.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.38

LEVETIRACETAM 750 MG PO TABS

Facility

$0.34

Service Code	NDC 0904712561
Hospital Charge Code	0904712561
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.27
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.17
Rate for Payer: Aetna Government	$0.17
Rate for Payer: Brighton Health Commercial	$0.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.27
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.23
Rate for Payer: EmblemHealth Commercial	$0.17
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	$0.22

Know your out-of-pocket cost for care.

All Charges