St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

ACETAMINOPHEN-CODEINE 300-30 MG PO TABS

Facility

$1.43

Service Code	NDC 0406048401
Hospital Charge Code	0406048401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$1.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.78
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.71
Rate for Payer: Aetna Government	$0.71
Rate for Payer: Brighton Health Commercial	$1.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.14
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.97
Rate for Payer: EmblemHealth Commercial	$0.71
Rate for Payer: Group Health Inc Commercial	$0.71
Rate for Payer: Group Health Inc Medicare	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.71
Rate for Payer: Hamaspik Choice Inc Medicare	$0.71
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.93

ACETAMINOPHEN-CODEINE 300-30 MG PO TABS

Facility

$0.91

Service Code	NDC 0406048423
Hospital Charge Code	0406048423
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.73
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.46
Rate for Payer: Aetna Government	$0.46
Rate for Payer: Brighton Health Commercial	$0.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.73
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.62
Rate for Payer: EmblemHealth Commercial	$0.46
Rate for Payer: Group Health Inc Commercial	$0.46
Rate for Payer: Group Health Inc Medicare	$0.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.46
Rate for Payer: Hamaspik Choice Inc Medicare	$0.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.59

ACETAMINOPHEN-CODEINE 300-30 MG PO TABS

Facility

$0.95

Service Code	NDC 6516203310
Hospital Charge Code	6516203310
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.48

ACETAMINOPHEN-CODEINE 300-30 MG PO TABS

Facility

$0.95

Service Code	NDC 6516203310
Hospital Charge Code	6516203310
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.52
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.48
Rate for Payer: Aetna Government	$0.48
Rate for Payer: Brighton Health Commercial	$0.71
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.65
Rate for Payer: EmblemHealth Commercial	$0.48
Rate for Payer: Group Health Inc Commercial	$0.48
Rate for Payer: Group Health Inc Medicare	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.48
Rate for Payer: Hamaspik Choice Inc Medicare	$0.48
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.62

ACETAMINOPHEN-CODEINE 300-30 MG PO TABS

Facility

$0.23

Service Code	NDC 7193005512
Hospital Charge Code	7193005512
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.18
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.11
Rate for Payer: Aetna Government	$0.11
Rate for Payer: Brighton Health Commercial	$0.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.16
Rate for Payer: EmblemHealth Commercial	$0.11
Rate for Payer: Group Health Inc Commercial	$0.11
Rate for Payer: Group Health Inc Medicare	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.11
Rate for Payer: Hamaspik Choice Inc Medicare	$0.11
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.15

ACETAMINOPHEN-CODEINE 300-30 MG PO TABS

Facility

$0.61

Service Code	NDC 6068760401
Hospital Charge Code	6068760401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.31

ACETAMINOPHEN-CODEINE 300-30 MG PO TABS

Facility

$1.43

Service Code	NDC 0406048401
Hospital Charge Code	0406048401
Hospital Revenue Code	250
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$0.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.71

ACETAMINOPHEN-CODEINE 300-30 MG PO TABS

Facility

$0.92

Service Code	NDC 0406048462
Hospital Charge Code	0406048462
Hospital Revenue Code	250
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.46
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.46

ACETAZOLAMIDE 250 MG PO TABS

Facility

$4.33

Service Code	NDC 0904666361
Hospital Charge Code	0904666361
Hospital Revenue Code	250
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$2.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.17

ACETAZOLAMIDE 250 MG PO TABS

Facility

$4.19

Service Code	NDC 5026805411
Hospital Charge Code	5026805411
Hospital Revenue Code	250
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$3.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.09
Rate for Payer: Aetna Government	$2.09
Rate for Payer: Brighton Health Commercial	$3.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.85
Rate for Payer: EmblemHealth Commercial	$2.09
Rate for Payer: Group Health Inc Commercial	$2.09
Rate for Payer: Group Health Inc Medicare	$1.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.09
Rate for Payer: Hamaspik Choice Inc Medicare	$2.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.72

ACETAZOLAMIDE 250 MG PO TABS

Facility

$4.33

Service Code	NDC 0904666361
Hospital Charge Code	0904666361
Hospital Revenue Code	250
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$3.47
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.17
Rate for Payer: Aetna Government	$2.17
Rate for Payer: Brighton Health Commercial	$3.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.47
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.95
Rate for Payer: EmblemHealth Commercial	$2.17
Rate for Payer: Group Health Inc Commercial	$2.17
Rate for Payer: Group Health Inc Medicare	$1.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.17
Rate for Payer: Hamaspik Choice Inc Medicare	$2.17
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.82

ACETAZOLAMIDE 250 MG PO TABS

Facility

$0.42

Service Code	NDC 5167240231
Hospital Charge Code	5167240231
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.21

ACETAZOLAMIDE 250 MG PO TABS

Facility

$4.19

Service Code	NDC 5026805411
Hospital Charge Code	5026805411
Hospital Revenue Code	250
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$2.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.09

ACETAZOLAMIDE 250 MG PO TABS

Facility

$4.19

Service Code	NDC 5026805415
Hospital Charge Code	5026805415
Hospital Revenue Code	250
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$3.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.09
Rate for Payer: Aetna Government	$2.09
Rate for Payer: Brighton Health Commercial	$3.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.85
Rate for Payer: EmblemHealth Commercial	$2.09
Rate for Payer: Group Health Inc Commercial	$2.09
Rate for Payer: Group Health Inc Medicare	$1.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.09
Rate for Payer: Hamaspik Choice Inc Medicare	$2.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.72

ACETAZOLAMIDE 250 MG PO TABS

Facility

$0.42

Service Code	NDC 5167240231
Hospital Charge Code	5167240231
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.34
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.23
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.21
Rate for Payer: Aetna Government	$0.21
Rate for Payer: Brighton Health Commercial	$0.32
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.34
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.29
Rate for Payer: EmblemHealth Commercial	$0.21
Rate for Payer: Group Health Inc Commercial	$0.21
Rate for Payer: Group Health Inc Medicare	$0.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.21
Rate for Payer: Hamaspik Choice Inc Medicare	$0.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.27

ACETAZOLAMIDE 250 MG PO TABS

Facility

$4.19

Service Code	NDC 5026805415
Hospital Charge Code	5026805415
Hospital Revenue Code	250
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$2.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.09

ACETAZOLAMIDE 50 MG/ML SUSPENSION PEDIATRIC (SBH)

Facility

$4.76

Service Code	HCPCS J1120
Hospital Charge Code	9999000102
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$2.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.38

ACETAZOLAMIDE 50 MG/ML SUSPENSION PEDIATRIC (SBH)

Facility

$4.76

Service Code	HCPCS J1120
Hospital Charge Code	9999000102
Hospital Revenue Code	250
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$20.13
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.13
Rate for Payer: Aetna Government	$20.13
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: Healthfirst CHP/FHP/Medicaid	$19.84
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.10

ACETAZOLAMIDE 5MG/ML INJ PEDIATRIC (SBH)

Facility

$4.76

Service Code	HCPCS J1120
Hospital Charge Code	9999000102
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$2.38
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.38

ACETAZOLAMIDE 5MG/ML INJ PEDIATRIC (SBH)

Facility

$4.76

Service Code	HCPCS J1120
Hospital Charge Code	9999000102
Hospital Revenue Code	250
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$20.13
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.13
Rate for Payer: Aetna Government	$20.13
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: Healthfirst CHP/FHP/Medicaid	$19.84
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.10

ACETAZOLAMIDE ER 500 MG PO CP12

Facility

$4.29

Service Code	NDC 7071015911
Hospital Charge Code	7071015911
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$3.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.15
Rate for Payer: Aetna Government	$2.15
Rate for Payer: Brighton Health Commercial	$3.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.92
Rate for Payer: EmblemHealth Commercial	$2.15
Rate for Payer: Group Health Inc Commercial	$2.15
Rate for Payer: Group Health Inc Medicare	$1.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.15
Rate for Payer: Hamaspik Choice Inc Medicare	$2.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.79

ACETAZOLAMIDE ER 500 MG PO CP12

Facility

$4.29

Service Code	NDC 5074223301
Hospital Charge Code	5074223301
Hospital Revenue Code	250
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$2.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.15

ACETAZOLAMIDE ER 500 MG PO CP12

Facility

$4.29

Service Code	NDC 7071015911
Hospital Charge Code	7071015911
Hospital Revenue Code	250
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$2.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.15

ACETAZOLAMIDE ER 500 MG PO CP12

Facility

$4.29

Service Code	NDC 1672933101
Hospital Charge Code	1672933101
Hospital Revenue Code	250
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$2.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.15

ACETAZOLAMIDE ER 500 MG PO CP12

Facility

$4.29

Service Code	NDC 1672933101
Hospital Charge Code	1672933101
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$3.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.15
Rate for Payer: Aetna Government	$2.15
Rate for Payer: Brighton Health Commercial	$3.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.92
Rate for Payer: EmblemHealth Commercial	$2.15
Rate for Payer: Group Health Inc Commercial	$2.15
Rate for Payer: Group Health Inc Medicare	$1.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.15
Rate for Payer: Hamaspik Choice Inc Medicare	$2.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.79

Know your out-of-pocket cost for care.

All Charges