St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

LETROZOLE 2.5 MG PO TABS [21509]

Facility

$18.12

Service Code	NDC 51991075933
Hospital Charge Code	51991075933
Hospital Revenue Code	250
Min. Negotiated Rate	$6.34
Max. Negotiated Rate	$14.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9.96
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.06
Rate for Payer: Aetna Government	$9.06
Rate for Payer: Brighton Health Commercial	$13.59
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14.49
Rate for Payer: Cigna LocalPlus Benefit Plan	$12.32
Rate for Payer: Group Health Inc Commercial	$9.06
Rate for Payer: Group Health Inc Medicare	$6.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.06
Rate for Payer: Hamaspik Choice Inc Medicare	$9.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.77

LETROZOLE 2.5 MG PO TABS [21509]

Facility

$18.14

Service Code	NDC 59651018030
Hospital Charge Code	59651018030
Hospital Revenue Code	250
Min. Negotiated Rate	$6.35
Max. Negotiated Rate	$14.51
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9.97
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.07
Rate for Payer: Aetna Government	$9.07
Rate for Payer: Brighton Health Commercial	$13.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14.51
Rate for Payer: Cigna LocalPlus Benefit Plan	$12.33
Rate for Payer: Group Health Inc Commercial	$9.07
Rate for Payer: Group Health Inc Medicare	$6.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.07
Rate for Payer: Hamaspik Choice Inc Medicare	$9.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.79

LETROZOLE 2.5 MG PO TABS [21509]

Facility

$18.05

Service Code	NDC 16729003415
Hospital Charge Code	16729003415
Hospital Revenue Code	250
Min. Negotiated Rate	$6.32
Max. Negotiated Rate	$14.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9.93
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.03
Rate for Payer: Aetna Government	$9.03
Rate for Payer: Brighton Health Commercial	$13.54
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$12.28
Rate for Payer: Group Health Inc Commercial	$9.03
Rate for Payer: Group Health Inc Medicare	$6.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.03
Rate for Payer: Hamaspik Choice Inc Medicare	$9.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.73

LETROZOLE 2.5 MG TAB

Facility

$0.52

Hospital Charge Code	41651950
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.29
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.26
Rate for Payer: Aetna Government	$0.26
Rate for Payer: Brighton Health Commercial	$0.39
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.42
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.35
Rate for Payer: Group Health Inc Commercial	$0.26
Rate for Payer: Group Health Inc Medicare	$0.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.26
Rate for Payer: Hamaspik Choice Inc Medicare	$0.26
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.34

LETROZOLE 2.5 MG TAB

Facility

$0.52

Hospital Charge Code	41641950
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.29
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.26
Rate for Payer: Aetna Government	$0.26
Rate for Payer: Brighton Health Commercial	$0.39
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.42
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.35
Rate for Payer: Group Health Inc Commercial	$0.26
Rate for Payer: Group Health Inc Medicare	$0.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.26
Rate for Payer: Hamaspik Choice Inc Medicare	$0.26
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.34

LETS KIT [119419]

Facility

$1.39

Service Code	NDC 51552134501
Hospital Charge Code	51552134501
Hospital Revenue Code	250
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$1.11
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.69
Rate for Payer: Aetna Government	$0.69
Rate for Payer: Brighton Health Commercial	$1.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.11
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.94
Rate for Payer: Group Health Inc Commercial	$0.69
Rate for Payer: Group Health Inc Medicare	$0.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.69
Rate for Payer: Hamaspik Choice Inc Medicare	$0.69
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.90

LEUCOVORIN 100 MG INJ

Facility

$6.00

Service Code	HCPCS J0640
Hospital Charge Code	41642878
Hospital Revenue Code	636
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$5.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.66
Rate for Payer: Aetna Government	$3.66
Rate for Payer: Brighton Health Commercial	$3.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.45
Rate for Payer: Group Health Inc Commercial	$3.00
Rate for Payer: Group Health Inc Medicare	$2.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5.45
Rate for Payer: SOMOS Essential	$5.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.90

LEUCOVORIN 100 MG INJ

Facility

$6.00

Service Code	HCPCS J0640
Hospital Charge Code	41652878
Hospital Revenue Code	636
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$5.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.66
Rate for Payer: Aetna Government	$3.66
Rate for Payer: Brighton Health Commercial	$3.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.45
Rate for Payer: Group Health Inc Commercial	$3.00
Rate for Payer: Group Health Inc Medicare	$2.10
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5.45
Rate for Payer: SOMOS Essential	$5.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.90

LEUCOVORIN 100 MG INJ

Facility

$6.00

Service Code	HCPCS J0640
Hospital Charge Code	41652878
Hospital Revenue Code	636
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$3.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3.00

LEUCOVORIN 100 MG INJ

Facility

$6.00

Service Code	HCPCS J0640
Hospital Charge Code	41642878
Hospital Revenue Code	636
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$3.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.00
Rate for Payer: Hamaspik Choice Inc Medicare	$3.00

LEUCOVORIN 200 MG INJ

Facility

$10.00

Service Code	HCPCS J0640
Hospital Charge Code	41645454
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$6.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.66
Rate for Payer: Aetna Government	$3.66
Rate for Payer: Brighton Health Commercial	$6.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.75
Rate for Payer: Group Health Inc Commercial	$5.00
Rate for Payer: Group Health Inc Medicare	$3.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5.45
Rate for Payer: SOMOS Essential	$5.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$6.50

LEUCOVORIN 200 MG INJ

Facility

$10.00

Service Code	HCPCS J0640
Hospital Charge Code	41655454
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$6.50
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$5.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.66
Rate for Payer: Aetna Government	$3.66
Rate for Payer: Brighton Health Commercial	$6.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.75
Rate for Payer: Group Health Inc Commercial	$5.00
Rate for Payer: Group Health Inc Medicare	$3.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5.00
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5.45
Rate for Payer: SOMOS Essential	$5.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$6.50

LEUCOVORIN 200 MG INJ

Facility

$10.00

Service Code	HCPCS J0640
Hospital Charge Code	41645454
Hospital Revenue Code	636
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$5.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5.00

LEUCOVORIN 200 MG INJ

Facility

$10.00

Service Code	HCPCS J0640
Hospital Charge Code	41655454
Hospital Revenue Code	636
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$5.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$5.00
Rate for Payer: Hamaspik Choice Inc Medicare	$5.00

LEUCOVORIN 350 MG INJ

Facility

$1.36

Service Code	HCPCS J0640
Hospital Charge Code	41642879
Hospital Revenue Code	636
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.68
Rate for Payer: Hamaspik Choice Inc Medicare	$0.68

LEUCOVORIN 350 MG INJ

Facility

$1.36

Service Code	HCPCS J0640
Hospital Charge Code	41652879
Hospital Revenue Code	636
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.68
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.68
Rate for Payer: Hamaspik Choice Inc Medicare	$0.68

LEUCOVORIN 350 MG INJ

Facility

$1.36

Service Code	HCPCS J0640
Hospital Charge Code	41652879
Hospital Revenue Code	636
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$5.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.66
Rate for Payer: Aetna Government	$3.66
Rate for Payer: Brighton Health Commercial	$0.82
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.68
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.78
Rate for Payer: Group Health Inc Commercial	$0.68
Rate for Payer: Group Health Inc Medicare	$0.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.68
Rate for Payer: Hamaspik Choice Inc Medicare	$0.68
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5.45
Rate for Payer: SOMOS Essential	$5.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.88

LEUCOVORIN 350 MG INJ

Facility

$1.36

Service Code	HCPCS J0640
Hospital Charge Code	41642879
Hospital Revenue Code	636
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$5.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.66
Rate for Payer: Aetna Government	$3.66
Rate for Payer: Brighton Health Commercial	$0.82
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.68
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.78
Rate for Payer: Group Health Inc Commercial	$0.68
Rate for Payer: Group Health Inc Medicare	$0.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.68
Rate for Payer: Hamaspik Choice Inc Medicare	$0.68
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5.45
Rate for Payer: SOMOS Essential	$5.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.88

LEUCOVORIN 500 MG INJ

Facility

$17.00

Service Code	HCPCS J0640
Hospital Charge Code	41655584
Hospital Revenue Code	636
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$8.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.50
Rate for Payer: Hamaspik Choice Inc Medicare	$8.50

LEUCOVORIN 500 MG INJ

Facility

$17.00

Service Code	HCPCS J0640
Hospital Charge Code	41645584
Hospital Revenue Code	636
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$11.05
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9.35
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.66
Rate for Payer: Aetna Government	$3.66
Rate for Payer: Brighton Health Commercial	$10.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.78
Rate for Payer: Group Health Inc Commercial	$8.50
Rate for Payer: Group Health Inc Medicare	$5.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.50
Rate for Payer: Hamaspik Choice Inc Medicare	$8.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5.45
Rate for Payer: SOMOS Essential	$5.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.05

LEUCOVORIN 500 MG INJ

Facility

$17.00

Service Code	HCPCS J0640
Hospital Charge Code	41655584
Hospital Revenue Code	636
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$11.05
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9.35
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.66
Rate for Payer: Aetna Government	$3.66
Rate for Payer: Brighton Health Commercial	$10.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$8.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.78
Rate for Payer: Group Health Inc Commercial	$8.50
Rate for Payer: Group Health Inc Medicare	$5.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.50
Rate for Payer: Hamaspik Choice Inc Medicare	$8.50
Rate for Payer: SOMOS CHP/HARP/Medicaid	$5.45
Rate for Payer: SOMOS Essential	$5.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.05

LEUCOVORIN 500 MG INJ

Facility

$17.00

Service Code	HCPCS J0640
Hospital Charge Code	41645584
Hospital Revenue Code	636
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$8.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.50
Rate for Payer: Hamaspik Choice Inc Medicare	$8.50

LEUCOVORIN 50 MG INJ

Facility

$5.00

Service Code	HCPCS J0640
Hospital Charge Code	41642877
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

LEUCOVORIN 50 MG INJ

Facility

$5.00

Service Code	HCPCS J0640
Hospital Charge Code	41652877
Hospital Revenue Code	636
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$5.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.66
Rate for Payer: Aetna Government	$3.66
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	$5.45
Rate for Payer: SOMOS Essential	$5.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.25

LEUCOVORIN 50 MG INJ

Facility

$5.00

Service Code	HCPCS J0640
Hospital Charge Code	41642877
Hospital Revenue Code	636
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$5.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.66
Rate for Payer: Aetna Government	$3.66
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	$5.45
Rate for Payer: SOMOS Essential	$5.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.25

Know your out-of-pocket cost for care.

All Charges