|
LEUCOVORIN 50 MG INJ
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
41652877
|
|
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 5 MG TAB
|
Facility
|
OP
|
$3.00
|
|
| Hospital Charge Code |
41650230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.50
|
| Rate for Payer: Aetna Government |
$1.50
|
| 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: 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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.95
|
|
|
LEUCOVORIN 5 MG TAB
|
Facility
|
OP
|
$3.00
|
|
| Hospital Charge Code |
41640230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.50
|
| Rate for Payer: Aetna Government |
$1.50
|
| 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: 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: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.95
|
|
|
LEUCOVORIN CALCIUM 100 MG/10ML IJ SOLN [110989]
|
Facility
|
OP
|
$2.89
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
63323063110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$5.45 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.59
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.66
|
| Rate for Payer: Aetna Government |
$3.66
|
| Rate for Payer: Brighton Health Commercial |
$2.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.31
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.97
|
| Rate for Payer: Group Health Inc Commercial |
$1.45
|
| Rate for Payer: Group Health Inc Medicare |
$1.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.45
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$5.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$5.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.88
|
|
|
LEUCOVORIN CALCIUM 100 MG IJ SOLR [4392]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
67457052810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.66
|
| Rate for Payer: Aetna Government |
$3.66
|
| Rate for Payer: Brighton Health Commercial |
$18.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.32
|
| Rate for Payer: Group Health Inc Commercial |
$12.00
|
| Rate for Payer: Group Health Inc Medicare |
$8.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.00
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$5.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$5.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.60
|
|
|
LEUCOVORIN CALCIUM 100 MG IJ SOLR [4392]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25021081430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$13.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.66
|
| Rate for Payer: Aetna Government |
$3.66
|
| Rate for Payer: Brighton Health Commercial |
$18.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$19.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$16.32
|
| Rate for Payer: Group Health Inc Commercial |
$12.00
|
| Rate for Payer: Group Health Inc Medicare |
$8.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$12.00
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$5.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$5.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.60
|
|
|
LEUCOVORIN CALCIUM 100 MG IJ SOLR [4392]
|
Facility
|
OP
|
$19.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
00143955401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$15.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10.56
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.66
|
| Rate for Payer: Aetna Government |
$3.66
|
| Rate for Payer: Brighton Health Commercial |
$14.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$15.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.06
|
| Rate for Payer: Group Health Inc Commercial |
$9.60
|
| Rate for Payer: Group Health Inc Medicare |
$6.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9.60
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$5.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$5.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12.48
|
|
|
LEUCOVORIN CALCIUM 200 MG IJ SOLR [15426]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25021081530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$26.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.66
|
| Rate for Payer: Aetna Government |
$3.66
|
| Rate for Payer: Brighton Health Commercial |
$36.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$38.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$32.64
|
| Rate for Payer: Group Health Inc Commercial |
$24.00
|
| Rate for Payer: Group Health Inc Medicare |
$16.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.00
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$5.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$5.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$31.20
|
|
|
LEUCOVORIN CALCIUM 350 MG IJ SOLR [4393]
|
Facility
|
OP
|
$22.74
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
00703514501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$18.19 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12.51
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.66
|
| Rate for Payer: Aetna Government |
$3.66
|
| Rate for Payer: Brighton Health Commercial |
$17.06
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$18.19
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.46
|
| Rate for Payer: Group Health Inc Commercial |
$11.37
|
| Rate for Payer: Group Health Inc Medicare |
$7.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.37
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$5.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$5.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14.78
|
|
|
LEUCOVORIN CALCIUM 350 MG IJ SOLR [4393]
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25021081630
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$67.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$46.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.66
|
| Rate for Payer: Aetna Government |
$3.66
|
| Rate for Payer: Brighton Health Commercial |
$63.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$67.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$57.12
|
| Rate for Payer: Group Health Inc Commercial |
$42.00
|
| Rate for Payer: Group Health Inc Medicare |
$29.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$42.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$42.00
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$5.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$5.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$54.60
|
|
|
LEUCOVORIN CALCIUM 350 MG IJ SOLR [4393]
|
Facility
|
OP
|
$31.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
67457053035
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$24.96 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$17.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.66
|
| Rate for Payer: Aetna Government |
$3.66
|
| Rate for Payer: Brighton Health Commercial |
$23.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.96
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$21.22
|
| Rate for Payer: Group Health Inc Commercial |
$15.60
|
| Rate for Payer: Group Health Inc Medicare |
$10.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.60
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$5.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$5.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$20.28
|
|
|
LEUCOVORIN CALCIUM 350 MG IJ SOLR [4393]
|
Facility
|
OP
|
$31.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
00143955201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$24.96 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$17.16
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.66
|
| Rate for Payer: Aetna Government |
$3.66
|
| Rate for Payer: Brighton Health Commercial |
$23.40
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$24.96
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$21.22
|
| Rate for Payer: Group Health Inc Commercial |
$15.60
|
| Rate for Payer: Group Health Inc Medicare |
$10.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$15.60
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$5.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$5.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$20.28
|
|
|
LEUCOVORIN CALCIUM 500 MG IJ SOLR [23617]
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25021082850
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$66.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.66
|
| Rate for Payer: Aetna Government |
$3.66
|
| Rate for Payer: Brighton Health Commercial |
$90.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$96.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$81.60
|
| Rate for Payer: Group Health Inc Commercial |
$60.00
|
| Rate for Payer: Group Health Inc Medicare |
$42.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$60.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$60.00
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$5.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$5.45
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$5.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$78.00
|
|
|
LEUCOVORIN CALCIUM 5 MG PO TABS [4398]
|
Facility
|
OP
|
$2.05
|
|
|
Service Code
|
NDC 00054449613
|
| Hospital Charge Code |
00054449613
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.13
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.02
|
| Rate for Payer: Aetna Government |
$1.02
|
| Rate for Payer: Brighton Health Commercial |
$1.54
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.39
|
| Rate for Payer: Group Health Inc Commercial |
$1.02
|
| Rate for Payer: Group Health Inc Medicare |
$0.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.33
|
|
|
LEUCOVORIN CALCIUM 5 MG PO TABS [4398]
|
Facility
|
OP
|
$2.03
|
|
|
Service Code
|
NDC 00054449625
|
| Hospital Charge Code |
00054449625
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.11
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.01
|
| Rate for Payer: Aetna Government |
$1.01
|
| Rate for Payer: Brighton Health Commercial |
$1.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.38
|
| Rate for Payer: Group Health Inc Commercial |
$1.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.71
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.32
|
|
|
LEUCOVORIN CALCIUM 5 MG PO TABS [4398]
|
Facility
|
OP
|
$2.80
|
|
|
Service Code
|
NDC 00054849619
|
| Hospital Charge Code |
00054849619
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.54
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1.40
|
| Rate for Payer: Aetna Government |
$1.40
|
| Rate for Payer: Brighton Health Commercial |
$2.10
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.90
|
| Rate for Payer: Group Health Inc Commercial |
$1.40
|
| Rate for Payer: Group Health Inc Medicare |
$0.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.82
|
|
|
LEUKEMIA/LYMPHOMA EVALULATION.
|
Facility
|
OP
|
$149.83
|
|
|
Service Code
|
HCPCS 88182
|
| Hospital Charge Code |
40708013
|
|
Hospital Revenue Code
|
311
|
| Min. Negotiated Rate |
$43.86 |
| Max. Negotiated Rate |
$82.41 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$82.41
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$62.66
|
| Rate for Payer: Aetna Government |
$62.66
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$43.86
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$43.86
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$43.86
|
| Rate for Payer: Brighton Health Commercial |
$62.66
|
| Rate for Payer: Cash Price |
$62.66
|
| Rate for Payer: Cash Price |
$62.66
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$62.66
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$78.29
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$66.24
|
| Rate for Payer: Elderplan Medicare Advantage |
$62.66
|
| Rate for Payer: EmblemHealth Commercial |
$62.66
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$53.26
|
| Rate for Payer: Fidelis Essential Plan QHP |
$55.77
|
| Rate for Payer: Fidelis Medicare Advantage |
$62.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$55.77
|
| Rate for Payer: Group Health Inc Commercial |
$62.66
|
| Rate for Payer: Group Health Inc Medicare |
$62.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$74.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$62.66
|
| Rate for Payer: Healthfirst Medicare Advantage |
$62.66
|
| Rate for Payer: Healthfirst QHP |
$62.66
|
| Rate for Payer: Humana Medicare |
$63.91
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$62.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$62.66
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$50.13
|
| Rate for Payer: Wellcare Medicare |
$56.39
|
|
|
LEUKEMIA/LYMPHOMA EVALULATION.
|
Facility
|
IP
|
$149.83
|
|
|
Service Code
|
HCPCS 88182
|
| Hospital Charge Code |
40708013
|
|
Hospital Revenue Code
|
311
|
| Rate for Payer: Cash Price |
$62.66
|
|
|
LEUKOCYTE
|
Facility
|
OP
|
$434.63
|
|
|
Service Code
|
HCPCS 86950
|
| Hospital Charge Code |
40701026
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$325.97 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$239.05
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$197.52
|
| Rate for Payer: Aetna Government |
$197.52
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$138.26
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$138.26
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$138.26
|
| Rate for Payer: Brighton Health Commercial |
$325.97
|
| Rate for Payer: Cash Price |
$197.52
|
| Rate for Payer: Cash Price |
$197.52
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$197.52
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$57.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$48.72
|
| Rate for Payer: Elderplan Medicare Advantage |
$197.52
|
| Rate for Payer: EmblemHealth Commercial |
$197.52
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$167.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$175.79
|
| Rate for Payer: Fidelis Medicare Advantage |
$197.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$175.79
|
| Rate for Payer: Group Health Inc Commercial |
$197.52
|
| Rate for Payer: Group Health Inc Medicare |
$197.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$217.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$197.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$197.52
|
| Rate for Payer: Healthfirst QHP |
$197.52
|
| Rate for Payer: Humana Medicare |
$201.47
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$197.52
|
| Rate for Payer: United Healthcare Commercial |
$13.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$197.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$197.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$158.02
|
| Rate for Payer: Wellcare Medicare |
$177.77
|
|
|
LEUKOCYTE
|
Facility
|
IP
|
$434.63
|
|
|
Service Code
|
HCPCS 86950
|
| Hospital Charge Code |
40701026
|
|
Hospital Revenue Code
|
300
|
| Rate for Payer: Cash Price |
$197.52
|
|
|
LEUPROLIDE ACET 22.5MG SQ
|
Facility
|
OP
|
$787.00
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
41645865
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.91 |
| Max. Negotiated Rate |
$511.55 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$432.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$181.30
|
| Rate for Payer: Aetna Government |
$181.30
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$126.91
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$126.91
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$126.91
|
| Rate for Payer: Brighton Health Commercial |
$472.20
|
| Rate for Payer: Cash Price |
$181.30
|
| Rate for Payer: Cash Price |
$181.30
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$181.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$393.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$452.52
|
| Rate for Payer: Elderplan Medicare Advantage |
$181.30
|
| Rate for Payer: EmblemHealth Commercial |
$181.30
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$181.30
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$181.30
|
| Rate for Payer: Fidelis Essential Plan QHP |
$190.37
|
| Rate for Payer: Fidelis Medicare Advantage |
$181.30
|
| Rate for Payer: Fidelis Qualified Health Plan |
$190.37
|
| Rate for Payer: Group Health Inc Commercial |
$181.30
|
| Rate for Payer: Group Health Inc Medicare |
$181.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$393.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$393.50
|
| Rate for Payer: Healthfirst Medicare Advantage |
$154.11
|
| Rate for Payer: Healthfirst QHP |
$181.30
|
| Rate for Payer: Humana Medicare |
$184.93
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$181.30
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$196.80
|
| Rate for Payer: SOMOS Essential |
$196.80
|
| Rate for Payer: United Healthcare Commercial |
$188.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$511.55
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.04
|
| Rate for Payer: Wellcare Medicare |
$172.24
|
|
|
LEUPROLIDE ACET 22.5MG SQ
|
Facility
|
IP
|
$787.00
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
41645865
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$393.50 |
| Max. Negotiated Rate |
$393.50 |
| Rate for Payer: Cash Price |
$181.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$393.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$393.50
|
|
|
LEUPROLIDE ACET 22.5MG SQ
|
Facility
|
OP
|
$787.00
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
41655865
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.91 |
| Max. Negotiated Rate |
$511.55 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$432.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$181.30
|
| Rate for Payer: Aetna Government |
$181.30
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$126.91
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$126.91
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$126.91
|
| Rate for Payer: Brighton Health Commercial |
$472.20
|
| Rate for Payer: Cash Price |
$181.30
|
| Rate for Payer: Cash Price |
$181.30
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$181.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$393.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$452.52
|
| Rate for Payer: Elderplan Medicare Advantage |
$181.30
|
| Rate for Payer: EmblemHealth Commercial |
$181.30
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$181.30
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$181.30
|
| Rate for Payer: Fidelis Essential Plan QHP |
$190.37
|
| Rate for Payer: Fidelis Medicare Advantage |
$181.30
|
| Rate for Payer: Fidelis Qualified Health Plan |
$190.37
|
| Rate for Payer: Group Health Inc Commercial |
$181.30
|
| Rate for Payer: Group Health Inc Medicare |
$181.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$393.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$393.50
|
| Rate for Payer: Healthfirst Medicare Advantage |
$154.11
|
| Rate for Payer: Healthfirst QHP |
$181.30
|
| Rate for Payer: Humana Medicare |
$184.93
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$181.30
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$196.80
|
| Rate for Payer: SOMOS Essential |
$196.80
|
| Rate for Payer: United Healthcare Commercial |
$188.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$511.55
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.04
|
| Rate for Payer: Wellcare Medicare |
$172.24
|
|
|
LEUPROLIDE ACET 22.5MG SQ
|
Facility
|
IP
|
$787.00
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
41655865
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$393.50 |
| Max. Negotiated Rate |
$393.50 |
| Rate for Payer: Cash Price |
$181.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$393.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$393.50
|
|
|
LEUPROLIDE ACETATE/3.75 MG
|
Facility
|
IP
|
$1,126.88
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
30301149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$563.44 |
| Max. Negotiated Rate |
$563.44 |
| Rate for Payer: Cash Price |
$1,564.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$563.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$563.44
|
|
