|
LEUPROLIDE ACETATE/3.75 MG
|
Facility
|
OP
|
$1,126.88
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
30301149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$563.44 |
| Max. Negotiated Rate |
$1,670.69 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$619.78
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,564.60
|
| Rate for Payer: Aetna Government |
$1,564.60
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,095.22
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,095.22
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,095.22
|
| Rate for Payer: Brighton Health Commercial |
$676.13
|
| Rate for Payer: Cash Price |
$1,564.60
|
| Rate for Payer: Cash Price |
$1,564.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,564.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$563.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$647.96
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,564.60
|
| Rate for Payer: EmblemHealth Commercial |
$1,564.60
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,564.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,564.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,642.83
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,564.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,642.83
|
| Rate for Payer: Group Health Inc Commercial |
$1,564.60
|
| Rate for Payer: Group Health Inc Medicare |
$1,564.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$563.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$563.44
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,329.91
|
| Rate for Payer: Healthfirst QHP |
$1,564.60
|
| Rate for Payer: Humana Medicare |
$1,595.90
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,564.60
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,670.69
|
| Rate for Payer: SOMOS Essential |
$1,670.69
|
| Rate for Payer: United Healthcare Commercial |
$1,474.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,564.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$732.47
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,251.68
|
| Rate for Payer: Wellcare Medicare |
$1,486.37
|
|
|
LEUPROLIDE ACETATE 3.75 MG IM KIT [13691]
|
Facility
|
OP
|
$2,058.41
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
00074364103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,029.20 |
| Max. Negotiated Rate |
$1,670.69 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,132.13
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,564.60
|
| Rate for Payer: Aetna Government |
$1,564.60
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,095.22
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,095.22
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,095.22
|
| Rate for Payer: Brighton Health Commercial |
$1,543.81
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,564.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,646.73
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,399.72
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,564.60
|
| Rate for Payer: EmblemHealth Commercial |
$1,564.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,329.91
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,392.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,564.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,392.50
|
| Rate for Payer: Group Health Inc Commercial |
$1,564.60
|
| Rate for Payer: Group Health Inc Medicare |
$1,564.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,029.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,564.60
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,329.91
|
| Rate for Payer: Healthfirst QHP |
$1,564.60
|
| Rate for Payer: Humana Medicare |
$1,595.90
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1,576.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,670.69
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,670.69
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1,670.69
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,564.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,564.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,337.97
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,251.68
|
| Rate for Payer: Wellcare Medicare |
$1,486.37
|
|
|
LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT [21045]
|
Facility
|
OP
|
$7,358.72
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
00074334603
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$126.91 |
| Max. Negotiated Rate |
$5,886.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,047.30
|
| 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 |
$5,519.04
|
| 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 |
$5,886.98
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5,003.93
|
| Rate for Payer: Elderplan Medicare Advantage |
$181.30
|
| Rate for Payer: EmblemHealth Commercial |
$181.30
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$154.11
|
| Rate for Payer: Fidelis Essential Plan QHP |
$161.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$181.30
|
| Rate for Payer: Fidelis Qualified Health Plan |
$161.36
|
| 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 |
$3,679.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$181.30
|
| 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: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$185.66
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$196.80
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$196.80
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$196.80
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$181.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4,783.17
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.04
|
| Rate for Payer: Wellcare Medicare |
$172.24
|
|
|
LEUPROLIDE ACETATE (3 MONTH) 22.5 MG SC KIT [33669]
|
Facility
|
OP
|
$1,626.08
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
62935022305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$126.91 |
| Max. Negotiated Rate |
$1,300.86 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$894.34
|
| 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 |
$1,219.56
|
| 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 |
$1,300.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,105.73
|
| Rate for Payer: Elderplan Medicare Advantage |
$181.30
|
| Rate for Payer: EmblemHealth Commercial |
$181.30
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$154.11
|
| Rate for Payer: Fidelis Essential Plan QHP |
$161.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$181.30
|
| Rate for Payer: Fidelis Qualified Health Plan |
$161.36
|
| 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 |
$813.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$181.30
|
| 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: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$185.66
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$196.80
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$196.80
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$196.80
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$181.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,056.95
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.04
|
| Rate for Payer: Wellcare Medicare |
$172.24
|
|
|
LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT [21108]
|
Facility
|
OP
|
$9,811.66
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
00074368303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$126.91 |
| Max. Negotiated Rate |
$7,849.33 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,396.41
|
| 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 |
$7,358.74
|
| 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 |
$7,849.33
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6,671.93
|
| Rate for Payer: Elderplan Medicare Advantage |
$181.30
|
| Rate for Payer: EmblemHealth Commercial |
$181.30
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$154.11
|
| Rate for Payer: Fidelis Essential Plan QHP |
$161.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$181.30
|
| Rate for Payer: Fidelis Qualified Health Plan |
$161.36
|
| 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 |
$4,905.83
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$181.30
|
| 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: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$185.66
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$196.80
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$196.80
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$196.80
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$181.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,377.58
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.04
|
| Rate for Payer: Wellcare Medicare |
$172.24
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG IM KIT [110751]
|
Facility
|
OP
|
$14,717.70
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
00074347303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$126.91 |
| Max. Negotiated Rate |
$11,774.16 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8,094.74
|
| 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 |
$11,038.28
|
| 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 |
$11,774.16
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10,008.04
|
| Rate for Payer: Elderplan Medicare Advantage |
$181.30
|
| Rate for Payer: EmblemHealth Commercial |
$181.30
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$154.11
|
| Rate for Payer: Fidelis Essential Plan QHP |
$161.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$181.30
|
| Rate for Payer: Fidelis Qualified Health Plan |
$161.36
|
| 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 |
$7,358.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$181.30
|
| 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: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$185.66
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$196.80
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$196.80
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$196.80
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$181.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$9,566.50
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.04
|
| Rate for Payer: Wellcare Medicare |
$172.24
|
|
|
LEUPROLIDE ACETATE 7.5 MG IM KIT [10392]
|
Facility
|
OP
|
$2,452.92
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
00074364203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$126.91 |
| Max. Negotiated Rate |
$1,962.34 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,349.11
|
| 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 |
$1,839.69
|
| 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 |
$1,962.34
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,667.99
|
| Rate for Payer: Elderplan Medicare Advantage |
$181.30
|
| Rate for Payer: EmblemHealth Commercial |
$181.30
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$154.11
|
| Rate for Payer: Fidelis Essential Plan QHP |
$161.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$181.30
|
| Rate for Payer: Fidelis Qualified Health Plan |
$161.36
|
| 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 |
$1,226.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$181.30
|
| 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: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$185.66
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$196.80
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$196.80
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$196.80
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$181.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,594.40
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.04
|
| Rate for Payer: Wellcare Medicare |
$172.24
|
|
|
LEUPROLIDE DEPOT 22.5 MG INJ (DEPOT-3 MO
|
Facility
|
IP
|
$1,491.12
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
41655154
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$745.56 |
| Max. Negotiated Rate |
$745.56 |
| Rate for Payer: Cash Price |
$181.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$745.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$745.56
|
|
|
LEUPROLIDE DEPOT 22.5 MG INJ (DEPOT-3 MO
|
Facility
|
IP
|
$1,491.12
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
41645154
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$745.56 |
| Max. Negotiated Rate |
$745.56 |
| Rate for Payer: Cash Price |
$181.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$745.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$745.56
|
|
|
LEUPROLIDE DEPOT 22.5 MG INJ (DEPOT-3 MO
|
Facility
|
OP
|
$1,491.12
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
41645154
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.91 |
| Max. Negotiated Rate |
$969.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$820.12
|
| 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 |
$894.67
|
| 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 |
$745.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$857.39
|
| 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 |
$745.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$745.56
|
| 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 |
$969.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.04
|
| Rate for Payer: Wellcare Medicare |
$172.24
|
|
|
LEUPROLIDE DEPOT 22.5 MG INJ (DEPOT-3 MO
|
Facility
|
OP
|
$1,491.12
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
41655154
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.91 |
| Max. Negotiated Rate |
$969.23 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$820.12
|
| 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 |
$894.67
|
| 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 |
$745.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$857.39
|
| 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 |
$745.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$745.56
|
| 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 |
$969.23
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.04
|
| Rate for Payer: Wellcare Medicare |
$172.24
|
|
|
LEUPROLIDE DEPOT 3.75 MG INJ (DEPOT)
|
Facility
|
IP
|
$2,922.00
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
41643392
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,461.00 |
| Max. Negotiated Rate |
$1,461.00 |
| Rate for Payer: Cash Price |
$1,564.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,461.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,461.00
|
|
|
LEUPROLIDE DEPOT 3.75 MG INJ (DEPOT)
|
Facility
|
IP
|
$2,922.00
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
41653392
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,461.00 |
| Max. Negotiated Rate |
$1,461.00 |
| Rate for Payer: Cash Price |
$1,564.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,461.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,461.00
|
|
|
LEUPROLIDE DEPOT 3.75 MG INJ (DEPOT)
|
Facility
|
OP
|
$2,922.00
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
41653392
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,095.22 |
| Max. Negotiated Rate |
$1,899.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,607.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,564.60
|
| Rate for Payer: Aetna Government |
$1,564.60
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,095.22
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,095.22
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,095.22
|
| Rate for Payer: Brighton Health Commercial |
$1,753.20
|
| Rate for Payer: Cash Price |
$1,564.60
|
| Rate for Payer: Cash Price |
$1,564.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,564.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,461.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,680.15
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,564.60
|
| Rate for Payer: EmblemHealth Commercial |
$1,564.60
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,564.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,564.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,642.83
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,564.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,642.83
|
| Rate for Payer: Group Health Inc Commercial |
$1,564.60
|
| Rate for Payer: Group Health Inc Medicare |
$1,564.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,461.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,461.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,329.91
|
| Rate for Payer: Healthfirst QHP |
$1,564.60
|
| Rate for Payer: Humana Medicare |
$1,595.90
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,564.60
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,670.69
|
| Rate for Payer: SOMOS Essential |
$1,670.69
|
| Rate for Payer: United Healthcare Commercial |
$1,474.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,564.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,899.30
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,251.68
|
| Rate for Payer: Wellcare Medicare |
$1,486.37
|
|
|
LEUPROLIDE DEPOT 3.75 MG INJ (DEPOT)
|
Facility
|
OP
|
$2,922.00
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
41643392
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,095.22 |
| Max. Negotiated Rate |
$1,899.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,607.10
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,564.60
|
| Rate for Payer: Aetna Government |
$1,564.60
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$1,095.22
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$1,095.22
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$1,095.22
|
| Rate for Payer: Brighton Health Commercial |
$1,753.20
|
| Rate for Payer: Cash Price |
$1,564.60
|
| Rate for Payer: Cash Price |
$1,564.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,564.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,461.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,680.15
|
| Rate for Payer: Elderplan Medicare Advantage |
$1,564.60
|
| Rate for Payer: EmblemHealth Commercial |
$1,564.60
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,564.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,564.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,642.83
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,564.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,642.83
|
| Rate for Payer: Group Health Inc Commercial |
$1,564.60
|
| Rate for Payer: Group Health Inc Medicare |
$1,564.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,461.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,461.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,329.91
|
| Rate for Payer: Healthfirst QHP |
$1,564.60
|
| Rate for Payer: Humana Medicare |
$1,595.90
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,564.60
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,670.69
|
| Rate for Payer: SOMOS Essential |
$1,670.69
|
| Rate for Payer: United Healthcare Commercial |
$1,474.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,564.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,899.30
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$1,251.68
|
| Rate for Payer: Wellcare Medicare |
$1,486.37
|
|
|
LEUPROLIDE DEPOT 7.5 MG INJ (DEPOT)
|
Facility
|
IP
|
$1,720.44
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
41653269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$860.22 |
| Max. Negotiated Rate |
$860.22 |
| Rate for Payer: Cash Price |
$181.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$860.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.22
|
|
|
LEUPROLIDE DEPOT 7.5 MG INJ (DEPOT)
|
Facility
|
OP
|
$1,720.44
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
41643269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.91 |
| Max. Negotiated Rate |
$1,118.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$946.24
|
| 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 |
$1,032.26
|
| 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 |
$860.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$989.25
|
| 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 |
$860.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.22
|
| 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 |
$1,118.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.04
|
| Rate for Payer: Wellcare Medicare |
$172.24
|
|
|
LEUPROLIDE DEPOT 7.5 MG INJ (DEPOT)
|
Facility
|
OP
|
$1,720.44
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
41653269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.91 |
| Max. Negotiated Rate |
$1,118.29 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$946.24
|
| 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 |
$1,032.26
|
| 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 |
$860.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$989.25
|
| 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 |
$860.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.22
|
| 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 |
$1,118.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$145.04
|
| Rate for Payer: Wellcare Medicare |
$172.24
|
|
|
LEUPROLIDE DEPOT 7.5 MG INJ (DEPOT)
|
Facility
|
IP
|
$1,720.44
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
41643269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$860.22 |
| Max. Negotiated Rate |
$860.22 |
| Rate for Payer: Cash Price |
$181.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$860.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.22
|
|
|
LEVALBUTEROL 0.31 MG/3 ML NEB SOLN
|
Facility
|
IP
|
$41.03
|
|
|
Service Code
|
HCPCS J7613
|
| Hospital Charge Code |
41645197
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.52 |
| Max. Negotiated Rate |
$20.52 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.52
|
|
|
LEVALBUTEROL 0.31 MG/3 ML NEB SOLN
|
Facility
|
OP
|
$41.03
|
|
|
Service Code
|
HCPCS J7613
|
| Hospital Charge Code |
41655197
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$26.67 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$22.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.05
|
| Rate for Payer: Aetna Government |
$0.05
|
| Rate for Payer: Brighton Health Commercial |
$24.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$20.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$23.59
|
| Rate for Payer: Group Health Inc Commercial |
$20.52
|
| Rate for Payer: Group Health Inc Medicare |
$14.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.52
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.04
|
| Rate for Payer: SOMOS Essential |
$0.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$26.67
|
|
|
LEVALBUTEROL 0.31 MG/3 ML NEB SOLN
|
Facility
|
OP
|
$41.03
|
|
|
Service Code
|
HCPCS J7613
|
| Hospital Charge Code |
41645197
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$26.67 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$22.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.05
|
| Rate for Payer: Aetna Government |
$0.05
|
| Rate for Payer: Brighton Health Commercial |
$24.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$20.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$23.59
|
| Rate for Payer: Group Health Inc Commercial |
$20.52
|
| Rate for Payer: Group Health Inc Medicare |
$14.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.52
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.04
|
| Rate for Payer: SOMOS Essential |
$0.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$26.67
|
|
|
LEVALBUTEROL 0.31 MG/3 ML NEB SOLN
|
Facility
|
IP
|
$41.03
|
|
|
Service Code
|
HCPCS J7613
|
| Hospital Charge Code |
41655197
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.52 |
| Max. Negotiated Rate |
$20.52 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$20.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$20.52
|
|
|
LEVALBUTEROL 0.63 MG/3 ML NEB SOLN
|
Facility
|
IP
|
$8.83
|
|
|
Service Code
|
HCPCS J7614
|
| Hospital Charge Code |
41642620
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.42 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.42
|
|
|
LEVALBUTEROL 0.63 MG/3 ML NEB SOLN
|
Facility
|
OP
|
$8.83
|
|
|
Service Code
|
HCPCS J7614
|
| Hospital Charge Code |
41642620
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.86
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.06
|
| Rate for Payer: Aetna Government |
$0.06
|
| Rate for Payer: Brighton Health Commercial |
$5.30
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.42
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.08
|
| Rate for Payer: Group Health Inc Commercial |
$4.42
|
| Rate for Payer: Group Health Inc Medicare |
$3.09
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.42
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.05
|
| Rate for Payer: SOMOS Essential |
$0.05
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.74
|
|
