St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

CYCLOPHOSPHAMIDE 500 MG IJ SOLR [38271]

Facility

$439.50

Service Code	HCPCS J9075
Hospital Charge Code	10019095501
Hospital Revenue Code	250
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$351.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$241.72
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$219.75
Rate for Payer: Aetna Government	$219.75
Rate for Payer: Brighton Health Commercial	$329.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$351.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$298.86
Rate for Payer: Group Health Inc Commercial	$219.75
Rate for Payer: Group Health Inc Medicare	$153.82
Rate for Payer: Hamaspik Choice Inc Medicaid	$219.75
Rate for Payer: Hamaspik Choice Inc Medicare	$219.75
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.92
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.97
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.97
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.97
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$285.68

CYCLOPHOSPHAMIDE 500 MG INJ

Facility

$24.74

Service Code	HCPCS J9070
Hospital Charge Code	41653749
Hospital Revenue Code	636
Min. Negotiated Rate	$12.37
Max. Negotiated Rate	$22.13
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$13.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.15
Rate for Payer: Aetna Government	$20.15
Rate for Payer: Affinity Essential Plan 1&2	$14.11
Rate for Payer: Affinity Essential Plan 3&4	$14.11
Rate for Payer: Affinity Medicaid/CHP/HARP	$14.11
Rate for Payer: Brighton Health Commercial	$14.84
Rate for Payer: Cash Price	$20.15
Rate for Payer: Cash Price	$20.15
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$20.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.37
Rate for Payer: Cigna LocalPlus Benefit Plan	$14.23
Rate for Payer: Elderplan Medicare Advantage	$20.15
Rate for Payer: EmblemHealth Commercial	$20.15
Rate for Payer: Fidelis CHP/HARP/Medicaid	$20.15
Rate for Payer: Fidelis Essential Plan Aliesa	$20.15
Rate for Payer: Fidelis Essential Plan QHP	$21.16
Rate for Payer: Fidelis Medicare Advantage	$20.15
Rate for Payer: Fidelis Qualified Health Plan	$21.16
Rate for Payer: Group Health Inc Commercial	$20.15
Rate for Payer: Group Health Inc Medicare	$20.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$12.37
Rate for Payer: Hamaspik Choice Inc Medicare	$12.37
Rate for Payer: Healthfirst Medicare Advantage	$17.13
Rate for Payer: Healthfirst QHP	$20.15
Rate for Payer: Humana Medicare	$20.56
Rate for Payer: Senior Whole Health Medicare Advantage	$20.15
Rate for Payer: United Healthcare Commercial	$22.13
Rate for Payer: United Healthcare Medicare Advantage	$20.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$16.08
Rate for Payer: Wellcare CHP/FHP/Medicaid	$16.12
Rate for Payer: Wellcare Medicare	$19.15

CYCLOPHOSPHAMIDE 500 MG INJ

Facility

$24.74

Service Code	HCPCS J9070
Hospital Charge Code	41643749
Hospital Revenue Code	636
Min. Negotiated Rate	$12.37
Max. Negotiated Rate	$22.13
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$13.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$20.15
Rate for Payer: Aetna Government	$20.15
Rate for Payer: Affinity Essential Plan 1&2	$14.11
Rate for Payer: Affinity Essential Plan 3&4	$14.11
Rate for Payer: Affinity Medicaid/CHP/HARP	$14.11
Rate for Payer: Brighton Health Commercial	$14.84
Rate for Payer: Cash Price	$20.15
Rate for Payer: Cash Price	$20.15
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$20.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.37
Rate for Payer: Cigna LocalPlus Benefit Plan	$14.23
Rate for Payer: Elderplan Medicare Advantage	$20.15
Rate for Payer: EmblemHealth Commercial	$20.15
Rate for Payer: Fidelis CHP/HARP/Medicaid	$20.15
Rate for Payer: Fidelis Essential Plan Aliesa	$20.15
Rate for Payer: Fidelis Essential Plan QHP	$21.16
Rate for Payer: Fidelis Medicare Advantage	$20.15
Rate for Payer: Fidelis Qualified Health Plan	$21.16
Rate for Payer: Group Health Inc Commercial	$20.15
Rate for Payer: Group Health Inc Medicare	$20.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$12.37
Rate for Payer: Hamaspik Choice Inc Medicare	$12.37
Rate for Payer: Healthfirst Medicare Advantage	$17.13
Rate for Payer: Healthfirst QHP	$20.15
Rate for Payer: Humana Medicare	$20.56
Rate for Payer: Senior Whole Health Medicare Advantage	$20.15
Rate for Payer: United Healthcare Commercial	$22.13
Rate for Payer: United Healthcare Medicare Advantage	$20.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$16.08
Rate for Payer: Wellcare CHP/FHP/Medicaid	$16.12
Rate for Payer: Wellcare Medicare	$19.15

CYCLOPHOSPHAMIDE 500 MG INJ

Facility

$24.74

Service Code	HCPCS J9070
Hospital Charge Code	41653749
Hospital Revenue Code	636
Min. Negotiated Rate	$12.37
Max. Negotiated Rate	$12.37
Rate for Payer: Cash Price	$20.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$12.37
Rate for Payer: Hamaspik Choice Inc Medicare	$12.37

CYCLOPHOSPHAMIDE 500 MG INJ

Facility

$24.74

Service Code	HCPCS J9070
Hospital Charge Code	41643749
Hospital Revenue Code	636
Min. Negotiated Rate	$12.37
Max. Negotiated Rate	$12.37
Rate for Payer: Cash Price	$20.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$12.37
Rate for Payer: Hamaspik Choice Inc Medicare	$12.37

CYCLOPHOSPHAMIDE 50 MG PO CAPS [126405]

Facility

$17.75

Service Code	HCPCS J8530
Hospital Charge Code	69097051707
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$14.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$9.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Brighton Health Commercial	$13.31
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$14.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$12.07
Rate for Payer: Group Health Inc Commercial	$8.87
Rate for Payer: Group Health Inc Medicare	$6.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.87
Rate for Payer: Hamaspik Choice Inc Medicare	$8.87
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.86
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.91
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.91
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.91
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.54

CYCLOSERINE 250 MG CAP - NF

Facility

$14.84

Hospital Charge Code	41643697
Hospital Revenue Code	250
Min. Negotiated Rate	$5.19
Max. Negotiated Rate	$11.87
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.42
Rate for Payer: Aetna Government	$7.42
Rate for Payer: Brighton Health Commercial	$11.13
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.87
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.09
Rate for Payer: Group Health Inc Commercial	$7.42
Rate for Payer: Group Health Inc Medicare	$5.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.42
Rate for Payer: Hamaspik Choice Inc Medicare	$7.42
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.65

CYCLOSERINE 250 MG CAP - NF

Facility

$14.84

Hospital Charge Code	41653697
Hospital Revenue Code	250
Min. Negotiated Rate	$5.19
Max. Negotiated Rate	$11.87
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.16
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.42
Rate for Payer: Aetna Government	$7.42
Rate for Payer: Brighton Health Commercial	$11.13
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.87
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.09
Rate for Payer: Group Health Inc Commercial	$7.42
Rate for Payer: Group Health Inc Medicare	$5.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.42
Rate for Payer: Hamaspik Choice Inc Medicare	$7.42
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.65

CYCLOSERINE 250 MG PO CAPS [9704]

Facility

$83.60

Service Code	NDC 13845120202
Hospital Charge Code	13845120202
Hospital Revenue Code	250
Min. Negotiated Rate	$29.26
Max. Negotiated Rate	$66.88
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$45.98
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$41.80
Rate for Payer: Aetna Government	$41.80
Rate for Payer: Brighton Health Commercial	$62.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$66.88
Rate for Payer: Cigna LocalPlus Benefit Plan	$56.85
Rate for Payer: Group Health Inc Commercial	$41.80
Rate for Payer: Group Health Inc Medicare	$29.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$41.80
Rate for Payer: Hamaspik Choice Inc Medicare	$41.80
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$54.34

CYCLOSPORINE 100 MG PO CAPS [9706]

Facility

$15.35

Service Code	HCPCS J7502
Hospital Charge Code	60505013400
Hospital Revenue Code	250
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$12.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.44
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.42
Rate for Payer: Aetna Government	$2.42
Rate for Payer: Brighton Health Commercial	$11.52
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.44
Rate for Payer: Group Health Inc Commercial	$7.68
Rate for Payer: Group Health Inc Medicare	$5.37
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.68
Rate for Payer: Hamaspik Choice Inc Medicare	$7.68
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$2.30
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$2.43
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$2.43
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$2.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.98

CYCLOSPORINE, BLOOD

Facility

$45.13

Service Code	HCPCS 80158
Hospital Charge Code	40609001
Hospital Revenue Code	300
Rate for Payer: Cash Price	$18.05

CYCLOSPORINE, BLOOD

Facility

$45.13

Service Code	HCPCS 80158
Hospital Charge Code	40609001
Hospital Revenue Code	300
Min. Negotiated Rate	$12.64
Max. Negotiated Rate	$33.85
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$24.82
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$18.05
Rate for Payer: Aetna Government	$18.05
Rate for Payer: Affinity Essential Plan 1&2	$12.64
Rate for Payer: Affinity Essential Plan 3&4	$12.64
Rate for Payer: Affinity Medicaid/CHP/HARP	$12.64
Rate for Payer: Brighton Health Commercial	$33.85
Rate for Payer: Cash Price	$18.05
Rate for Payer: Cash Price	$18.05
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$18.05
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$28.69
Rate for Payer: Cigna LocalPlus Benefit Plan	$24.28
Rate for Payer: Elderplan Medicare Advantage	$18.05
Rate for Payer: EmblemHealth Commercial	$18.05
Rate for Payer: Fidelis Essential Plan Aliesa	$15.34
Rate for Payer: Fidelis Essential Plan QHP	$16.06
Rate for Payer: Fidelis Medicare Advantage	$18.05
Rate for Payer: Fidelis Qualified Health Plan	$16.06
Rate for Payer: Group Health Inc Commercial	$18.05
Rate for Payer: Group Health Inc Medicare	$18.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.56
Rate for Payer: Hamaspik Choice Inc Medicare	$18.05
Rate for Payer: Healthfirst Medicare Advantage	$18.05
Rate for Payer: Healthfirst QHP	$18.05
Rate for Payer: Humana Medicare	$18.41
Rate for Payer: Senior Whole Health Medicare Advantage	$18.05
Rate for Payer: United Healthcare Commercial	$22.86
Rate for Payer: United Healthcare Medicare Advantage	$18.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$18.05
Rate for Payer: Wellcare CHP/FHP/Medicaid	$14.44
Rate for Payer: Wellcare Medicare	$16.24

CYCLOSPORINE MODIFIED 100 MG PO CAPS [28843]

Facility

$5.50

Service Code	HCPCS J7502
Hospital Charge Code	00093902065
Hospital Revenue Code	250
Min. Negotiated Rate	$1.92
Max. Negotiated Rate	$4.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.42
Rate for Payer: Aetna Government	$2.42
Rate for Payer: Brighton Health Commercial	$4.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.74
Rate for Payer: Group Health Inc Commercial	$2.75
Rate for Payer: Group Health Inc Medicare	$1.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.75
Rate for Payer: Hamaspik Choice Inc Medicare	$2.75
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$2.30
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$2.43
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$2.43
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$2.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.57

CYCLOSPORINE MODIFIED 100 MG PO CAPS [28843]

Facility

$5.50

Service Code	HCPCS J7502
Hospital Charge Code	00093902019
Hospital Revenue Code	250
Min. Negotiated Rate	$1.92
Max. Negotiated Rate	$4.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.02
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.42
Rate for Payer: Aetna Government	$2.42
Rate for Payer: Brighton Health Commercial	$4.12
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.74
Rate for Payer: Group Health Inc Commercial	$2.75
Rate for Payer: Group Health Inc Medicare	$1.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.75
Rate for Payer: Hamaspik Choice Inc Medicare	$2.75
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$2.30
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$2.43
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$2.43
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$2.43
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.57

CYCLOSPORINE MODIFIED 25 MG PO CAPS [28842]

Facility

$1.38

Service Code	HCPCS J7515
Hospital Charge Code	00093901865
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$1.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.82
Rate for Payer: Aetna Government	$0.82
Rate for Payer: Brighton Health Commercial	$1.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.10
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	$0.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.69
Rate for Payer: Hamaspik Choice Inc Medicare	$0.69
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.92
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.98
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.98
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.98
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.89

CYCLOSPORINE MODIFIED 25 MG PO CAPS [28842]

Facility

$1.38

Service Code	HCPCS J7515
Hospital Charge Code	00093901819
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$1.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.82
Rate for Payer: Aetna Government	$0.82
Rate for Payer: Brighton Health Commercial	$1.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.10
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	$0.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.69
Rate for Payer: Hamaspik Choice Inc Medicare	$0.69
Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid	$0.92
Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage	$0.98
Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa)	$0.98
Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa)	$0.98
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.89

CYCLOSPORINE (NEORAL) 100 MG CAP - NF

Facility

$4.00

Hospital Charge Code	41650362
Hospital Revenue Code	636
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$2.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.00
Rate for Payer: Aetna Government	$2.00
Rate for Payer: Brighton Health Commercial	$2.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.30
Rate for Payer: Group Health Inc Commercial	$2.00
Rate for Payer: Group Health Inc Medicare	$1.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.60

CYCLOSPORINE (NEORAL) 100 MG CAP - NF

Facility

$4.00

Hospital Charge Code	41640362
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$2.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2.00

CYCLOSPORINE (NEORAL) 100 MG CAP - NF

Facility

$4.00

Hospital Charge Code	41650362
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$2.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2.00

CYCLOSPORINE (NEORAL) 100 MG CAP - NF

Facility

$4.00

Hospital Charge Code	41640362
Hospital Revenue Code	636
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$2.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.00
Rate for Payer: Aetna Government	$2.00
Rate for Payer: Brighton Health Commercial	$2.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.30
Rate for Payer: Group Health Inc Commercial	$2.00
Rate for Payer: Group Health Inc Medicare	$1.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.00
Rate for Payer: Hamaspik Choice Inc Medicare	$2.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.60

CYCLOSPORINE (NEORAL) 25 MG CAP- NF

Facility

$1.04

Service Code	HCPCS J7515
Hospital Charge Code	41650392
Hospital Revenue Code	636
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.52
Rate for Payer: Hamaspik Choice Inc Medicare	$0.52

CYCLOSPORINE (NEORAL) 25 MG CAP- NF

Facility

$1.04

Service Code	HCPCS J7515
Hospital Charge Code	41640392
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.82
Rate for Payer: Aetna Government	$0.82
Rate for Payer: Brighton Health Commercial	$0.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.60
Rate for Payer: Group Health Inc Commercial	$0.52
Rate for Payer: Group Health Inc Medicare	$0.36
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.52
Rate for Payer: Hamaspik Choice Inc Medicare	$0.52
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.98
Rate for Payer: SOMOS Essential	$0.98
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.68

CYCLOSPORINE (NEORAL) 25 MG CAP- NF

Facility

$1.04

Service Code	HCPCS J7515
Hospital Charge Code	41650392
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.57
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.82
Rate for Payer: Aetna Government	$0.82
Rate for Payer: Brighton Health Commercial	$0.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.60
Rate for Payer: Group Health Inc Commercial	$0.52
Rate for Payer: Group Health Inc Medicare	$0.36
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.52
Rate for Payer: Hamaspik Choice Inc Medicare	$0.52
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.98
Rate for Payer: SOMOS Essential	$0.98
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.68

CYCLOSPORINE (NEORAL) 25 MG CAP- NF

Facility

$1.04

Service Code	HCPCS J7515
Hospital Charge Code	41640392
Hospital Revenue Code	636
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.52
Rate for Payer: Hamaspik Choice Inc Medicare	$0.52

CYCLOSPORINE(SANDIMMUNE)100MG/ML

Facility

$14.00

Service Code	HCPCS J7502
Hospital Charge Code	41641148
Hospital Revenue Code	636
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$7.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00
Rate for Payer: Hamaspik Choice Inc Medicare	$7.00

Know your out-of-pocket cost for care.

All Charges