|
LETROZOLE 2.5 MG PO TABS
|
Facility
|
OP
|
$18.12
|
|
|
Service Code
|
NDC 5199175933
|
| Hospital Charge Code |
5199175933
|
|
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: EmblemHealth Commercial |
$9.06
|
| 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
|
Facility
|
IP
|
$18.05
|
|
|
Service Code
|
NDC 5026847611
|
| Hospital Charge Code |
5026847611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.03 |
| Max. Negotiated Rate |
$9.03 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.03
|
|
|
LETS KIT
|
Facility
|
IP
|
$1.39
|
|
|
Service Code
|
NDC 5155213451
|
| Hospital Charge Code |
5155213451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.69
|
|
|
LETS KIT
|
Facility
|
OP
|
$1.39
|
|
|
Service Code
|
NDC 5155213451
|
| Hospital Charge Code |
5155213451
|
|
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: EmblemHealth Commercial |
$0.69
|
| 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 CALCIUM 100 MG/10ML IJ SOLN
|
Facility
|
IP
|
$2.89
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
6332363110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.45
|
|
|
LEUCOVORIN CALCIUM 100 MG/10ML IJ SOLN
|
Facility
|
OP
|
$2.89
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
6332363110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$3.66 |
| 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: EmblemHealth Commercial |
$1.45
|
| 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: Healthfirst CHP/FHP/Medicaid |
$3.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.88
|
|
|
LEUCOVORIN CALCIUM 100 MG IJ SOLR
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
2502181430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.22 |
| 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: EmblemHealth Commercial |
$12.00
|
| 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: Healthfirst CHP/FHP/Medicaid |
$3.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.60
|
|
|
LEUCOVORIN CALCIUM 100 MG IJ SOLR
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
2502181430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.00
|
|
|
LEUCOVORIN CALCIUM 100 MG IJ SOLR
|
Facility
|
OP
|
$19.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
0143955401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.22 |
| 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: EmblemHealth Commercial |
$9.60
|
| 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: Healthfirst CHP/FHP/Medicaid |
$3.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12.48
|
|
|
LEUCOVORIN CALCIUM 100 MG IJ SOLR
|
Facility
|
IP
|
$19.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
0143955401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9.60
|
|
|
LEUCOVORIN CALCIUM 100 MG IJ SOLR
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
6745752810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.22 |
| 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: EmblemHealth Commercial |
$12.00
|
| 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: Healthfirst CHP/FHP/Medicaid |
$3.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$15.60
|
|
|
LEUCOVORIN CALCIUM 100 MG IJ SOLR
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
6745752810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$12.00
|
|
|
LEUCOVORIN CALCIUM 200 MG IJ SOLR
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
2502181530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.22 |
| 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: EmblemHealth Commercial |
$24.00
|
| 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: Healthfirst CHP/FHP/Medicaid |
$3.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$31.20
|
|
|
LEUCOVORIN CALCIUM 200 MG IJ SOLR
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
2502181530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.00
|
|
|
LEUCOVORIN CALCIUM 350 MG IJ SOLR
|
Facility
|
OP
|
$31.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
6745753035
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.22 |
| 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: EmblemHealth Commercial |
$15.60
|
| 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: Healthfirst CHP/FHP/Medicaid |
$3.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$20.28
|
|
|
LEUCOVORIN CALCIUM 350 MG IJ SOLR
|
Facility
|
IP
|
$31.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
0143955201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.60
|
|
|
LEUCOVORIN CALCIUM 350 MG IJ SOLR
|
Facility
|
OP
|
$22.74
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
0703514501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.22 |
| 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 |
$17.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$18.19
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$15.46
|
| Rate for Payer: EmblemHealth Commercial |
$11.37
|
| 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: Healthfirst CHP/FHP/Medicaid |
$3.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14.78
|
|
|
LEUCOVORIN CALCIUM 350 MG IJ SOLR
|
Facility
|
IP
|
$22.74
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
0703514501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.37 |
| Max. Negotiated Rate |
$11.37 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.37
|
|
|
LEUCOVORIN CALCIUM 350 MG IJ SOLR
|
Facility
|
IP
|
$31.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
6745753035
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$15.60
|
|
|
LEUCOVORIN CALCIUM 350 MG IJ SOLR
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
2502181630
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$42.00
|
|
|
LEUCOVORIN CALCIUM 350 MG IJ SOLR
|
Facility
|
OP
|
$31.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
0143955201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.22 |
| 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: EmblemHealth Commercial |
$15.60
|
| 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: Healthfirst CHP/FHP/Medicaid |
$3.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$20.28
|
|
|
LEUCOVORIN CALCIUM 350 MG IJ SOLR
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
2502181630
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.22 |
| 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: EmblemHealth Commercial |
$42.00
|
| 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: Healthfirst CHP/FHP/Medicaid |
$3.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$54.60
|
|
|
LEUCOVORIN CALCIUM 500 MG IJ SOLR
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
2502182850
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.22 |
| 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: EmblemHealth Commercial |
$60.00
|
| 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: Healthfirst CHP/FHP/Medicaid |
$3.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$78.00
|
|
|
LEUCOVORIN CALCIUM 500 MG IJ SOLR
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
2502182850
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.00 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$60.00
|
|
|
LEUCOVORIN CALCIUM 5 MG PO TABS
|
Facility
|
IP
|
$2.03
|
|
|
Service Code
|
NDC 0054449625
|
| Hospital Charge Code |
0054449625
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.01
|
|
