St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

LEUCOVORIN CALCIUM 5 MG PO TABS

Facility

$2.03

Service Code	NDC 0054449625
Hospital Charge Code	0054449625
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: EmblemHealth Commercial	$1.01
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

Facility

$2.05

Service Code	NDC 0054449613
Hospital Charge Code	0054449613
Hospital Revenue Code	250
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.02

LEUCOVORIN CALCIUM 5 MG PO TABS

Facility

$2.05

Service Code	NDC 0054449613
Hospital Charge Code	0054449613
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: EmblemHealth Commercial	$1.02
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

Facility

$2.80

Service Code	NDC 0054849619
Hospital Charge Code	0054849619
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: EmblemHealth Commercial	$1.40
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

LEUCOVORIN CALCIUM 5 MG PO TABS

Facility

$2.80

Service Code	NDC 0054849619
Hospital Charge Code	0054849619
Hospital Revenue Code	250
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$1.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.40

LEUPROLIDE ACETATE 3.75 MG IM KIT

Facility

$2.00

Service Code	HCPCS J1950
Hospital Charge Code	0074364103
Hospital Revenue Code	250
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1,764.93
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,730.32
Rate for Payer: Aetna Government	$1,730.32
Rate for Payer: Affinity Essential Plan 1&2	$1,211.22
Rate for Payer: Affinity Essential Plan 3&4	$1,211.22
Rate for Payer: Affinity Medicaid/CHP/HARP	$1,211.22
Rate for Payer: Brighton Health Commercial	$1.50
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$1,730.32
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.36
Rate for Payer: Elderplan Medicare Advantage	$1,730.32
Rate for Payer: EmblemHealth Commercial	$1,730.32
Rate for Payer: Fidelis CHP/HARP/Medicaid	$1,557.29
Rate for Payer: Fidelis Essential Plan Aliesa	$1,470.77
Rate for Payer: Fidelis Essential Plan QHP	$1,539.98
Rate for Payer: Fidelis Medicare Advantage	$1,730.32
Rate for Payer: Fidelis Qualified Health Plan	$1,539.98
Rate for Payer: Group Health Inc Commercial	$1,730.32
Rate for Payer: Group Health Inc Medicare	$1,730.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,730.32
Rate for Payer: Hamaspik Choice Inc Medicare	$1,730.32
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$1,730.32
Rate for Payer: Healthfirst Medicare Advantage	$1,470.77
Rate for Payer: Healthfirst QHP	$1,730.32
Rate for Payer: Humana Medicare	$1,764.93
Rate for Payer: Senior Whole Health Medicare Advantage	$1,730.32
Rate for Payer: United Healthcare Medicare Advantage	$1,730.32
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30
Rate for Payer: Wellcare CHP/FHP/Medicaid	$1,643.80
Rate for Payer: Wellcare Medicare	$1,643.80

LEUPROLIDE ACETATE 3.75 MG IM KIT

Facility

$2.00

Service Code	HCPCS J1950
Hospital Charge Code	0074364103
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00

LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT

Facility

$7.00

Service Code	HCPCS J9217
Hospital Charge Code	0074334603
Hospital Revenue Code	250
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$179.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.85
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$176.45
Rate for Payer: Aetna Government	$176.45
Rate for Payer: Affinity Essential Plan 1&2	$123.52
Rate for Payer: Affinity Essential Plan 3&4	$123.52
Rate for Payer: Affinity Medicaid/CHP/HARP	$123.52
Rate for Payer: Brighton Health Commercial	$5.25
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$176.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.76
Rate for Payer: Elderplan Medicare Advantage	$176.45
Rate for Payer: EmblemHealth Commercial	$176.45
Rate for Payer: Fidelis CHP/HARP/Medicaid	$158.81
Rate for Payer: Fidelis Essential Plan Aliesa	$149.98
Rate for Payer: Fidelis Essential Plan QHP	$157.04
Rate for Payer: Fidelis Medicare Advantage	$176.45
Rate for Payer: Fidelis Qualified Health Plan	$157.04
Rate for Payer: Group Health Inc Commercial	$176.45
Rate for Payer: Group Health Inc Medicare	$176.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$176.45
Rate for Payer: Hamaspik Choice Inc Medicare	$176.45
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$176.45
Rate for Payer: Healthfirst Medicare Advantage	$149.98
Rate for Payer: Healthfirst QHP	$176.45
Rate for Payer: Humana Medicare	$179.98
Rate for Payer: Senior Whole Health Medicare Advantage	$176.45
Rate for Payer: United Healthcare Medicare Advantage	$176.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.55
Rate for Payer: Wellcare CHP/FHP/Medicaid	$167.63
Rate for Payer: Wellcare Medicare	$167.63

LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT

Facility

$7.00

Service Code	HCPCS J9217
Hospital Charge Code	0074334603
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$3.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.50

LEUPROLIDE ACETATE (3 MONTH) 22.5 MG SC KIT

Facility

$1.00

Service Code	HCPCS J9217
Hospital Charge Code	6293522305
Hospital Revenue Code	250
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$179.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$176.45
Rate for Payer: Aetna Government	$176.45
Rate for Payer: Affinity Essential Plan 1&2	$123.52
Rate for Payer: Affinity Essential Plan 3&4	$123.52
Rate for Payer: Affinity Medicaid/CHP/HARP	$123.52
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$176.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Elderplan Medicare Advantage	$176.45
Rate for Payer: EmblemHealth Commercial	$176.45
Rate for Payer: Fidelis CHP/HARP/Medicaid	$158.81
Rate for Payer: Fidelis Essential Plan Aliesa	$149.98
Rate for Payer: Fidelis Essential Plan QHP	$157.04
Rate for Payer: Fidelis Medicare Advantage	$176.45
Rate for Payer: Fidelis Qualified Health Plan	$157.04
Rate for Payer: Group Health Inc Commercial	$176.45
Rate for Payer: Group Health Inc Medicare	$176.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$176.45
Rate for Payer: Hamaspik Choice Inc Medicare	$176.45
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$176.45
Rate for Payer: Healthfirst Medicare Advantage	$149.98
Rate for Payer: Healthfirst QHP	$176.45
Rate for Payer: Humana Medicare	$179.98
Rate for Payer: Senior Whole Health Medicare Advantage	$176.45
Rate for Payer: United Healthcare Medicare Advantage	$176.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65
Rate for Payer: Wellcare CHP/FHP/Medicaid	$167.63
Rate for Payer: Wellcare Medicare	$167.63

LEUPROLIDE ACETATE (3 MONTH) 22.5 MG SC KIT

Facility

$1.00

Service Code	HCPCS J9217
Hospital Charge Code	6293522305
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50

LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT

Facility

$9.00

Service Code	HCPCS J9217
Hospital Charge Code	0074368303
Hospital Revenue Code	250
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.50

LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT

Facility

$9.00

Service Code	HCPCS J9217
Hospital Charge Code	0074368303
Hospital Revenue Code	250
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$179.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.95
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$176.45
Rate for Payer: Aetna Government	$176.45
Rate for Payer: Affinity Essential Plan 1&2	$123.52
Rate for Payer: Affinity Essential Plan 3&4	$123.52
Rate for Payer: Affinity Medicaid/CHP/HARP	$123.52
Rate for Payer: Brighton Health Commercial	$6.75
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$176.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.12
Rate for Payer: Elderplan Medicare Advantage	$176.45
Rate for Payer: EmblemHealth Commercial	$176.45
Rate for Payer: Fidelis CHP/HARP/Medicaid	$158.81
Rate for Payer: Fidelis Essential Plan Aliesa	$149.98
Rate for Payer: Fidelis Essential Plan QHP	$157.04
Rate for Payer: Fidelis Medicare Advantage	$176.45
Rate for Payer: Fidelis Qualified Health Plan	$157.04
Rate for Payer: Group Health Inc Commercial	$176.45
Rate for Payer: Group Health Inc Medicare	$176.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$176.45
Rate for Payer: Hamaspik Choice Inc Medicare	$176.45
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$176.45
Rate for Payer: Healthfirst Medicare Advantage	$149.98
Rate for Payer: Healthfirst QHP	$176.45
Rate for Payer: Humana Medicare	$179.98
Rate for Payer: Senior Whole Health Medicare Advantage	$176.45
Rate for Payer: United Healthcare Medicare Advantage	$176.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.85
Rate for Payer: Wellcare CHP/FHP/Medicaid	$167.63
Rate for Payer: Wellcare Medicare	$167.63

LEUPROLIDE ACETATE (6 MONTH) 45 MG IM KIT

Facility

$14.00

Service Code	HCPCS J9217
Hospital Charge Code	0074347303
Hospital Revenue Code	250
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$179.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$7.70
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$176.45
Rate for Payer: Aetna Government	$176.45
Rate for Payer: Affinity Essential Plan 1&2	$123.52
Rate for Payer: Affinity Essential Plan 3&4	$123.52
Rate for Payer: Affinity Medicaid/CHP/HARP	$123.52
Rate for Payer: Brighton Health Commercial	$10.50
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$176.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$11.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$9.52
Rate for Payer: Elderplan Medicare Advantage	$176.45
Rate for Payer: EmblemHealth Commercial	$176.45
Rate for Payer: Fidelis CHP/HARP/Medicaid	$158.81
Rate for Payer: Fidelis Essential Plan Aliesa	$149.98
Rate for Payer: Fidelis Essential Plan QHP	$157.04
Rate for Payer: Fidelis Medicare Advantage	$176.45
Rate for Payer: Fidelis Qualified Health Plan	$157.04
Rate for Payer: Group Health Inc Commercial	$176.45
Rate for Payer: Group Health Inc Medicare	$176.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$176.45
Rate for Payer: Hamaspik Choice Inc Medicare	$176.45
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$176.45
Rate for Payer: Healthfirst Medicare Advantage	$149.98
Rate for Payer: Healthfirst QHP	$176.45
Rate for Payer: Humana Medicare	$179.98
Rate for Payer: Senior Whole Health Medicare Advantage	$176.45
Rate for Payer: United Healthcare Medicare Advantage	$176.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$9.10
Rate for Payer: Wellcare CHP/FHP/Medicaid	$167.63
Rate for Payer: Wellcare Medicare	$167.63

LEUPROLIDE ACETATE (6 MONTH) 45 MG IM KIT

Facility

$14.00

Service Code	HCPCS J9217
Hospital Charge Code	0074347303
Hospital Revenue Code	250
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$7.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.00

LEUPROLIDE ACETATE 7.5 MG IM KIT

Facility

$2.00

Service Code	HCPCS J9217
Hospital Charge Code	0074364203
Hospital Revenue Code	250
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00

LEUPROLIDE ACETATE 7.5 MG IM KIT

Facility

$2.00

Service Code	HCPCS J9217
Hospital Charge Code	0074364203
Hospital Revenue Code	250
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$179.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$176.45
Rate for Payer: Aetna Government	$176.45
Rate for Payer: Affinity Essential Plan 1&2	$123.52
Rate for Payer: Affinity Essential Plan 3&4	$123.52
Rate for Payer: Affinity Medicaid/CHP/HARP	$123.52
Rate for Payer: Brighton Health Commercial	$1.50
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$176.45
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.36
Rate for Payer: Elderplan Medicare Advantage	$176.45
Rate for Payer: EmblemHealth Commercial	$176.45
Rate for Payer: Fidelis CHP/HARP/Medicaid	$158.81
Rate for Payer: Fidelis Essential Plan Aliesa	$149.98
Rate for Payer: Fidelis Essential Plan QHP	$157.04
Rate for Payer: Fidelis Medicare Advantage	$176.45
Rate for Payer: Fidelis Qualified Health Plan	$157.04
Rate for Payer: Group Health Inc Commercial	$176.45
Rate for Payer: Group Health Inc Medicare	$176.45
Rate for Payer: Hamaspik Choice Inc Medicaid	$176.45
Rate for Payer: Hamaspik Choice Inc Medicare	$176.45
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$176.45
Rate for Payer: Healthfirst Medicare Advantage	$149.98
Rate for Payer: Healthfirst QHP	$176.45
Rate for Payer: Humana Medicare	$179.98
Rate for Payer: Senior Whole Health Medicare Advantage	$176.45
Rate for Payer: United Healthcare Medicare Advantage	$176.45
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30
Rate for Payer: Wellcare CHP/FHP/Medicaid	$167.63
Rate for Payer: Wellcare Medicare	$167.63

LEVALBUTEROL HCL 0.31 MG/3ML IN NEBU

Facility

$0.67

Service Code	HCPCS J7614
Hospital Charge Code	7620470011
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.53
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.37
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.06
Rate for Payer: Aetna Government	$0.06
Rate for Payer: Brighton Health Commercial	$0.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.45
Rate for Payer: EmblemHealth Commercial	$0.33
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.43

LEVALBUTEROL HCL 0.31 MG/3ML IN NEBU

Facility

$0.67

Service Code	HCPCS J7614
Hospital Charge Code	7620470001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33

LEVALBUTEROL HCL 0.31 MG/3ML IN NEBU

Facility

$0.67

Service Code	HCPCS J7614
Hospital Charge Code	7620470011
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33

LEVALBUTEROL HCL 0.31 MG/3ML IN NEBU

Facility

$0.67

Service Code	HCPCS J7614
Hospital Charge Code	7620470001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.53
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.37
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.06
Rate for Payer: Aetna Government	$0.06
Rate for Payer: Brighton Health Commercial	$0.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.45
Rate for Payer: EmblemHealth Commercial	$0.33
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.43

LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU

Facility

$0.67

Service Code	HCPCS J7614
Hospital Charge Code	7620480001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.53
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.37
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.06
Rate for Payer: Aetna Government	$0.06
Rate for Payer: Brighton Health Commercial	$0.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.45
Rate for Payer: EmblemHealth Commercial	$0.33
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.43

LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU

Facility

$0.67

Service Code	HCPCS J7614
Hospital Charge Code	7620480011
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33

LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU

Facility

$0.67

Service Code	HCPCS J7614
Hospital Charge Code	7620480011
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.53
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.37
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.06
Rate for Payer: Aetna Government	$0.06
Rate for Payer: Brighton Health Commercial	$0.50
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.45
Rate for Payer: EmblemHealth Commercial	$0.33
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$0.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.43

LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU

Facility

$2.24

Service Code	HCPCS J7614
Hospital Charge Code	0093414656
Hospital Revenue Code	250
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$1.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.12

Know your out-of-pocket cost for care.

All Charges