|
Transurethral prostatectomy
|
Facility
|
IP
|
$79,603.07
|
|
|
Service Code
|
APR-DRG 4824
|
| Min. Negotiated Rate |
$18,345.00 |
| Max. Negotiated Rate |
$79,603.07 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$79,603.07
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$79,603.07
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$35,379.14
|
| Rate for Payer: Amida Care Medicaid |
$35,379.14
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$79,603.07
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$35,379.14
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$35,379.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$42,454.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$35,379.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$35,379.14
|
| Rate for Payer: Healthfirst Commercial |
$42,085.00
|
| Rate for Payer: Healthfirst Essential Plan |
$79,603.07
|
| Rate for Payer: Healthfirst QHP |
$18,345.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$35,379.14
|
| Rate for Payer: SOMOS Essential |
$79,603.07
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$79,603.07
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$79,603.07
|
| Rate for Payer: United Healthcare Medicaid |
$35,379.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$35,379.14
|
|
|
TRASTUZUMAB 150 MG IV SOLR
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS J9355
|
| Hospital Charge Code |
5024213201
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
|
|
TRASTUZUMAB 150 MG IV SOLR
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS J9355
|
| Hospital Charge Code |
5024213201
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$76.53 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$75.03
|
| Rate for Payer: Aetna Government |
$75.03
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$52.52
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$52.52
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$52.52
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$75.03
|
| 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 |
$75.03
|
| Rate for Payer: EmblemHealth Commercial |
$75.03
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$67.53
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$63.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$66.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$75.03
|
| Rate for Payer: Fidelis Qualified Health Plan |
$66.78
|
| Rate for Payer: Group Health Inc Commercial |
$75.03
|
| Rate for Payer: Group Health Inc Medicare |
$75.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$75.03
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$75.03
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$75.03
|
| Rate for Payer: Healthfirst Medicare Advantage |
$63.78
|
| Rate for Payer: Healthfirst QHP |
$75.03
|
| Rate for Payer: Humana Medicare |
$76.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$75.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.03
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$71.28
|
| Rate for Payer: Wellcare Medicare |
$71.28
|
|
|
TRASTUZUMAB-ANNS 150 MG IV SOLR
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
5551314101
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
|
|
TRASTUZUMAB-ANNS 150 MG IV SOLR
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
5551314101
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$48.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$47.55
|
| Rate for Payer: Aetna Government |
$47.55
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$33.28
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$33.28
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$33.28
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$47.55
|
| 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 |
$47.55
|
| Rate for Payer: EmblemHealth Commercial |
$47.55
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$42.80
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$40.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$42.32
|
| Rate for Payer: Fidelis Medicare Advantage |
$47.55
|
| Rate for Payer: Fidelis Qualified Health Plan |
$42.32
|
| Rate for Payer: Group Health Inc Commercial |
$47.55
|
| Rate for Payer: Group Health Inc Medicare |
$47.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$47.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$47.55
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$47.55
|
| Rate for Payer: Healthfirst Medicare Advantage |
$40.42
|
| Rate for Payer: Healthfirst QHP |
$47.55
|
| Rate for Payer: Humana Medicare |
$48.50
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$47.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.55
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$45.17
|
| Rate for Payer: Wellcare Medicare |
$45.17
|
|
|
TRASTUZUMAB-ANNS 420 MG IV SOLR
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
5551316401
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
|
|
TRASTUZUMAB-ANNS 420 MG IV SOLR
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
5551313201
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$48.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$47.55
|
| Rate for Payer: Aetna Government |
$47.55
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$33.28
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$33.28
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$33.28
|
| Rate for Payer: Brighton Health Commercial |
$3.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$47.55
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.72
|
| Rate for Payer: Elderplan Medicare Advantage |
$47.55
|
| Rate for Payer: EmblemHealth Commercial |
$47.55
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$42.80
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$40.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$42.32
|
| Rate for Payer: Fidelis Medicare Advantage |
$47.55
|
| Rate for Payer: Fidelis Qualified Health Plan |
$42.32
|
| Rate for Payer: Group Health Inc Commercial |
$47.55
|
| Rate for Payer: Group Health Inc Medicare |
$47.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$47.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$47.55
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$47.55
|
| Rate for Payer: Healthfirst Medicare Advantage |
$40.42
|
| Rate for Payer: Healthfirst QHP |
$47.55
|
| Rate for Payer: Humana Medicare |
$48.50
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$47.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.55
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$45.17
|
| Rate for Payer: Wellcare Medicare |
$45.17
|
|
|
TRASTUZUMAB-ANNS 420 MG IV SOLR
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
5551316401
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$48.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$47.55
|
| Rate for Payer: Aetna Government |
$47.55
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$33.28
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$33.28
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$33.28
|
| Rate for Payer: Brighton Health Commercial |
$3.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$47.55
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.72
|
| Rate for Payer: Elderplan Medicare Advantage |
$47.55
|
| Rate for Payer: EmblemHealth Commercial |
$47.55
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$42.80
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$40.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$42.32
|
| Rate for Payer: Fidelis Medicare Advantage |
$47.55
|
| Rate for Payer: Fidelis Qualified Health Plan |
$42.32
|
| Rate for Payer: Group Health Inc Commercial |
$47.55
|
| Rate for Payer: Group Health Inc Medicare |
$47.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$47.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$47.55
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$47.55
|
| Rate for Payer: Healthfirst Medicare Advantage |
$40.42
|
| Rate for Payer: Healthfirst QHP |
$47.55
|
| Rate for Payer: Humana Medicare |
$48.50
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$47.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.55
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$45.17
|
| Rate for Payer: Wellcare Medicare |
$45.17
|
|
|
TRASTUZUMAB-ANNS 420 MG IV SOLR
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
5551313201
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
|
|
TRASTUZUMAB-DKST 150 MG IV SOLR
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS Q5114
|
| Hospital Charge Code |
6745799115
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
|
|
TRASTUZUMAB-DKST 150 MG IV SOLR
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS Q5114
|
| Hospital Charge Code |
6745799115
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$41.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$40.29
|
| Rate for Payer: Aetna Government |
$40.29
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$28.20
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$28.20
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$28.20
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$40.29
|
| 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 |
$40.29
|
| Rate for Payer: EmblemHealth Commercial |
$40.29
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$36.26
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$34.25
|
| Rate for Payer: Fidelis Essential Plan QHP |
$35.86
|
| Rate for Payer: Fidelis Medicare Advantage |
$40.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$35.86
|
| Rate for Payer: Group Health Inc Commercial |
$40.29
|
| Rate for Payer: Group Health Inc Medicare |
$40.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$40.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$40.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$34.25
|
| Rate for Payer: Healthfirst QHP |
$40.29
|
| Rate for Payer: Humana Medicare |
$41.10
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$40.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$38.28
|
| Rate for Payer: Wellcare Medicare |
$38.28
|
|
|
TRASTUZUMAB-DKST 420 MG IV SOLR
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
HCPCS Q5114
|
| Hospital Charge Code |
6745784744
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$41.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$40.29
|
| Rate for Payer: Aetna Government |
$40.29
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$28.20
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$28.20
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$28.20
|
| Rate for Payer: Brighton Health Commercial |
$2.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$40.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.04
|
| Rate for Payer: Elderplan Medicare Advantage |
$40.29
|
| Rate for Payer: EmblemHealth Commercial |
$40.29
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$36.26
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$34.25
|
| Rate for Payer: Fidelis Essential Plan QHP |
$35.86
|
| Rate for Payer: Fidelis Medicare Advantage |
$40.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$35.86
|
| Rate for Payer: Group Health Inc Commercial |
$40.29
|
| Rate for Payer: Group Health Inc Medicare |
$40.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$40.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$40.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$34.25
|
| Rate for Payer: Healthfirst QHP |
$40.29
|
| Rate for Payer: Humana Medicare |
$41.10
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$40.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.95
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$38.28
|
| Rate for Payer: Wellcare Medicare |
$38.28
|
|
|
TRASTUZUMAB-DKST 420 MG IV SOLR
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS Q5114
|
| Hospital Charge Code |
6745784744
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.50
|
|
|
TRASTUZUMAB-DKST 420 MG IV SOLR
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
HCPCS Q5114
|
| Hospital Charge Code |
6745784550
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$41.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.65
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$40.29
|
| Rate for Payer: Aetna Government |
$40.29
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$28.20
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$28.20
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$28.20
|
| Rate for Payer: Brighton Health Commercial |
$2.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$40.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.04
|
| Rate for Payer: Elderplan Medicare Advantage |
$40.29
|
| Rate for Payer: EmblemHealth Commercial |
$40.29
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$36.26
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$34.25
|
| Rate for Payer: Fidelis Essential Plan QHP |
$35.86
|
| Rate for Payer: Fidelis Medicare Advantage |
$40.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$35.86
|
| Rate for Payer: Group Health Inc Commercial |
$40.29
|
| Rate for Payer: Group Health Inc Medicare |
$40.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$40.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$40.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$34.25
|
| Rate for Payer: Healthfirst QHP |
$40.29
|
| Rate for Payer: Humana Medicare |
$41.10
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$40.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.95
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$38.28
|
| Rate for Payer: Wellcare Medicare |
$38.28
|
|
|
TRASTUZUMAB-DKST 420 MG IV SOLR
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS Q5114
|
| Hospital Charge Code |
6745784550
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.50
|
|
|
TRASTUZUMAB-DTTB 150 MG IV SOLR
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS Q5112
|
| Hospital Charge Code |
7820614701
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
|
|
TRASTUZUMAB-DTTB 150 MG IV SOLR
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS Q5112
|
| Hospital Charge Code |
7820614701
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$19.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.00
|
| Rate for Payer: Aetna Government |
$19.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$13.30
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$13.30
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$13.30
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$19.00
|
| 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 |
$19.00
|
| Rate for Payer: EmblemHealth Commercial |
$19.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$17.10
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$16.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.91
|
| Rate for Payer: Fidelis Medicare Advantage |
$19.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$16.91
|
| Rate for Payer: Group Health Inc Commercial |
$19.00
|
| Rate for Payer: Group Health Inc Medicare |
$19.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$19.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$16.15
|
| Rate for Payer: Healthfirst QHP |
$19.00
|
| Rate for Payer: Humana Medicare |
$19.38
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$19.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$18.05
|
| Rate for Payer: Wellcare Medicare |
$18.05
|
|
|
TRASTUZUMAB-DTTB 420 MG IV SOLR
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
HCPCS Q5112
|
| Hospital Charge Code |
7820614801
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
|
|
TRASTUZUMAB-DTTB 420 MG IV SOLR
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
HCPCS Q5112
|
| Hospital Charge Code |
7820614801
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$19.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$19.00
|
| Rate for Payer: Aetna Government |
$19.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$13.30
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$13.30
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$13.30
|
| Rate for Payer: Brighton Health Commercial |
$3.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$19.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.72
|
| Rate for Payer: Elderplan Medicare Advantage |
$19.00
|
| Rate for Payer: EmblemHealth Commercial |
$19.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$17.10
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$16.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$16.91
|
| Rate for Payer: Fidelis Medicare Advantage |
$19.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$16.91
|
| Rate for Payer: Group Health Inc Commercial |
$19.00
|
| Rate for Payer: Group Health Inc Medicare |
$19.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$19.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$16.15
|
| Rate for Payer: Healthfirst QHP |
$19.00
|
| Rate for Payer: Humana Medicare |
$19.38
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$19.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$18.05
|
| Rate for Payer: Wellcare Medicare |
$18.05
|
|
|
TRASTUZUMAB-PKRB 150 MG IV SOLR
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS Q5113
|
| Hospital Charge Code |
6345930343
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
|
|
TRASTUZUMAB-PKRB 150 MG IV SOLR
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS Q5113
|
| Hospital Charge Code |
6345930343
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$70.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$69.37
|
| Rate for Payer: Aetna Government |
$69.37
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$48.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$48.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$48.56
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$69.37
|
| 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 |
$69.37
|
| Rate for Payer: EmblemHealth Commercial |
$69.37
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$62.43
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$58.96
|
| Rate for Payer: Fidelis Essential Plan QHP |
$61.74
|
| Rate for Payer: Fidelis Medicare Advantage |
$69.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$61.74
|
| Rate for Payer: Group Health Inc Commercial |
$69.37
|
| Rate for Payer: Group Health Inc Medicare |
$69.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$69.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$69.37
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$69.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$58.96
|
| Rate for Payer: Healthfirst QHP |
$69.37
|
| Rate for Payer: Humana Medicare |
$70.76
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$69.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$69.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$65.90
|
| Rate for Payer: Wellcare Medicare |
$65.90
|
|
|
TRASTUZUMAB-PKRB 420 MG IV SOLR
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
HCPCS Q5113
|
| Hospital Charge Code |
6345930741
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$70.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$69.37
|
| Rate for Payer: Aetna Government |
$69.37
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$48.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$48.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$48.56
|
| Rate for Payer: Brighton Health Commercial |
$3.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$69.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.72
|
| Rate for Payer: Elderplan Medicare Advantage |
$69.37
|
| Rate for Payer: EmblemHealth Commercial |
$69.37
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$62.43
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$58.96
|
| Rate for Payer: Fidelis Essential Plan QHP |
$61.74
|
| Rate for Payer: Fidelis Medicare Advantage |
$69.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$61.74
|
| Rate for Payer: Group Health Inc Commercial |
$69.37
|
| Rate for Payer: Group Health Inc Medicare |
$69.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$69.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$69.37
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$69.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$58.96
|
| Rate for Payer: Healthfirst QHP |
$69.37
|
| Rate for Payer: Humana Medicare |
$70.76
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$69.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$69.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$65.90
|
| Rate for Payer: Wellcare Medicare |
$65.90
|
|
|
TRASTUZUMAB-PKRB 420 MG IV SOLR
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
HCPCS Q5113
|
| Hospital Charge Code |
6345930547
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
|
|
TRASTUZUMAB-PKRB 420 MG IV SOLR
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
HCPCS Q5113
|
| Hospital Charge Code |
6345930547
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$70.76 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$69.37
|
| Rate for Payer: Aetna Government |
$69.37
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$48.56
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$48.56
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$48.56
|
| Rate for Payer: Brighton Health Commercial |
$3.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$69.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.72
|
| Rate for Payer: Elderplan Medicare Advantage |
$69.37
|
| Rate for Payer: EmblemHealth Commercial |
$69.37
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$62.43
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$58.96
|
| Rate for Payer: Fidelis Essential Plan QHP |
$61.74
|
| Rate for Payer: Fidelis Medicare Advantage |
$69.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$61.74
|
| Rate for Payer: Group Health Inc Commercial |
$69.37
|
| Rate for Payer: Group Health Inc Medicare |
$69.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$69.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$69.37
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$69.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$58.96
|
| Rate for Payer: Healthfirst QHP |
$69.37
|
| Rate for Payer: Humana Medicare |
$70.76
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$69.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$69.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$65.90
|
| Rate for Payer: Wellcare Medicare |
$65.90
|
|
|
TRASTUZUMAB-PKRB 420 MG IV SOLR
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
HCPCS Q5113
|
| Hospital Charge Code |
6345930741
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
|
