|
PEG 3350-KCL-NABCB-NACL-NASULF 236 G PO SOLR [10839]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 52268010001
|
| Hospital Charge Code |
52268010001
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.00
|
| Rate for Payer: Aetna Government |
$0.00
|
| Rate for Payer: Brighton Health Commercial |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.00
|
| Rate for Payer: Group Health Inc Commercial |
$0.00
|
| Rate for Payer: Group Health Inc Medicare |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.00
|
|
|
PEGADENOSON 0.4MG/5ML
|
Facility
|
OP
|
$90.63
|
|
|
Service Code
|
HCPCS J2785
|
| Hospital Charge Code |
41657934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.47 |
| Max. Negotiated Rate |
$59.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$49.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$59.70
|
| Rate for Payer: Aetna Government |
$59.70
|
| Rate for Payer: Brighton Health Commercial |
$54.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$45.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$52.11
|
| Rate for Payer: Group Health Inc Commercial |
$45.32
|
| Rate for Payer: Group Health Inc Medicare |
$31.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$45.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$45.32
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$7.47
|
| Rate for Payer: SOMOS Essential |
$7.47
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$58.91
|
|
|
PEGADENOSON 0.4MG/5ML
|
Facility
|
IP
|
$90.63
|
|
|
Service Code
|
HCPCS J2785
|
| Hospital Charge Code |
41657934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.32 |
| Max. Negotiated Rate |
$45.32 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$45.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$45.32
|
|
|
PEG BONE FX 2.7MM DIA 16MML
|
Facility
|
OP
|
$245.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64902298
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$85.88 |
| Max. Negotiated Rate |
$257.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$134.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$147.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$122.69
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$141.09
|
| Rate for Payer: EmblemHealth Commercial |
$122.69
|
| Rate for Payer: Fidelis Medicare Advantage |
$257.65
|
| Rate for Payer: Group Health Inc Commercial |
$122.69
|
| Rate for Payer: Group Health Inc Medicare |
$85.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$159.50
|
|
|
PEG BONE FX 2.7MM DIA 16MML
|
Facility
|
IP
|
$245.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64902298
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$122.69 |
| Max. Negotiated Rate |
$122.69 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.69
|
|
|
PEG BONE FX 2.7MM DIA 24MML
|
Facility
|
OP
|
$245.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904424
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$85.88 |
| Max. Negotiated Rate |
$257.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$134.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$147.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$122.69
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$141.09
|
| Rate for Payer: EmblemHealth Commercial |
$122.69
|
| Rate for Payer: Fidelis Medicare Advantage |
$257.65
|
| Rate for Payer: Group Health Inc Commercial |
$122.69
|
| Rate for Payer: Group Health Inc Medicare |
$85.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$159.50
|
|
|
PEG BONE FX 2.7MM DIA 24MML
|
Facility
|
IP
|
$245.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904424
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$122.69 |
| Max. Negotiated Rate |
$122.69 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.69
|
|
|
PEG BONE FX 2.7MM DIA 26MML
|
Facility
|
IP
|
$245.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904425
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$122.69 |
| Max. Negotiated Rate |
$122.69 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.69
|
|
|
PEG BONE FX 2.7MM DIA 26MML
|
Facility
|
OP
|
$245.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904425
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$85.88 |
| Max. Negotiated Rate |
$257.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$134.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$147.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$122.69
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$141.09
|
| Rate for Payer: EmblemHealth Commercial |
$122.69
|
| Rate for Payer: Fidelis Medicare Advantage |
$257.65
|
| Rate for Payer: Group Health Inc Commercial |
$122.69
|
| Rate for Payer: Group Health Inc Medicare |
$85.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$159.50
|
|
|
PEG BONE FX 2MM DIA 18MML TI
|
Facility
|
OP
|
$245.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$85.88 |
| Max. Negotiated Rate |
$257.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$134.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$147.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$122.69
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$141.09
|
| Rate for Payer: EmblemHealth Commercial |
$122.69
|
| Rate for Payer: Fidelis Medicare Advantage |
$257.65
|
| Rate for Payer: Group Health Inc Commercial |
$122.69
|
| Rate for Payer: Group Health Inc Medicare |
$85.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$159.50
|
|
|
PEG BONE FX 2MM DIA 18MML TI
|
Facility
|
IP
|
$245.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$122.69 |
| Max. Negotiated Rate |
$122.69 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.69
|
|
|
PEG BONE FX 2MM DIA 20MML TI
|
Facility
|
OP
|
$245.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903062
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$85.88 |
| Max. Negotiated Rate |
$257.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$134.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$147.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$122.69
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$141.09
|
| Rate for Payer: EmblemHealth Commercial |
$122.69
|
| Rate for Payer: Fidelis Medicare Advantage |
$257.65
|
| Rate for Payer: Group Health Inc Commercial |
$122.69
|
| Rate for Payer: Group Health Inc Medicare |
$85.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$159.50
|
|
|
PEG BONE FX 2MM DIA 20MML TI
|
Facility
|
IP
|
$245.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903062
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$122.69 |
| Max. Negotiated Rate |
$122.69 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.69
|
|
|
PEG BONE FX LOCKING 2MM DIA
|
Facility
|
IP
|
$245.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$122.69 |
| Max. Negotiated Rate |
$122.69 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.69
|
|
|
PEG BONE FX LOCKING 2MM DIA
|
Facility
|
OP
|
$245.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$85.88 |
| Max. Negotiated Rate |
$257.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$134.96
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Brighton Health Commercial |
$147.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$122.69
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$141.09
|
| Rate for Payer: EmblemHealth Commercial |
$122.69
|
| Rate for Payer: Fidelis Medicare Advantage |
$257.65
|
| Rate for Payer: Group Health Inc Commercial |
$122.69
|
| Rate for Payer: Group Health Inc Medicare |
$85.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$122.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$159.50
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML INJ
|
Facility
|
OP
|
$12,236.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41653656
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,282.60 |
| Max. Negotiated Rate |
$7,953.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6,729.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,118.00
|
| Rate for Payer: Aetna Government |
$6,118.00
|
| Rate for Payer: Brighton Health Commercial |
$7,341.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6,118.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7,035.70
|
| Rate for Payer: Group Health Inc Commercial |
$6,118.00
|
| Rate for Payer: Group Health Inc Medicare |
$4,282.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6,118.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,118.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7,953.40
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML INJ
|
Facility
|
IP
|
$12,236.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41643656
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,118.00 |
| Max. Negotiated Rate |
$6,118.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6,118.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,118.00
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML INJ
|
Facility
|
IP
|
$12,236.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41653656
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,118.00 |
| Max. Negotiated Rate |
$6,118.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6,118.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,118.00
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML INJ
|
Facility
|
OP
|
$12,236.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
41643656
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,282.60 |
| Max. Negotiated Rate |
$7,953.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6,729.80
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6,118.00
|
| Rate for Payer: Aetna Government |
$6,118.00
|
| Rate for Payer: Brighton Health Commercial |
$7,341.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6,118.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7,035.70
|
| Rate for Payer: Group Health Inc Commercial |
$6,118.00
|
| Rate for Payer: Group Health Inc Medicare |
$4,282.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6,118.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,118.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7,953.40
|
|
|
PEGFILGRASTIM 6 MG/0.6ML SC PSKT [129658]
|
Facility
|
OP
|
$12,835.98
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
55513019201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.47 |
| Max. Negotiated Rate |
$10,268.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7,059.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$50.68
|
| Rate for Payer: Aetna Government |
$50.68
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$35.47
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$35.47
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$35.47
|
| Rate for Payer: Brighton Health Commercial |
$9,626.99
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$50.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10,268.79
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8,728.47
|
| Rate for Payer: Elderplan Medicare Advantage |
$50.68
|
| Rate for Payer: EmblemHealth Commercial |
$50.68
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$43.08
|
| Rate for Payer: Fidelis Essential Plan QHP |
$45.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$50.68
|
| Rate for Payer: Fidelis Qualified Health Plan |
$45.10
|
| Rate for Payer: Group Health Inc Commercial |
$50.68
|
| Rate for Payer: Group Health Inc Medicare |
$50.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6,417.99
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$50.68
|
| Rate for Payer: Healthfirst Medicare Advantage |
$43.08
|
| Rate for Payer: Healthfirst QHP |
$50.68
|
| Rate for Payer: Humana Medicare |
$51.69
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$109.75
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$116.34
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$116.34
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$116.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$50.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8,343.39
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$40.54
|
| Rate for Payer: Wellcare Medicare |
$48.14
|
|
|
PEGFILGRASTIM 6 MG/0.6ML SC SOSY [129657]
|
Facility
|
OP
|
$12,835.98
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
55513019001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.47 |
| Max. Negotiated Rate |
$10,268.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7,059.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$50.68
|
| Rate for Payer: Aetna Government |
$50.68
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$35.47
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$35.47
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$35.47
|
| Rate for Payer: Brighton Health Commercial |
$9,626.99
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$50.68
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$10,268.79
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$8,728.47
|
| Rate for Payer: Elderplan Medicare Advantage |
$50.68
|
| Rate for Payer: EmblemHealth Commercial |
$50.68
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$43.08
|
| Rate for Payer: Fidelis Essential Plan QHP |
$45.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$50.68
|
| Rate for Payer: Fidelis Qualified Health Plan |
$45.10
|
| Rate for Payer: Group Health Inc Commercial |
$50.68
|
| Rate for Payer: Group Health Inc Medicare |
$50.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6,417.99
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$50.68
|
| Rate for Payer: Healthfirst Medicare Advantage |
$43.08
|
| Rate for Payer: Healthfirst QHP |
$50.68
|
| Rate for Payer: Humana Medicare |
$51.69
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$109.75
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$116.34
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$116.34
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$116.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$50.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$50.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8,343.39
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$40.54
|
| Rate for Payer: Wellcare Medicare |
$48.14
|
|
|
PEGFILGRASTIM-APGF 6 MG/0.6ML SC SOSY [176068]
|
Facility
|
OP
|
$7,850.00
|
|
|
Service Code
|
HCPCS Q5122
|
| Hospital Charge Code |
00069032401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.66 |
| Max. Negotiated Rate |
$6,280.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,317.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$62.38
|
| Rate for Payer: Aetna Government |
$62.38
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$43.66
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$43.66
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$43.66
|
| Rate for Payer: Brighton Health Commercial |
$5,887.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$62.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6,280.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5,338.00
|
| Rate for Payer: Elderplan Medicare Advantage |
$62.38
|
| Rate for Payer: EmblemHealth Commercial |
$62.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$53.02
|
| Rate for Payer: Fidelis Essential Plan QHP |
$55.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$62.38
|
| Rate for Payer: Fidelis Qualified Health Plan |
$55.52
|
| Rate for Payer: Group Health Inc Commercial |
$62.38
|
| Rate for Payer: Group Health Inc Medicare |
$62.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,925.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$62.38
|
| Rate for Payer: Healthfirst Medicare Advantage |
$53.02
|
| Rate for Payer: Healthfirst QHP |
$62.38
|
| Rate for Payer: Humana Medicare |
$63.62
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$65.51
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$69.44
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$69.44
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$69.44
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$62.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5,102.50
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$49.90
|
| Rate for Payer: Wellcare Medicare |
$59.26
|
|
|
PEGFILGRASTIM-BMEZ 6 MG/0.6ML SC SOSY [170318]
|
Facility
|
OP
|
$7,851.07
|
|
|
Service Code
|
HCPCS Q5120
|
| Hospital Charge Code |
61314086601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$242.73 |
| Max. Negotiated Rate |
$6,280.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,318.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$346.76
|
| Rate for Payer: Aetna Government |
$346.76
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$242.73
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$242.73
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$242.73
|
| Rate for Payer: Brighton Health Commercial |
$5,888.30
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$346.76
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6,280.85
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5,338.73
|
| Rate for Payer: Elderplan Medicare Advantage |
$346.76
|
| Rate for Payer: EmblemHealth Commercial |
$346.76
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$294.74
|
| Rate for Payer: Fidelis Essential Plan QHP |
$308.61
|
| Rate for Payer: Fidelis Medicare Advantage |
$346.76
|
| Rate for Payer: Fidelis Qualified Health Plan |
$308.61
|
| Rate for Payer: Group Health Inc Commercial |
$346.76
|
| Rate for Payer: Group Health Inc Medicare |
$346.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,925.53
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$346.76
|
| Rate for Payer: Healthfirst Medicare Advantage |
$294.74
|
| Rate for Payer: Healthfirst QHP |
$346.76
|
| Rate for Payer: Humana Medicare |
$353.69
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$346.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$346.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5,103.19
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$277.40
|
| Rate for Payer: Wellcare Medicare |
$329.42
|
|
|
PEGFILGRASTIM-CBQV 6 MG/0.6ML SC SOSY [164810]
|
Facility
|
OP
|
$8,350.00
|
|
|
Service Code
|
HCPCS Q5111
|
| Hospital Charge Code |
70114010101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.47 |
| Max. Negotiated Rate |
$6,680.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,592.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$122.10
|
| Rate for Payer: Aetna Government |
$122.10
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$85.47
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$85.47
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$85.47
|
| Rate for Payer: Brighton Health Commercial |
$6,262.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$122.10
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6,680.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5,678.00
|
| Rate for Payer: Elderplan Medicare Advantage |
$122.10
|
| Rate for Payer: EmblemHealth Commercial |
$122.10
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$103.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$108.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$122.10
|
| Rate for Payer: Fidelis Qualified Health Plan |
$108.67
|
| Rate for Payer: Group Health Inc Commercial |
$122.10
|
| Rate for Payer: Group Health Inc Medicare |
$122.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$122.10
|
| Rate for Payer: Healthfirst Medicare Advantage |
$103.79
|
| Rate for Payer: Healthfirst QHP |
$122.10
|
| Rate for Payer: Humana Medicare |
$124.55
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$135.49
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$143.62
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$143.62
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$143.62
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$122.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$122.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5,427.50
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$97.68
|
| Rate for Payer: Wellcare Medicare |
$116.00
|
|
|
PEGFILGRASTIM-FPGK 6 MG/0.6ML SC SOSY [188082]
|
Facility
|
OP
|
$8,600.50
|
|
|
Service Code
|
NDC 65219037110
|
| Hospital Charge Code |
65219037110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,010.18 |
| Max. Negotiated Rate |
$6,880.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,730.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,300.25
|
| Rate for Payer: Aetna Government |
$4,300.25
|
| Rate for Payer: Brighton Health Commercial |
$6,450.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6,880.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5,848.34
|
| Rate for Payer: Group Health Inc Commercial |
$4,300.25
|
| Rate for Payer: Group Health Inc Medicare |
$3,010.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,300.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,300.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5,590.32
|
|
