|
PEGFILGRASTIM-APGF 6 MG/0.6ML SC SOSY
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS Q5122
|
| Hospital Charge Code |
0069032401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.50
|
|
|
PEGFILGRASTIM-APGF 6 MG/0.6ML SC SOSY
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS Q5122
|
| Hospital Charge Code |
0069032401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$133.78 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$131.16
|
| Rate for Payer: Aetna Government |
$131.16
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$91.81
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$91.81
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$91.81
|
| Rate for Payer: Brighton Health Commercial |
$5.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$131.16
|
| 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 |
$131.16
|
| Rate for Payer: EmblemHealth Commercial |
$131.16
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$118.04
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$111.49
|
| Rate for Payer: Fidelis Essential Plan QHP |
$116.73
|
| Rate for Payer: Fidelis Medicare Advantage |
$131.16
|
| Rate for Payer: Fidelis Qualified Health Plan |
$116.73
|
| Rate for Payer: Group Health Inc Commercial |
$131.16
|
| Rate for Payer: Group Health Inc Medicare |
$131.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$131.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$131.16
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$131.16
|
| Rate for Payer: Healthfirst Medicare Advantage |
$111.49
|
| Rate for Payer: Healthfirst QHP |
$131.16
|
| Rate for Payer: Humana Medicare |
$133.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$131.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$131.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.55
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$124.60
|
| Rate for Payer: Wellcare Medicare |
$124.60
|
|
|
PEGFILGRASTIM-BMEZ 6 MG/0.6ML SC SOSY
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS Q5120
|
| Hospital Charge Code |
6131486601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3.50
|
|
|
PEGFILGRASTIM-BMEZ 6 MG/0.6ML SC SOSY
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS Q5120
|
| Hospital Charge Code |
6131486601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$30.93 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3.85
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.32
|
| Rate for Payer: Aetna Government |
$30.32
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$21.22
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$21.22
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$21.22
|
| Rate for Payer: Brighton Health Commercial |
$5.25
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$30.32
|
| 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 |
$30.32
|
| Rate for Payer: EmblemHealth Commercial |
$30.32
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$27.29
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$25.77
|
| Rate for Payer: Fidelis Essential Plan QHP |
$26.98
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.32
|
| Rate for Payer: Fidelis Qualified Health Plan |
$26.98
|
| Rate for Payer: Group Health Inc Commercial |
$30.32
|
| Rate for Payer: Group Health Inc Medicare |
$30.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.32
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$30.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.77
|
| Rate for Payer: Healthfirst QHP |
$30.32
|
| Rate for Payer: Humana Medicare |
$30.93
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.32
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.55
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$28.80
|
| Rate for Payer: Wellcare Medicare |
$28.80
|
|
|
PEGFILGRASTIM-CBQV 6 MG/0.6ML SC SOSY
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS Q5111
|
| Hospital Charge Code |
7011410101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.40 |
| Max. Negotiated Rate |
$108.46 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$106.33
|
| Rate for Payer: Aetna Government |
$106.33
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$74.43
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$74.43
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$74.43
|
| Rate for Payer: Brighton Health Commercial |
$6.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$106.33
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.44
|
| Rate for Payer: Elderplan Medicare Advantage |
$106.33
|
| Rate for Payer: EmblemHealth Commercial |
$106.33
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$95.70
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$90.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$94.63
|
| Rate for Payer: Fidelis Medicare Advantage |
$106.33
|
| Rate for Payer: Fidelis Qualified Health Plan |
$94.63
|
| Rate for Payer: Group Health Inc Commercial |
$106.33
|
| Rate for Payer: Group Health Inc Medicare |
$106.33
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$106.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$106.33
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$106.33
|
| Rate for Payer: Healthfirst Medicare Advantage |
$90.38
|
| Rate for Payer: Healthfirst QHP |
$106.33
|
| Rate for Payer: Humana Medicare |
$108.46
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$106.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$106.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.20
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$101.01
|
| Rate for Payer: Wellcare Medicare |
$101.01
|
|
|
PEGFILGRASTIM-CBQV 6 MG/0.6ML SC SOSY
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS Q5111
|
| Hospital Charge Code |
7011410101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.00
|
|
|
PEGFILGRASTIM-FPGK 6 MG/0.6ML SC SOSY
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 6521937110
|
| Hospital Charge Code |
6521937110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.00
|
|
|
PEGFILGRASTIM-FPGK 6 MG/0.6ML SC SOSY
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 6521937110
|
| Hospital Charge Code |
6521937110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.00
|
| Rate for Payer: Aetna Government |
$4.00
|
| Rate for Payer: Brighton Health Commercial |
$6.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.44
|
| Rate for Payer: EmblemHealth Commercial |
$4.00
|
| Rate for Payer: Group Health Inc Commercial |
$4.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.20
|
|
|
PEGFILGRASTIM-JMDB 6 MG/0.6ML SC SOSY
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
8325700541
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$101.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$99.13
|
| Rate for Payer: Aetna Government |
$99.13
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$69.39
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$69.39
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$69.39
|
| Rate for Payer: Brighton Health Commercial |
$3.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$99.13
|
| 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 |
$99.13
|
| Rate for Payer: EmblemHealth Commercial |
$99.13
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$89.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$84.26
|
| Rate for Payer: Fidelis Essential Plan QHP |
$88.23
|
| Rate for Payer: Fidelis Medicare Advantage |
$99.13
|
| Rate for Payer: Fidelis Qualified Health Plan |
$88.23
|
| Rate for Payer: Group Health Inc Commercial |
$99.13
|
| Rate for Payer: Group Health Inc Medicare |
$99.13
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$99.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$99.13
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$99.13
|
| Rate for Payer: Healthfirst Medicare Advantage |
$84.26
|
| Rate for Payer: Healthfirst QHP |
$99.13
|
| Rate for Payer: Humana Medicare |
$101.11
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$99.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$99.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$94.17
|
| Rate for Payer: Wellcare Medicare |
$94.17
|
|
|
PEGFILGRASTIM-JMDB 6 MG/0.6ML SC SOSY
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
6745783306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
|
|
PEGFILGRASTIM-JMDB 6 MG/0.6ML SC SOSY
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
8325700541
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
|
|
PEGFILGRASTIM-JMDB 6 MG/0.6ML SC SOSY
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
6745783306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$101.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$99.13
|
| Rate for Payer: Aetna Government |
$99.13
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$69.39
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$69.39
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$69.39
|
| Rate for Payer: Brighton Health Commercial |
$3.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$99.13
|
| 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 |
$99.13
|
| Rate for Payer: EmblemHealth Commercial |
$99.13
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$89.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$84.26
|
| Rate for Payer: Fidelis Essential Plan QHP |
$88.23
|
| Rate for Payer: Fidelis Medicare Advantage |
$99.13
|
| Rate for Payer: Fidelis Qualified Health Plan |
$88.23
|
| Rate for Payer: Group Health Inc Commercial |
$99.13
|
| Rate for Payer: Group Health Inc Medicare |
$99.13
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$99.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$99.13
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$99.13
|
| Rate for Payer: Healthfirst Medicare Advantage |
$84.26
|
| Rate for Payer: Healthfirst QHP |
$99.13
|
| Rate for Payer: Humana Medicare |
$101.11
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$99.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$99.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$94.17
|
| Rate for Payer: Wellcare Medicare |
$94.17
|
|
|
PEGFILGRASTIM-PBBK 6 MG/0.6ML SC SOSY
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 7012116271
|
| Hospital Charge Code |
7012116271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.50
|
|
|
PEGFILGRASTIM-PBBK 6 MG/0.6ML SC SOSY
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 7012116271
|
| Hospital Charge Code |
7012116271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.50
|
| Rate for Payer: Aetna Government |
$2.50
|
| Rate for Payer: Brighton Health Commercial |
$3.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.40
|
| Rate for Payer: EmblemHealth Commercial |
$2.50
|
| Rate for Payer: Group Health Inc Commercial |
$2.50
|
| Rate for Payer: Group Health Inc Medicare |
$1.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.25
|
|
|
PEGINTERFERON ALFA-2A 180 MCG/ML SC SOLN
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS S0145
|
| Hospital Charge Code |
0004035009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
|
|
PEGINTERFERON ALFA-2A 180 MCG/ML SC SOLN
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS S0145
|
| Hospital Charge Code |
0004035009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$845.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$845.80
|
| Rate for Payer: Aetna Government |
$845.80
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.68
|
| Rate for Payer: EmblemHealth Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
PEGLOTICASE 8 MG/ML IV SOLN
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
HCPCS J2507
|
| Hospital Charge Code |
7598708010
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$3,734.05 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$18.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3,660.83
|
| Rate for Payer: Aetna Government |
$3,660.83
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$2,562.58
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$2,562.58
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$2,562.58
|
| Rate for Payer: Brighton Health Commercial |
$25.50
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$3,660.83
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$27.20
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$23.12
|
| Rate for Payer: Elderplan Medicare Advantage |
$3,660.83
|
| Rate for Payer: EmblemHealth Commercial |
$3,660.83
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3,294.75
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3,111.71
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3,258.14
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,660.83
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3,258.14
|
| Rate for Payer: Group Health Inc Commercial |
$3,660.83
|
| Rate for Payer: Group Health Inc Medicare |
$3,660.83
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,660.83
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,660.83
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3,660.83
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3,111.71
|
| Rate for Payer: Healthfirst QHP |
$3,660.83
|
| Rate for Payer: Humana Medicare |
$3,734.05
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$3,660.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,660.83
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$22.10
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$3,477.79
|
| Rate for Payer: Wellcare Medicare |
$3,477.79
|
|
|
PEGLOTICASE 8 MG/ML IV SOLN
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
HCPCS J2507
|
| Hospital Charge Code |
7598708010
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17.00
|
|
|
Pelvic evisceration, radical hysterectomy & other radical GYN procs
|
Facility
|
IP
|
$144,739.98
|
|
|
Service Code
|
APR-DRG 5104
|
| Min. Negotiated Rate |
$64,328.88 |
| Max. Negotiated Rate |
$144,739.98 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$144,739.98
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$144,739.98
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$64,328.88
|
| Rate for Payer: Amida Care Medicaid |
$64,328.88
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$144,739.98
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$64,328.88
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$64,328.88
|
| Rate for Payer: Fidelis Qualified Health Plan |
$77,194.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$64,328.88
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$64,328.88
|
| Rate for Payer: Healthfirst Commercial |
$96,631.00
|
| Rate for Payer: Healthfirst Essential Plan |
$144,739.98
|
| Rate for Payer: Healthfirst QHP |
$79,200.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$64,328.88
|
| Rate for Payer: SOMOS Essential |
$144,739.98
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$144,739.98
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$144,739.98
|
| Rate for Payer: United Healthcare Medicaid |
$64,328.88
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$64,328.88
|
|
|
Pelvic evisceration, radical hysterectomy & other radical GYN procs
|
Facility
|
IP
|
$51,792.01
|
|
|
Service Code
|
APR-DRG 5101
|
| Min. Negotiated Rate |
$14,321.00 |
| Max. Negotiated Rate |
$51,792.01 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$51,792.01
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$51,792.01
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$23,018.67
|
| Rate for Payer: Amida Care Medicaid |
$23,018.67
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$51,792.01
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$23,018.67
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$23,018.67
|
| Rate for Payer: Fidelis Qualified Health Plan |
$27,622.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23,018.67
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$23,018.67
|
| Rate for Payer: Healthfirst Commercial |
$24,839.00
|
| Rate for Payer: Healthfirst Essential Plan |
$51,792.01
|
| Rate for Payer: Healthfirst QHP |
$14,321.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$23,018.67
|
| Rate for Payer: SOMOS Essential |
$51,792.01
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$51,792.01
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$51,792.01
|
| Rate for Payer: United Healthcare Medicaid |
$23,018.67
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$23,018.67
|
|
|
Pelvic evisceration, radical hysterectomy & other radical GYN procs
|
Facility
|
IP
|
$57,233.57
|
|
|
Service Code
|
APR-DRG 5102
|
| Min. Negotiated Rate |
$16,710.00 |
| Max. Negotiated Rate |
$57,233.57 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$57,233.57
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$57,233.57
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$25,437.14
|
| Rate for Payer: Amida Care Medicaid |
$25,437.14
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$57,233.57
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$25,437.14
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$25,437.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$30,524.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$25,437.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$25,437.14
|
| Rate for Payer: Healthfirst Commercial |
$30,113.00
|
| Rate for Payer: Healthfirst Essential Plan |
$57,233.57
|
| Rate for Payer: Healthfirst QHP |
$16,710.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$25,437.14
|
| Rate for Payer: SOMOS Essential |
$57,233.57
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$57,233.57
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$57,233.57
|
| Rate for Payer: United Healthcare Medicaid |
$25,437.14
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$25,437.14
|
|
|
Pelvic evisceration, radical hysterectomy & other radical GYN procs
|
Facility
|
IP
|
$78,294.55
|
|
|
Service Code
|
APR-DRG 5103
|
| Min. Negotiated Rate |
$32,303.00 |
| Max. Negotiated Rate |
$78,294.55 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$78,294.55
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$78,294.55
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$34,797.58
|
| Rate for Payer: Amida Care Medicaid |
$34,797.58
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$78,294.55
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$34,797.58
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$34,797.58
|
| Rate for Payer: Fidelis Qualified Health Plan |
$41,757.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$34,797.58
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$34,797.58
|
| Rate for Payer: Healthfirst Commercial |
$52,787.00
|
| Rate for Payer: Healthfirst Essential Plan |
$78,294.55
|
| Rate for Payer: Healthfirst QHP |
$32,303.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$34,797.58
|
| Rate for Payer: SOMOS Essential |
$78,294.55
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$78,294.55
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$78,294.55
|
| Rate for Payer: United Healthcare Medicaid |
$34,797.58
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$34,797.58
|
|
|
PELVIS, FEMUR AND UPPER LEG PROCEDURES
|
Facility
|
OP
|
$2,767.90
|
|
|
Service Code
|
EAPG 00027
|
| Min. Negotiated Rate |
$2,767.90 |
| Max. Negotiated Rate |
$2,767.90 |
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$2,767.90
|
|
|
PEMBROLIZUMAB 100 MG/4ML IV SOLN
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS J9271
|
| Hospital Charge Code |
0006302602
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$61.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$60.29
|
| Rate for Payer: Aetna Government |
$60.29
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$42.20
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$42.20
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$42.20
|
| Rate for Payer: Brighton Health Commercial |
$0.75
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$60.29
|
| 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 |
$60.29
|
| Rate for Payer: EmblemHealth Commercial |
$60.29
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$54.26
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$51.25
|
| Rate for Payer: Fidelis Essential Plan QHP |
$53.66
|
| Rate for Payer: Fidelis Medicare Advantage |
$60.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$53.66
|
| Rate for Payer: Group Health Inc Commercial |
$60.29
|
| Rate for Payer: Group Health Inc Medicare |
$60.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$60.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$60.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$60.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$51.25
|
| Rate for Payer: Healthfirst QHP |
$60.29
|
| Rate for Payer: Humana Medicare |
$61.50
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$60.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$60.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$57.28
|
| Rate for Payer: Wellcare Medicare |
$57.28
|
|
|
PEMBROLIZUMAB 100 MG/4ML IV SOLN
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS J9271
|
| Hospital Charge Code |
0006302602
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
|
