|
PEMBROLIZUMAB 100 MG/4ML IV SOLN
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS J9271
|
| Hospital Charge Code |
0006302604
|
|
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 |
0006302604
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
|
|
PEMETREXED 500 MG/20ML IV SOLN
|
Facility
|
IP
|
$59.46
|
|
|
Service Code
|
NDC 0480451401
|
| Hospital Charge Code |
0480451401
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$29.73 |
| Max. Negotiated Rate |
$29.73 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$29.73
|
|
|
PEMETREXED 500 MG/20ML IV SOLN
|
Facility
|
OP
|
$59.46
|
|
|
Service Code
|
NDC 0480451401
|
| Hospital Charge Code |
0480451401
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$20.81 |
| Max. Negotiated Rate |
$47.56 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$32.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$29.73
|
| Rate for Payer: Aetna Government |
$29.73
|
| Rate for Payer: Brighton Health Commercial |
$44.59
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$47.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$40.43
|
| Rate for Payer: EmblemHealth Commercial |
$29.73
|
| Rate for Payer: Group Health Inc Commercial |
$29.73
|
| Rate for Payer: Group Health Inc Medicare |
$20.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$29.73
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$29.73
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$38.65
|
|
|
PEMETREXED DISODIUM 500 MG IV SOLR
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
0002762301
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$4.45 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.36
|
| Rate for Payer: Aetna Government |
$4.36
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.05
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.05
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.05
|
| Rate for Payer: Brighton Health Commercial |
$3.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4.36
|
| 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 |
$4.36
|
| Rate for Payer: EmblemHealth Commercial |
$4.36
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3.71
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3.88
|
| Rate for Payer: Fidelis Medicare Advantage |
$4.36
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3.88
|
| Rate for Payer: Group Health Inc Commercial |
$4.36
|
| Rate for Payer: Group Health Inc Medicare |
$4.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.36
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$4.36
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3.71
|
| Rate for Payer: Healthfirst QHP |
$4.36
|
| Rate for Payer: Humana Medicare |
$4.45
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.36
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.60
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.14
|
| Rate for Payer: Wellcare Medicare |
$4.14
|
|
|
PEMETREXED DISODIUM 500 MG IV SOLR
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
5515038201
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$330.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.36
|
| Rate for Payer: Aetna Government |
$4.36
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.05
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.05
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.05
|
| Rate for Payer: Brighton Health Commercial |
$450.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4.36
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$480.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$408.00
|
| Rate for Payer: Elderplan Medicare Advantage |
$4.36
|
| Rate for Payer: EmblemHealth Commercial |
$4.36
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3.71
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3.88
|
| Rate for Payer: Fidelis Medicare Advantage |
$4.36
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3.88
|
| Rate for Payer: Group Health Inc Commercial |
$4.36
|
| Rate for Payer: Group Health Inc Medicare |
$4.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.36
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$4.36
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3.71
|
| Rate for Payer: Healthfirst QHP |
$4.36
|
| Rate for Payer: Humana Medicare |
$4.45
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.36
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$390.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.14
|
| Rate for Payer: Wellcare Medicare |
$4.14
|
|
|
PEMETREXED DISODIUM 500 MG IV SOLR
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
5515038201
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$300.00 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$300.00
|
|
|
PEMETREXED DISODIUM 500 MG IV SOLR
|
Facility
|
IP
|
$951.60
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
4359838711
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$475.80 |
| Max. Negotiated Rate |
$475.80 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$475.80
|
|
|
PEMETREXED DISODIUM 500 MG IV SOLR
|
Facility
|
OP
|
$951.60
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
4359838711
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$761.28 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$523.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.36
|
| Rate for Payer: Aetna Government |
$4.36
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.05
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.05
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.05
|
| Rate for Payer: Brighton Health Commercial |
$713.70
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4.36
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$761.28
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$647.09
|
| Rate for Payer: Elderplan Medicare Advantage |
$4.36
|
| Rate for Payer: EmblemHealth Commercial |
$4.36
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3.71
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3.88
|
| Rate for Payer: Fidelis Medicare Advantage |
$4.36
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3.88
|
| Rate for Payer: Group Health Inc Commercial |
$4.36
|
| Rate for Payer: Group Health Inc Medicare |
$4.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.36
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$4.36
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3.71
|
| Rate for Payer: Healthfirst QHP |
$4.36
|
| Rate for Payer: Humana Medicare |
$4.45
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.36
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$618.54
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.14
|
| Rate for Payer: Wellcare Medicare |
$4.14
|
|
|
PEMETREXED DISODIUM 500 MG IV SOLR
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
0002762301
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.00
|
|
|
PEMETREXED DISODIUM 500 MG IV SOLR
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
7128816750
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$99.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4.36
|
| Rate for Payer: Aetna Government |
$4.36
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$3.05
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$3.05
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$3.05
|
| Rate for Payer: Brighton Health Commercial |
$135.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$4.36
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$144.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$122.40
|
| Rate for Payer: Elderplan Medicare Advantage |
$4.36
|
| Rate for Payer: EmblemHealth Commercial |
$4.36
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3.71
|
| Rate for Payer: Fidelis Essential Plan QHP |
$3.88
|
| Rate for Payer: Fidelis Medicare Advantage |
$4.36
|
| Rate for Payer: Fidelis Qualified Health Plan |
$3.88
|
| Rate for Payer: Group Health Inc Commercial |
$4.36
|
| Rate for Payer: Group Health Inc Medicare |
$4.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.36
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$4.36
|
| Rate for Payer: Healthfirst Medicare Advantage |
$3.71
|
| Rate for Payer: Healthfirst QHP |
$4.36
|
| Rate for Payer: Humana Medicare |
$4.45
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.36
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$117.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$4.14
|
| Rate for Payer: Wellcare Medicare |
$4.14
|
|
|
PEMETREXED DISODIUM 500 MG IV SOLR
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
7128816750
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$90.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$90.00
|
|
|
PENICILLAMINE 250 MG PO CAPS
|
Facility
|
IP
|
$298.55
|
|
|
Service Code
|
NDC 0591417101
|
| Hospital Charge Code |
0591417101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$149.28 |
| Max. Negotiated Rate |
$149.28 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$149.28
|
|
|
PENICILLAMINE 250 MG PO CAPS
|
Facility
|
OP
|
$298.55
|
|
|
Service Code
|
NDC 0591417101
|
| Hospital Charge Code |
0591417101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$104.49 |
| Max. Negotiated Rate |
$238.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$164.20
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$149.28
|
| Rate for Payer: Aetna Government |
$149.28
|
| Rate for Payer: Brighton Health Commercial |
$223.91
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$238.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$203.01
|
| Rate for Payer: EmblemHealth Commercial |
$149.28
|
| Rate for Payer: Group Health Inc Commercial |
$149.28
|
| Rate for Payer: Group Health Inc Medicare |
$104.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$149.28
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$149.28
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$194.06
|
|
|
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY
|
Facility
|
IP
|
$166.36
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
6079370102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$83.18 |
| Max. Negotiated Rate |
$83.18 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$83.18
|
|
|
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY
|
Facility
|
OP
|
$166.36
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
6079370102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.01 |
| Max. Negotiated Rate |
$133.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$91.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.01
|
| Rate for Payer: Aetna Government |
$30.01
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$21.01
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$21.01
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$21.01
|
| Rate for Payer: Brighton Health Commercial |
$124.77
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$30.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$133.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$113.12
|
| Rate for Payer: Elderplan Medicare Advantage |
$30.01
|
| Rate for Payer: EmblemHealth Commercial |
$30.01
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$27.01
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$25.51
|
| Rate for Payer: Fidelis Essential Plan QHP |
$26.71
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.01
|
| Rate for Payer: Fidelis Qualified Health Plan |
$26.71
|
| Rate for Payer: Group Health Inc Commercial |
$30.01
|
| Rate for Payer: Group Health Inc Medicare |
$30.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.01
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$30.01
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.51
|
| Rate for Payer: Healthfirst QHP |
$30.01
|
| Rate for Payer: Humana Medicare |
$30.61
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$108.13
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$28.51
|
| Rate for Payer: Wellcare Medicare |
$28.51
|
|
|
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY
|
Facility
|
IP
|
$166.36
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
6079370110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$83.18 |
| Max. Negotiated Rate |
$83.18 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$83.18
|
|
|
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY
|
Facility
|
OP
|
$166.36
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
6079370110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.01 |
| Max. Negotiated Rate |
$133.09 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$91.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.01
|
| Rate for Payer: Aetna Government |
$30.01
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$21.01
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$21.01
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$21.01
|
| Rate for Payer: Brighton Health Commercial |
$124.77
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$30.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$133.09
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$113.12
|
| Rate for Payer: Elderplan Medicare Advantage |
$30.01
|
| Rate for Payer: EmblemHealth Commercial |
$30.01
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$27.01
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$25.51
|
| Rate for Payer: Fidelis Essential Plan QHP |
$26.71
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.01
|
| Rate for Payer: Fidelis Qualified Health Plan |
$26.71
|
| Rate for Payer: Group Health Inc Commercial |
$30.01
|
| Rate for Payer: Group Health Inc Medicare |
$30.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.01
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$30.01
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.51
|
| Rate for Payer: Healthfirst QHP |
$30.01
|
| Rate for Payer: Humana Medicare |
$30.61
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$108.13
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$28.51
|
| Rate for Payer: Wellcare Medicare |
$28.51
|
|
|
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY
|
Facility
|
IP
|
$170.45
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
6079370210
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.22 |
| Max. Negotiated Rate |
$85.22 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$85.22
|
|
|
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY
|
Facility
|
OP
|
$170.45
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
6079370204
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.01 |
| Max. Negotiated Rate |
$136.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$93.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.01
|
| Rate for Payer: Aetna Government |
$30.01
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$21.01
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$21.01
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$21.01
|
| Rate for Payer: Brighton Health Commercial |
$127.84
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$30.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$136.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$115.90
|
| Rate for Payer: Elderplan Medicare Advantage |
$30.01
|
| Rate for Payer: EmblemHealth Commercial |
$30.01
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$27.01
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$25.51
|
| Rate for Payer: Fidelis Essential Plan QHP |
$26.71
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.01
|
| Rate for Payer: Fidelis Qualified Health Plan |
$26.71
|
| Rate for Payer: Group Health Inc Commercial |
$30.01
|
| Rate for Payer: Group Health Inc Medicare |
$30.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.01
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$30.01
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.51
|
| Rate for Payer: Healthfirst QHP |
$30.01
|
| Rate for Payer: Humana Medicare |
$30.61
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$110.79
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$28.51
|
| Rate for Payer: Wellcare Medicare |
$28.51
|
|
|
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY
|
Facility
|
IP
|
$170.45
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
6079370204
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.22 |
| Max. Negotiated Rate |
$85.22 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$85.22
|
|
|
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY
|
Facility
|
OP
|
$170.45
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
6079370210
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.01 |
| Max. Negotiated Rate |
$136.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$93.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.01
|
| Rate for Payer: Aetna Government |
$30.01
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$21.01
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$21.01
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$21.01
|
| Rate for Payer: Brighton Health Commercial |
$127.84
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$30.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$136.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$115.90
|
| Rate for Payer: Elderplan Medicare Advantage |
$30.01
|
| Rate for Payer: EmblemHealth Commercial |
$30.01
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$27.01
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$25.51
|
| Rate for Payer: Fidelis Essential Plan QHP |
$26.71
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.01
|
| Rate for Payer: Fidelis Qualified Health Plan |
$26.71
|
| Rate for Payer: Group Health Inc Commercial |
$30.01
|
| Rate for Payer: Group Health Inc Medicare |
$30.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.01
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$30.01
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.51
|
| Rate for Payer: Healthfirst QHP |
$30.01
|
| Rate for Payer: Humana Medicare |
$30.61
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$110.79
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$28.51
|
| Rate for Payer: Wellcare Medicare |
$28.51
|
|
|
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY
|
Facility
|
OP
|
$192.10
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
6079370010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.01 |
| Max. Negotiated Rate |
$153.68 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$105.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.01
|
| Rate for Payer: Aetna Government |
$30.01
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$21.01
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$21.01
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$21.01
|
| Rate for Payer: Brighton Health Commercial |
$144.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$30.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$153.68
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$130.63
|
| Rate for Payer: Elderplan Medicare Advantage |
$30.01
|
| Rate for Payer: EmblemHealth Commercial |
$30.01
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$27.01
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$25.51
|
| Rate for Payer: Fidelis Essential Plan QHP |
$26.71
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.01
|
| Rate for Payer: Fidelis Qualified Health Plan |
$26.71
|
| Rate for Payer: Group Health Inc Commercial |
$30.01
|
| Rate for Payer: Group Health Inc Medicare |
$30.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.01
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$30.01
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.51
|
| Rate for Payer: Healthfirst QHP |
$30.01
|
| Rate for Payer: Humana Medicare |
$30.61
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$124.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$28.51
|
| Rate for Payer: Wellcare Medicare |
$28.51
|
|
|
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY
|
Facility
|
IP
|
$192.10
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
6079370010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.05 |
| Max. Negotiated Rate |
$96.05 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$96.05
|
|
|
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY
|
Facility
|
OP
|
$192.11
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
6079370001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.01 |
| Max. Negotiated Rate |
$153.69 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$105.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.01
|
| Rate for Payer: Aetna Government |
$30.01
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$21.01
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$21.01
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$21.01
|
| Rate for Payer: Brighton Health Commercial |
$144.08
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$30.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$153.69
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$130.63
|
| Rate for Payer: Elderplan Medicare Advantage |
$30.01
|
| Rate for Payer: EmblemHealth Commercial |
$30.01
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$27.01
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$25.51
|
| Rate for Payer: Fidelis Essential Plan QHP |
$26.71
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.01
|
| Rate for Payer: Fidelis Qualified Health Plan |
$26.71
|
| Rate for Payer: Group Health Inc Commercial |
$30.01
|
| Rate for Payer: Group Health Inc Medicare |
$30.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.01
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$30.01
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.51
|
| Rate for Payer: Healthfirst QHP |
$30.01
|
| Rate for Payer: Humana Medicare |
$30.61
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$124.87
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$28.51
|
| Rate for Payer: Wellcare Medicare |
$28.51
|
|
