|
PR ESRD RELATED SVC MONTHLY 12-19 YR OLD 2/3 VISITS
|
Professional
|
Both
|
$2,015.62
|
|
|
Service Code
|
HCPCS 90958
|
| Min. Negotiated Rate |
$221.58 |
| Max. Negotiated Rate |
$1,236.91 |
| Rate for Payer: Amida Care Medicaid |
$221.58
|
| Rate for Payer: Cash Price |
$553.91
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$549.74
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$494.77
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$494.77
|
| Rate for Payer: Fidelis Essential Plan QHP |
$522.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$549.74
|
| Rate for Payer: Fidelis Qualified Health Plan |
$522.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$549.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$549.74
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$412.31
|
| Rate for Payer: Healthfirst Commercial |
$549.74
|
| Rate for Payer: Healthfirst Essential Plan |
$1,236.91
|
| Rate for Payer: Healthfirst Medicare Advantage |
$522.25
|
| Rate for Payer: Healthfirst QHP |
$549.74
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$384.82
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$549.74
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$467.28
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$384.82
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$549.74
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$412.31
|
| Rate for Payer: SOMOS Essential |
$412.31
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$549.74
|
|
|
PR ESRD RELATED SVC MONTHLY 12-19 YR OLD 4/> VISITS
|
Professional
|
Both
|
$3,100.30
|
|
|
Service Code
|
HCPCS 90957
|
| Min. Negotiated Rate |
$328.00 |
| Max. Negotiated Rate |
$1,896.19 |
| Rate for Payer: Amida Care Medicaid |
$328.00
|
| Rate for Payer: Cash Price |
$850.59
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$842.75
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$758.48
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$758.48
|
| Rate for Payer: Fidelis Essential Plan QHP |
$800.61
|
| Rate for Payer: Fidelis Medicare Advantage |
$842.75
|
| Rate for Payer: Fidelis Qualified Health Plan |
$800.61
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$842.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$842.75
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$632.06
|
| Rate for Payer: Healthfirst Commercial |
$842.75
|
| Rate for Payer: Healthfirst Essential Plan |
$1,896.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$800.61
|
| Rate for Payer: Healthfirst QHP |
$842.75
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$589.92
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$842.75
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$716.34
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$589.92
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$842.75
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$632.06
|
| Rate for Payer: SOMOS Essential |
$632.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$842.75
|
|
|
PR ESRD RELATED SVC MONTHLY 20&/>YR OLD 1 VISIT
|
Professional
|
Both
|
$819.28
|
|
|
Service Code
|
HCPCS 90962
|
| Min. Negotiated Rate |
$85.17 |
| Max. Negotiated Rate |
$506.79 |
| Rate for Payer: Amida Care Medicaid |
$85.17
|
| Rate for Payer: Cash Price |
$225.88
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$225.24
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$202.72
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$202.72
|
| Rate for Payer: Fidelis Essential Plan QHP |
$213.98
|
| Rate for Payer: Fidelis Medicare Advantage |
$225.24
|
| Rate for Payer: Fidelis Qualified Health Plan |
$213.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$225.24
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$225.24
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$168.93
|
| Rate for Payer: Healthfirst Commercial |
$225.24
|
| Rate for Payer: Healthfirst Essential Plan |
$506.79
|
| Rate for Payer: Healthfirst Medicare Advantage |
$213.98
|
| Rate for Payer: Healthfirst QHP |
$225.24
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$157.67
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$225.24
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$191.45
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$157.67
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$225.24
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$168.93
|
| Rate for Payer: SOMOS Essential |
$168.93
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$225.24
|
|
|
PR ESRD RELATED SVC MONTHLY 20/>YR OLD 2/3 VISITS
|
Professional
|
Both
|
$1,186.89
|
|
|
Service Code
|
HCPCS 90961
|
| Min. Negotiated Rate |
$118.05 |
| Max. Negotiated Rate |
$731.90 |
| Rate for Payer: Amida Care Medicaid |
$118.05
|
| Rate for Payer: Cash Price |
$326.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$325.29
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$292.76
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$292.76
|
| Rate for Payer: Fidelis Essential Plan QHP |
$309.03
|
| Rate for Payer: Fidelis Medicare Advantage |
$325.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$309.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$325.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$325.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$243.97
|
| Rate for Payer: Healthfirst Commercial |
$325.29
|
| Rate for Payer: Healthfirst Essential Plan |
$731.90
|
| Rate for Payer: Healthfirst Medicare Advantage |
$309.03
|
| Rate for Payer: Healthfirst QHP |
$325.29
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$227.70
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$325.29
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$276.50
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$227.70
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$325.29
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$243.97
|
| Rate for Payer: SOMOS Essential |
$243.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$325.29
|
|
|
PR ESRD RELATED SVC MONTHLY 20&/> YR OLD 4/> VISITS
|
Professional
|
Both
|
$1,423.14
|
|
|
Service Code
|
HCPCS 90960
|
| Min. Negotiated Rate |
$146.47 |
| Max. Negotiated Rate |
$880.97 |
| Rate for Payer: Amida Care Medicaid |
$146.47
|
| Rate for Payer: Cash Price |
$392.20
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$391.54
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$352.39
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$352.39
|
| Rate for Payer: Fidelis Essential Plan QHP |
$371.96
|
| Rate for Payer: Fidelis Medicare Advantage |
$391.54
|
| Rate for Payer: Fidelis Qualified Health Plan |
$371.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$391.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$391.54
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$293.65
|
| Rate for Payer: Healthfirst Commercial |
$391.54
|
| Rate for Payer: Healthfirst Essential Plan |
$880.97
|
| Rate for Payer: Healthfirst Medicare Advantage |
$371.96
|
| Rate for Payer: Healthfirst QHP |
$391.54
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$274.08
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$391.54
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$332.81
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$274.08
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$391.54
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$293.65
|
| Rate for Payer: SOMOS Essential |
$293.65
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$391.54
|
|
|
PR ESRD RELATED SVC MONTHLY 2-11 YR OLD 1 VISIT
|
Professional
|
Both
|
$1,397.06
|
|
|
Service Code
|
HCPCS 90956
|
| Min. Negotiated Rate |
$156.82 |
| Max. Negotiated Rate |
$864.97 |
| Rate for Payer: Amida Care Medicaid |
$156.82
|
| Rate for Payer: Cash Price |
$385.86
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$384.43
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$345.99
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$345.99
|
| Rate for Payer: Fidelis Essential Plan QHP |
$365.21
|
| Rate for Payer: Fidelis Medicare Advantage |
$384.43
|
| Rate for Payer: Fidelis Qualified Health Plan |
$365.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$384.43
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$384.43
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$288.32
|
| Rate for Payer: Healthfirst Commercial |
$384.43
|
| Rate for Payer: Healthfirst Essential Plan |
$864.97
|
| Rate for Payer: Healthfirst Medicare Advantage |
$365.21
|
| Rate for Payer: Healthfirst QHP |
$384.43
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$269.10
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$384.43
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$326.77
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$269.10
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$384.43
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$288.32
|
| Rate for Payer: SOMOS Essential |
$288.32
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$384.43
|
|
|
PR ESRD RELATED SVC MONTHLY 2-11 YR OLD 2/3 VISITS
|
Professional
|
Both
|
$2,090.80
|
|
|
Service Code
|
HCPCS 90955
|
| Min. Negotiated Rate |
$231.52 |
| Max. Negotiated Rate |
$1,291.88 |
| Rate for Payer: Amida Care Medicaid |
$231.52
|
| Rate for Payer: Cash Price |
$578.86
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$574.17
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$516.75
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$516.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$545.46
|
| Rate for Payer: Fidelis Medicare Advantage |
$574.17
|
| Rate for Payer: Fidelis Qualified Health Plan |
$545.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$574.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$574.17
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$430.63
|
| Rate for Payer: Healthfirst Commercial |
$574.17
|
| Rate for Payer: Healthfirst Essential Plan |
$1,291.88
|
| Rate for Payer: Healthfirst Medicare Advantage |
$545.46
|
| Rate for Payer: Healthfirst QHP |
$574.17
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$401.92
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$574.17
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$488.04
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$401.92
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$574.17
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$430.63
|
| Rate for Payer: SOMOS Essential |
$430.63
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$574.17
|
|
|
PR ESRD RELATED SVC MONTHLY 2-11 YR OLD 4/> VISITS
|
Professional
|
Both
|
$4,053.39
|
|
|
Service Code
|
HCPCS 90954
|
| Min. Negotiated Rate |
$407.68 |
| Max. Negotiated Rate |
$2,468.39 |
| Rate for Payer: Amida Care Medicaid |
$407.68
|
| Rate for Payer: Cash Price |
$1,109.37
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,097.06
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$987.35
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$987.35
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,042.21
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,097.06
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,042.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,097.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,097.06
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$822.79
|
| Rate for Payer: Healthfirst Commercial |
$1,097.06
|
| Rate for Payer: Healthfirst Essential Plan |
$2,468.39
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,042.21
|
| Rate for Payer: Healthfirst QHP |
$1,097.06
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$767.94
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,097.06
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$932.50
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$767.94
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,097.06
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$822.79
|
| Rate for Payer: SOMOS Essential |
$822.79
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,097.06
|
|
|
PR ESRD RELATED SVC MONTHLY & <2 YR OLD 4/> VISITS
|
Professional
|
Both
|
$4,741.84
|
|
|
Service Code
|
HCPCS 90951
|
| Min. Negotiated Rate |
$499.15 |
| Max. Negotiated Rate |
$2,871.65 |
| Rate for Payer: Amida Care Medicaid |
$499.15
|
| Rate for Payer: Cash Price |
$1,297.48
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,276.29
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,148.66
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,148.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,212.48
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,276.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,212.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,276.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,276.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$957.22
|
| Rate for Payer: Healthfirst Commercial |
$1,276.29
|
| Rate for Payer: Healthfirst Essential Plan |
$2,871.65
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,212.48
|
| Rate for Payer: Healthfirst QHP |
$1,276.29
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$893.40
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,276.29
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1,084.85
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$893.40
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,276.29
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$957.22
|
| Rate for Payer: SOMOS Essential |
$957.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,276.29
|
|
|
PR ESRD SVC HOME DIALYSIS FULL MONTH 12-19 YR OLD
|
Professional
|
Both
|
$2,009.84
|
|
|
Service Code
|
HCPCS 90965
|
| Min. Negotiated Rate |
$222.71 |
| Max. Negotiated Rate |
$1,235.00 |
| Rate for Payer: Amida Care Medicaid |
$222.71
|
| Rate for Payer: Cash Price |
$553.04
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$548.89
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$494.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$494.00
|
| Rate for Payer: Fidelis Essential Plan QHP |
$521.45
|
| Rate for Payer: Fidelis Medicare Advantage |
$548.89
|
| Rate for Payer: Fidelis Qualified Health Plan |
$521.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$548.89
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$548.89
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$411.67
|
| Rate for Payer: Healthfirst Commercial |
$548.89
|
| Rate for Payer: Healthfirst Essential Plan |
$1,235.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$521.45
|
| Rate for Payer: Healthfirst QHP |
$548.89
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$384.22
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$548.89
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$466.56
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$384.22
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$548.89
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$411.67
|
| Rate for Payer: SOMOS Essential |
$411.67
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$548.89
|
|
|
PR ESRD SVC HOME DIALYSIS FULL MONTH 20 YR OLD
|
Professional
|
Both
|
$1,185.45
|
|
|
Service Code
|
HCPCS 90966
|
| Min. Negotiated Rate |
$116.68 |
| Max. Negotiated Rate |
$731.90 |
| Rate for Payer: Amida Care Medicaid |
$116.68
|
| Rate for Payer: Cash Price |
$326.15
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$325.29
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$292.76
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$292.76
|
| Rate for Payer: Fidelis Essential Plan QHP |
$309.03
|
| Rate for Payer: Fidelis Medicare Advantage |
$325.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$309.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$325.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$325.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$243.97
|
| Rate for Payer: Healthfirst Commercial |
$325.29
|
| Rate for Payer: Healthfirst Essential Plan |
$731.90
|
| Rate for Payer: Healthfirst Medicare Advantage |
$309.03
|
| Rate for Payer: Healthfirst QHP |
$325.29
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$227.70
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$325.29
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$276.50
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$227.70
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$325.29
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$243.97
|
| Rate for Payer: SOMOS Essential |
$243.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$325.29
|
|
|
PR ESRD SVC HOME DIALYSIS FULL MONTH 2-11 YR OLD
|
Professional
|
Both
|
$2,102.77
|
|
|
Service Code
|
HCPCS 90964
|
| Min. Negotiated Rate |
$234.17 |
| Max. Negotiated Rate |
$1,281.40 |
| Rate for Payer: Amida Care Medicaid |
$234.17
|
| Rate for Payer: Cash Price |
$576.35
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$569.51
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$512.56
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$512.56
|
| Rate for Payer: Fidelis Essential Plan QHP |
$541.03
|
| Rate for Payer: Fidelis Medicare Advantage |
$569.51
|
| Rate for Payer: Fidelis Qualified Health Plan |
$541.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$569.51
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$569.51
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$427.13
|
| Rate for Payer: Healthfirst Commercial |
$569.51
|
| Rate for Payer: Healthfirst Essential Plan |
$1,281.40
|
| Rate for Payer: Healthfirst Medicare Advantage |
$541.03
|
| Rate for Payer: Healthfirst QHP |
$569.51
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$398.66
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$569.51
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$484.08
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$398.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$569.51
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$427.13
|
| Rate for Payer: SOMOS Essential |
$427.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$569.51
|
|
|
PR ESRD SVC HOME DIALYSIS FULL MONTH <2YR OLD
|
Professional
|
Both
|
$2,446.82
|
|
|
Service Code
|
HCPCS 90963
|
| Min. Negotiated Rate |
$281.63 |
| Max. Negotiated Rate |
$1,493.98 |
| Rate for Payer: Amida Care Medicaid |
$281.63
|
| Rate for Payer: Cash Price |
$671.76
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$663.99
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$597.59
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$597.59
|
| Rate for Payer: Fidelis Essential Plan QHP |
$630.79
|
| Rate for Payer: Fidelis Medicare Advantage |
$663.99
|
| Rate for Payer: Fidelis Qualified Health Plan |
$630.79
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$663.99
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$663.99
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$497.99
|
| Rate for Payer: Healthfirst Commercial |
$663.99
|
| Rate for Payer: Healthfirst Essential Plan |
$1,493.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$630.79
|
| Rate for Payer: Healthfirst QHP |
$663.99
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$464.79
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$663.99
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$564.39
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$464.79
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$663.99
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$497.99
|
| Rate for Payer: SOMOS Essential |
$497.99
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$663.99
|
|
|
PRESSURE ULCERS
|
Facility
|
OP
|
$253.91
|
|
|
Service Code
|
EAPG 00676
|
| Min. Negotiated Rate |
$185.14 |
| Max. Negotiated Rate |
$253.91 |
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$185.14
|
| Rate for Payer: Healthfirst Commercial |
$253.91
|
|
|
PR ESWT HI NRG PHYS/QHP W/US GDN INVG PLNTAR FASCIA
|
Professional
|
Both
|
$912.80
|
|
|
Service Code
|
HCPCS 28890
|
| Min. Negotiated Rate |
$177.91 |
| Max. Negotiated Rate |
$571.86 |
| Rate for Payer: Cash Price |
$257.35
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$254.16
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$228.74
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$228.74
|
| Rate for Payer: Fidelis Essential Plan QHP |
$241.45
|
| Rate for Payer: Fidelis Medicare Advantage |
$254.16
|
| Rate for Payer: Fidelis Qualified Health Plan |
$241.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$254.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$254.16
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$190.62
|
| Rate for Payer: Healthfirst Commercial |
$254.16
|
| Rate for Payer: Healthfirst Essential Plan |
$571.86
|
| Rate for Payer: Healthfirst Medicare Advantage |
$241.45
|
| Rate for Payer: Healthfirst QHP |
$254.16
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$177.91
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$254.16
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$216.04
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$177.91
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$254.16
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$190.62
|
| Rate for Payer: SOMOS Essential |
$190.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$254.16
|
|
|
Preterm labor
|
Facility
|
IP
|
$42,474.17
|
|
|
Service Code
|
APR-DRG 5634
|
| Min. Negotiated Rate |
$6,998.00 |
| Max. Negotiated Rate |
$42,474.17 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$42,474.17
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$42,474.17
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$18,877.41
|
| Rate for Payer: Amida Care Medicaid |
$18,877.41
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$42,474.17
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$18,877.41
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$18,877.41
|
| Rate for Payer: Fidelis Qualified Health Plan |
$22,652.89
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18,877.41
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18,877.41
|
| Rate for Payer: Healthfirst Commercial |
$11,832.00
|
| Rate for Payer: Healthfirst Essential Plan |
$42,474.17
|
| Rate for Payer: Healthfirst QHP |
$6,998.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$18,877.41
|
| Rate for Payer: SOMOS Essential |
$42,474.17
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$42,474.17
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$42,474.17
|
| Rate for Payer: United Healthcare Medicaid |
$18,877.41
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$18,877.41
|
|
|
Preterm labor
|
Facility
|
IP
|
$39,382.29
|
|
|
Service Code
|
APR-DRG 5632
|
| Min. Negotiated Rate |
$5,176.00 |
| Max. Negotiated Rate |
$39,382.29 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$39,382.29
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$39,382.29
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$17,503.24
|
| Rate for Payer: Amida Care Medicaid |
$17,503.24
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$39,382.29
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$17,503.24
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$17,503.24
|
| Rate for Payer: Fidelis Qualified Health Plan |
$21,003.89
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$17,503.24
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$17,503.24
|
| Rate for Payer: Healthfirst Commercial |
$8,978.00
|
| Rate for Payer: Healthfirst Essential Plan |
$39,382.29
|
| Rate for Payer: Healthfirst QHP |
$5,176.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$17,503.24
|
| Rate for Payer: SOMOS Essential |
$39,382.29
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$39,382.29
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$39,382.29
|
| Rate for Payer: United Healthcare Medicaid |
$17,503.24
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$17,503.24
|
|
|
Preterm labor
|
Facility
|
IP
|
$42,474.17
|
|
|
Service Code
|
APR-DRG 5633
|
| Min. Negotiated Rate |
$6,947.00 |
| Max. Negotiated Rate |
$42,474.17 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$42,474.17
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$42,474.17
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$18,877.41
|
| Rate for Payer: Amida Care Medicaid |
$18,877.41
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$42,474.17
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$18,877.41
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$18,877.41
|
| Rate for Payer: Fidelis Qualified Health Plan |
$22,652.89
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18,877.41
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18,877.41
|
| Rate for Payer: Healthfirst Commercial |
$11,588.00
|
| Rate for Payer: Healthfirst Essential Plan |
$42,474.17
|
| Rate for Payer: Healthfirst QHP |
$6,947.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$18,877.41
|
| Rate for Payer: SOMOS Essential |
$42,474.17
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$42,474.17
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$42,474.17
|
| Rate for Payer: United Healthcare Medicaid |
$18,877.41
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$18,877.41
|
|
|
Preterm labor
|
Facility
|
IP
|
$38,137.10
|
|
|
Service Code
|
APR-DRG 5631
|
| Min. Negotiated Rate |
$4,395.00 |
| Max. Negotiated Rate |
$38,137.10 |
| Rate for Payer: Affinity Essential Plan 1&2 |
$38,137.10
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$38,137.10
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$16,949.82
|
| Rate for Payer: Amida Care Medicaid |
$16,949.82
|
| Rate for Payer: EmblemHealth Essential Plan 1&2 |
$38,137.10
|
| Rate for Payer: EmblemHealth Essential Plan 3&4 |
$16,949.82
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16,949.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$20,339.78
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16,949.82
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$16,949.82
|
| Rate for Payer: Healthfirst Commercial |
$7,801.00
|
| Rate for Payer: Healthfirst Essential Plan |
$38,137.10
|
| Rate for Payer: Healthfirst QHP |
$4,395.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$16,949.82
|
| Rate for Payer: SOMOS Essential |
$38,137.10
|
| Rate for Payer: United Healthcare Essential Plan 1&2 |
$38,137.10
|
| Rate for Payer: United Healthcare Essential Plan 3&4 |
$38,137.10
|
| Rate for Payer: United Healthcare Medicaid |
$16,949.82
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$16,949.82
|
|
|
PRETERM LABOR DIAGNOSES
|
Facility
|
OP
|
$295.27
|
|
|
Service Code
|
EAPG 00762
|
| Min. Negotiated Rate |
$215.23 |
| Max. Negotiated Rate |
$295.27 |
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$215.23
|
| Rate for Payer: Healthfirst Commercial |
$295.27
|
|
|
PR ETHMOIDECTOMY EXTRANASAL TOTAL
|
Professional
|
Both
|
$3,977.47
|
|
|
Service Code
|
HCPCS 31205
|
| Min. Negotiated Rate |
$747.60 |
| Max. Negotiated Rate |
$2,403.00 |
| Rate for Payer: Cash Price |
$1,088.99
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,068.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$961.20
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$961.20
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,014.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,068.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,014.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,068.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,068.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$801.00
|
| Rate for Payer: Healthfirst Commercial |
$1,068.00
|
| Rate for Payer: Healthfirst Essential Plan |
$2,403.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,014.60
|
| Rate for Payer: Healthfirst QHP |
$1,068.00
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$747.60
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,068.00
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$907.80
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$747.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,068.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$801.00
|
| Rate for Payer: SOMOS Essential |
$801.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,068.00
|
|
|
PR ETHMOIDECTOMY INTRANASAL ANTERIOR
|
Professional
|
Both
|
$2,668.86
|
|
|
Service Code
|
HCPCS 31200
|
| Min. Negotiated Rate |
$500.50 |
| Max. Negotiated Rate |
$1,608.75 |
| Rate for Payer: Cash Price |
$730.39
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$715.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$643.50
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$643.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$679.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$715.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$679.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$715.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$715.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$536.25
|
| Rate for Payer: Healthfirst Commercial |
$715.00
|
| Rate for Payer: Healthfirst Essential Plan |
$1,608.75
|
| Rate for Payer: Healthfirst Medicare Advantage |
$679.25
|
| Rate for Payer: Healthfirst QHP |
$715.00
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$500.50
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$715.00
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$607.75
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$500.50
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$715.00
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$536.25
|
| Rate for Payer: SOMOS Essential |
$536.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$715.00
|
|
|
PR ETHMOIDECTOMY INTRANASAL TOTAL
|
Professional
|
Both
|
$3,475.64
|
|
|
Service Code
|
HCPCS 31201
|
| Min. Negotiated Rate |
$629.37 |
| Max. Negotiated Rate |
$2,022.97 |
| Rate for Payer: Cash Price |
$916.44
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$899.10
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$809.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$809.19
|
| Rate for Payer: Fidelis Essential Plan QHP |
$854.14
|
| Rate for Payer: Fidelis Medicare Advantage |
$899.10
|
| Rate for Payer: Fidelis Qualified Health Plan |
$854.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$899.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$899.10
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$674.33
|
| Rate for Payer: Healthfirst Commercial |
$899.10
|
| Rate for Payer: Healthfirst Essential Plan |
$2,022.97
|
| Rate for Payer: Healthfirst Medicare Advantage |
$854.14
|
| Rate for Payer: Healthfirst QHP |
$899.10
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$629.37
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$899.10
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$764.24
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$629.37
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$899.10
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$674.33
|
| Rate for Payer: SOMOS Essential |
$674.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$899.10
|
|
|
PR EVACUATION SUBUNGUAL HEMATOMA
|
Professional
|
Both
|
$134.93
|
|
|
Service Code
|
HCPCS 11740
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$84.38 |
| Rate for Payer: Cash Price |
$37.18
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$37.50
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$33.75
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$33.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$35.62
|
| Rate for Payer: Fidelis Medicare Advantage |
$37.50
|
| Rate for Payer: Fidelis Qualified Health Plan |
$35.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$37.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$37.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$28.12
|
| Rate for Payer: Healthfirst Commercial |
$37.50
|
| Rate for Payer: Healthfirst Essential Plan |
$84.38
|
| Rate for Payer: Healthfirst Medicare Advantage |
$35.62
|
| Rate for Payer: Healthfirst QHP |
$37.50
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$26.25
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$37.50
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$31.88
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$26.25
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$37.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$28.12
|
| Rate for Payer: SOMOS Essential |
$28.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$37.50
|
|
|
PR EVAL AUD FUNCJ CAND/PO SURG IMPLT DEV 1ST HR
|
Professional
|
Both
|
$296.98
|
|
|
Service Code
|
HCPCS 92626
|
| Min. Negotiated Rate |
$56.69 |
| Max. Negotiated Rate |
$182.21 |
| Rate for Payer: Cash Price |
$81.19
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$80.98
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$72.88
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$72.88
|
| Rate for Payer: Fidelis Essential Plan QHP |
$76.93
|
| Rate for Payer: Fidelis Medicare Advantage |
$80.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$76.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$80.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$80.98
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$60.73
|
| Rate for Payer: Healthfirst Commercial |
$80.98
|
| Rate for Payer: Healthfirst Essential Plan |
$182.21
|
| Rate for Payer: Healthfirst Medicare Advantage |
$76.93
|
| Rate for Payer: Healthfirst QHP |
$80.98
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$56.69
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$80.98
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$68.83
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$56.69
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$80.98
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$60.73
|
| Rate for Payer: SOMOS Essential |
$60.73
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$80.98
|
|
