|
PR REPAIR EXTENSOR TENDON DISTAL INSERTION W/O GRF
|
Professional
|
Both
|
$2,541.49
|
|
|
Service Code
|
HCPCS 26433
|
| Min. Negotiated Rate |
$469.31 |
| Max. Negotiated Rate |
$1,508.51 |
| Rate for Payer: Cash Price |
$684.04
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$670.45
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$603.40
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$603.40
|
| Rate for Payer: Fidelis Essential Plan QHP |
$636.93
|
| Rate for Payer: Fidelis Medicare Advantage |
$670.45
|
| Rate for Payer: Fidelis Qualified Health Plan |
$636.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$670.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$670.45
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$502.84
|
| Rate for Payer: Healthfirst Commercial |
$670.45
|
| Rate for Payer: Healthfirst Essential Plan |
$1,508.51
|
| Rate for Payer: Healthfirst Medicare Advantage |
$636.93
|
| Rate for Payer: Healthfirst QHP |
$670.45
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$469.31
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$670.45
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$569.88
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$469.31
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$670.45
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$502.84
|
| Rate for Payer: SOMOS Essential |
$502.84
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$670.45
|
|
|
PR REPAIR EXTENSOR TENDON FINGER W/GRAFT EACH
|
Professional
|
Both
|
$3,289.44
|
|
|
Service Code
|
HCPCS 26420
|
| Min. Negotiated Rate |
$608.08 |
| Max. Negotiated Rate |
$1,954.53 |
| Rate for Payer: Cash Price |
$887.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$868.68
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$781.81
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$781.81
|
| Rate for Payer: Fidelis Essential Plan QHP |
$825.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$868.68
|
| Rate for Payer: Fidelis Qualified Health Plan |
$825.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$868.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$868.68
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$651.51
|
| Rate for Payer: Healthfirst Commercial |
$868.68
|
| Rate for Payer: Healthfirst Essential Plan |
$1,954.53
|
| Rate for Payer: Healthfirst Medicare Advantage |
$825.25
|
| Rate for Payer: Healthfirst QHP |
$868.68
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$608.08
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$868.68
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$738.38
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$608.08
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$868.68
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$651.51
|
| Rate for Payer: SOMOS Essential |
$651.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$868.68
|
|
|
PR REPAIR EXTENSOR TENDON FINGER W/O GRAFT EACH
|
Professional
|
Both
|
$2,762.24
|
|
|
Service Code
|
HCPCS 26418
|
| Min. Negotiated Rate |
$513.12 |
| Max. Negotiated Rate |
$1,649.32 |
| Rate for Payer: Cash Price |
$748.40
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$733.03
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$659.73
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$659.73
|
| Rate for Payer: Fidelis Essential Plan QHP |
$696.38
|
| Rate for Payer: Fidelis Medicare Advantage |
$733.03
|
| Rate for Payer: Fidelis Qualified Health Plan |
$696.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$733.03
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$733.03
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$549.77
|
| Rate for Payer: Healthfirst Commercial |
$733.03
|
| Rate for Payer: Healthfirst Essential Plan |
$1,649.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$696.38
|
| Rate for Payer: Healthfirst QHP |
$733.03
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$513.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$733.03
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$623.08
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$513.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$733.03
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$549.77
|
| Rate for Payer: SOMOS Essential |
$549.77
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$733.03
|
|
|
PR REPAIR EXTENSOR TENDON HAND W/GRAFT EACH
|
Professional
|
Both
|
$3,176.88
|
|
|
Service Code
|
HCPCS 26412
|
| Min. Negotiated Rate |
$587.16 |
| Max. Negotiated Rate |
$1,887.30 |
| Rate for Payer: Cash Price |
$855.24
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$838.80
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$754.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$754.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$796.86
|
| Rate for Payer: Fidelis Medicare Advantage |
$838.80
|
| Rate for Payer: Fidelis Qualified Health Plan |
$796.86
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$838.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$838.80
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$629.10
|
| Rate for Payer: Healthfirst Commercial |
$838.80
|
| Rate for Payer: Healthfirst Essential Plan |
$1,887.30
|
| Rate for Payer: Healthfirst Medicare Advantage |
$796.86
|
| Rate for Payer: Healthfirst QHP |
$838.80
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$587.16
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$838.80
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$712.98
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$587.16
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$838.80
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$629.10
|
| Rate for Payer: SOMOS Essential |
$629.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$838.80
|
|
|
PR REPAIR EXTENSOR TENDON HAND W/O GRAFT EACH
|
Professional
|
Both
|
$2,666.58
|
|
|
Service Code
|
HCPCS 26410
|
| Min. Negotiated Rate |
$493.44 |
| Max. Negotiated Rate |
$1,586.07 |
| Rate for Payer: Cash Price |
$719.79
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$704.92
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$634.43
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$634.43
|
| Rate for Payer: Fidelis Essential Plan QHP |
$669.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$704.92
|
| Rate for Payer: Fidelis Qualified Health Plan |
$669.67
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$704.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$704.92
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$528.69
|
| Rate for Payer: Healthfirst Commercial |
$704.92
|
| Rate for Payer: Healthfirst Essential Plan |
$1,586.07
|
| Rate for Payer: Healthfirst Medicare Advantage |
$669.67
|
| Rate for Payer: Healthfirst QHP |
$704.92
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$493.44
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$704.92
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$599.18
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$493.44
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$704.92
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$528.69
|
| Rate for Payer: SOMOS Essential |
$528.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$704.92
|
|
|
PR REPAIR FASCIAL DEFECT LEG
|
Professional
|
Both
|
$1,493.70
|
|
|
Service Code
|
HCPCS 27656
|
| Min. Negotiated Rate |
$276.86 |
| Max. Negotiated Rate |
$889.92 |
| Rate for Payer: Cash Price |
$401.71
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$395.52
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$355.97
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$355.97
|
| Rate for Payer: Fidelis Essential Plan QHP |
$375.74
|
| Rate for Payer: Fidelis Medicare Advantage |
$395.52
|
| Rate for Payer: Fidelis Qualified Health Plan |
$375.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$395.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$395.52
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$296.64
|
| Rate for Payer: Healthfirst Commercial |
$395.52
|
| Rate for Payer: Healthfirst Essential Plan |
$889.92
|
| Rate for Payer: Healthfirst Medicare Advantage |
$375.74
|
| Rate for Payer: Healthfirst QHP |
$395.52
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$276.86
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$395.52
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$336.19
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$276.86
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$395.52
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$296.64
|
| Rate for Payer: SOMOS Essential |
$296.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$395.52
|
|
|
PR REPAIR FIBULA NONUNION/MALUNION W/INT FIXATION
|
Professional
|
Both
|
$4,215.12
|
|
|
Service Code
|
HCPCS 27726
|
| Min. Negotiated Rate |
$792.86 |
| Max. Negotiated Rate |
$2,548.46 |
| Rate for Payer: Cash Price |
$1,134.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$1,132.65
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$1,019.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$1,019.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$1,076.02
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,132.65
|
| Rate for Payer: Fidelis Qualified Health Plan |
$1,076.02
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,132.65
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,132.65
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$849.49
|
| Rate for Payer: Healthfirst Commercial |
$1,132.65
|
| Rate for Payer: Healthfirst Essential Plan |
$2,548.46
|
| Rate for Payer: Healthfirst Medicare Advantage |
$1,076.02
|
| Rate for Payer: Healthfirst QHP |
$1,132.65
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$792.86
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1,132.65
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$962.75
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$792.86
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$1,132.65
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$849.49
|
| Rate for Payer: SOMOS Essential |
$849.49
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,132.65
|
|
|
PR REPAIR FISTULA OROMAXILLARY
|
Professional
|
Both
|
$1,942.92
|
|
|
Service Code
|
HCPCS 30580
|
| Min. Negotiated Rate |
$372.43 |
| Max. Negotiated Rate |
$1,197.09 |
| Rate for Payer: Cash Price |
$530.40
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$532.04
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$478.84
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$478.84
|
| Rate for Payer: Fidelis Essential Plan QHP |
$505.44
|
| Rate for Payer: Fidelis Medicare Advantage |
$532.04
|
| Rate for Payer: Fidelis Qualified Health Plan |
$505.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$532.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$532.04
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$399.03
|
| Rate for Payer: Healthfirst Commercial |
$532.04
|
| Rate for Payer: Healthfirst Essential Plan |
$1,197.09
|
| Rate for Payer: Healthfirst Medicare Advantage |
$505.44
|
| Rate for Payer: Healthfirst QHP |
$532.04
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$372.43
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$532.04
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$452.23
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$372.43
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$532.04
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$399.03
|
| Rate for Payer: SOMOS Essential |
$399.03
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$532.04
|
|
|
PR REPAIR FISTULA ORONASAL
|
Professional
|
Both
|
$1,608.71
|
|
|
Service Code
|
HCPCS 30600
|
| Min. Negotiated Rate |
$312.26 |
| Max. Negotiated Rate |
$1,003.70 |
| Rate for Payer: Cash Price |
$440.73
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$446.09
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$401.48
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$401.48
|
| Rate for Payer: Fidelis Essential Plan QHP |
$423.79
|
| Rate for Payer: Fidelis Medicare Advantage |
$446.09
|
| Rate for Payer: Fidelis Qualified Health Plan |
$423.79
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$446.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$446.09
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$334.57
|
| Rate for Payer: Healthfirst Commercial |
$446.09
|
| Rate for Payer: Healthfirst Essential Plan |
$1,003.70
|
| Rate for Payer: Healthfirst Medicare Advantage |
$423.79
|
| Rate for Payer: Healthfirst QHP |
$446.09
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$312.26
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$446.09
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$379.18
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$312.26
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$446.09
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$334.57
|
| Rate for Payer: SOMOS Essential |
$334.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$446.09
|
|
|
PR REPAIR FLEXOR TENDON LEG PRIMARY W/O GRAFT EACH
|
Professional
|
Both
|
$1,597.12
|
|
|
Service Code
|
HCPCS 27658
|
| Min. Negotiated Rate |
$305.31 |
| Max. Negotiated Rate |
$981.34 |
| Rate for Payer: Cash Price |
$436.02
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$436.15
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$392.54
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$392.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$414.34
|
| Rate for Payer: Fidelis Medicare Advantage |
$436.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$414.34
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$436.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$436.15
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$327.11
|
| Rate for Payer: Healthfirst Commercial |
$436.15
|
| Rate for Payer: Healthfirst Essential Plan |
$981.34
|
| Rate for Payer: Healthfirst Medicare Advantage |
$414.34
|
| Rate for Payer: Healthfirst QHP |
$436.15
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$305.31
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$436.15
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$370.73
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$305.31
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$436.15
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$327.11
|
| Rate for Payer: SOMOS Essential |
$327.11
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$436.15
|
|
|
PR REPAIR INCOMPLETE CIRCUMCISION
|
Professional
|
Both
|
$923.44
|
|
|
Service Code
|
HCPCS 54163
|
| Min. Negotiated Rate |
$177.25 |
| Max. Negotiated Rate |
$569.72 |
| Rate for Payer: Cash Price |
$254.36
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$253.21
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$227.89
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$227.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$240.55
|
| Rate for Payer: Fidelis Medicare Advantage |
$253.21
|
| Rate for Payer: Fidelis Qualified Health Plan |
$240.55
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$253.21
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$253.21
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$189.91
|
| Rate for Payer: Healthfirst Commercial |
$253.21
|
| Rate for Payer: Healthfirst Essential Plan |
$569.72
|
| Rate for Payer: Healthfirst Medicare Advantage |
$240.55
|
| Rate for Payer: Healthfirst QHP |
$253.21
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$177.25
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$253.21
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$215.23
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$177.25
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$253.21
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$189.91
|
| Rate for Payer: SOMOS Essential |
$189.91
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$253.21
|
|
|
PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 12.6-20.0CM
|
Professional
|
Both
|
$1,308.37
|
|
|
Service Code
|
HCPCS 12055
|
| Min. Negotiated Rate |
$246.43 |
| Max. Negotiated Rate |
$792.09 |
| Rate for Payer: Cash Price |
$354.57
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$352.04
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$316.84
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$316.84
|
| Rate for Payer: Fidelis Essential Plan QHP |
$334.44
|
| Rate for Payer: Fidelis Medicare Advantage |
$352.04
|
| Rate for Payer: Fidelis Qualified Health Plan |
$334.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$352.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$352.04
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$264.03
|
| Rate for Payer: Healthfirst Commercial |
$352.04
|
| Rate for Payer: Healthfirst Essential Plan |
$792.09
|
| Rate for Payer: Healthfirst Medicare Advantage |
$334.44
|
| Rate for Payer: Healthfirst QHP |
$352.04
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$246.43
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$352.04
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$299.23
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$246.43
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$352.04
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$264.03
|
| Rate for Payer: SOMOS Essential |
$264.03
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$352.04
|
|
|
PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 20.1-30.0CM
|
Professional
|
Both
|
$1,674.12
|
|
|
Service Code
|
HCPCS 12056
|
| Min. Negotiated Rate |
$315.85 |
| Max. Negotiated Rate |
$1,015.22 |
| Rate for Payer: Cash Price |
$452.04
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$451.21
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$406.09
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$406.09
|
| Rate for Payer: Fidelis Essential Plan QHP |
$428.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$451.21
|
| Rate for Payer: Fidelis Qualified Health Plan |
$428.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$451.21
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$451.21
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$338.41
|
| Rate for Payer: Healthfirst Commercial |
$451.21
|
| Rate for Payer: Healthfirst Essential Plan |
$1,015.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$428.65
|
| Rate for Payer: Healthfirst QHP |
$451.21
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$315.85
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$451.21
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$383.53
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$315.85
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$451.21
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$338.41
|
| Rate for Payer: SOMOS Essential |
$338.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$451.21
|
|
|
PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/<
|
Professional
|
Both
|
$720.34
|
|
|
Service Code
|
HCPCS 12051
|
| Min. Negotiated Rate |
$136.12 |
| Max. Negotiated Rate |
$437.54 |
| Rate for Payer: Cash Price |
$196.53
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$194.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$175.01
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$175.01
|
| Rate for Payer: Fidelis Essential Plan QHP |
$184.74
|
| Rate for Payer: Fidelis Medicare Advantage |
$194.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$184.74
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$194.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$194.46
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$145.84
|
| Rate for Payer: Healthfirst Commercial |
$194.46
|
| Rate for Payer: Healthfirst Essential Plan |
$437.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$184.74
|
| Rate for Payer: Healthfirst QHP |
$194.46
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$136.12
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$194.46
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$165.29
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$136.12
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$194.46
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$145.84
|
| Rate for Payer: SOMOS Essential |
$145.84
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$194.46
|
|
|
PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM
|
Professional
|
Both
|
$844.80
|
|
|
Service Code
|
HCPCS 12052
|
| Min. Negotiated Rate |
$160.43 |
| Max. Negotiated Rate |
$515.68 |
| Rate for Payer: Cash Price |
$230.04
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$229.19
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$206.27
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$206.27
|
| Rate for Payer: Fidelis Essential Plan QHP |
$217.73
|
| Rate for Payer: Fidelis Medicare Advantage |
$229.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$217.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$229.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$229.19
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$171.89
|
| Rate for Payer: Healthfirst Commercial |
$229.19
|
| Rate for Payer: Healthfirst Essential Plan |
$515.68
|
| Rate for Payer: Healthfirst Medicare Advantage |
$217.73
|
| Rate for Payer: Healthfirst QHP |
$229.19
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$160.43
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$229.19
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$194.81
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$160.43
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$229.19
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$171.89
|
| Rate for Payer: SOMOS Essential |
$171.89
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$229.19
|
|
|
PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC >30.0 CM
|
Professional
|
Both
|
$1,826.13
|
|
|
Service Code
|
HCPCS 12057
|
| Min. Negotiated Rate |
$344.60 |
| Max. Negotiated Rate |
$1,107.65 |
| Rate for Payer: Cash Price |
$493.47
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$492.29
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$443.06
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$443.06
|
| Rate for Payer: Fidelis Essential Plan QHP |
$467.68
|
| Rate for Payer: Fidelis Medicare Advantage |
$492.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$467.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$492.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$492.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$369.22
|
| Rate for Payer: Healthfirst Commercial |
$492.29
|
| Rate for Payer: Healthfirst Essential Plan |
$1,107.65
|
| Rate for Payer: Healthfirst Medicare Advantage |
$467.68
|
| Rate for Payer: Healthfirst QHP |
$492.29
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$344.60
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$492.29
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$418.45
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$344.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$492.29
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$369.22
|
| Rate for Payer: SOMOS Essential |
$369.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$492.29
|
|
|
PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 5.1-7.5 CM
|
Professional
|
Both
|
$914.59
|
|
|
Service Code
|
HCPCS 12053
|
| Min. Negotiated Rate |
$172.93 |
| Max. Negotiated Rate |
$555.84 |
| Rate for Payer: Cash Price |
$248.35
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$247.04
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$222.34
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$222.34
|
| Rate for Payer: Fidelis Essential Plan QHP |
$234.69
|
| Rate for Payer: Fidelis Medicare Advantage |
$247.04
|
| Rate for Payer: Fidelis Qualified Health Plan |
$234.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$247.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$247.04
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$185.28
|
| Rate for Payer: Healthfirst Commercial |
$247.04
|
| Rate for Payer: Healthfirst Essential Plan |
$555.84
|
| Rate for Payer: Healthfirst Medicare Advantage |
$234.69
|
| Rate for Payer: Healthfirst QHP |
$247.04
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$172.93
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$247.04
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$209.98
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$172.93
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$247.04
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$185.28
|
| Rate for Payer: SOMOS Essential |
$185.28
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$247.04
|
|
|
PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 7.6-12.5 CM
|
Professional
|
Both
|
$945.49
|
|
|
Service Code
|
HCPCS 12054
|
| Min. Negotiated Rate |
$177.65 |
| Max. Negotiated Rate |
$571.03 |
| Rate for Payer: Cash Price |
$255.58
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$253.79
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$228.41
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$228.41
|
| Rate for Payer: Fidelis Essential Plan QHP |
$241.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$253.79
|
| Rate for Payer: Fidelis Qualified Health Plan |
$241.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$253.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$253.79
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$190.34
|
| Rate for Payer: Healthfirst Commercial |
$253.79
|
| Rate for Payer: Healthfirst Essential Plan |
$571.03
|
| Rate for Payer: Healthfirst Medicare Advantage |
$241.10
|
| Rate for Payer: Healthfirst QHP |
$253.79
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$177.65
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$253.79
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$215.72
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$177.65
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$253.79
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$190.34
|
| Rate for Payer: SOMOS Essential |
$190.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$253.79
|
|
|
PR REPAIR INTERMEDIATE N/H/F/XTRNL GENT 12.6-20 CM
|
Professional
|
Both
|
$1,194.94
|
|
|
Service Code
|
HCPCS 12045
|
| Min. Negotiated Rate |
$222.78 |
| Max. Negotiated Rate |
$716.09 |
| Rate for Payer: Cash Price |
$322.48
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$318.26
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$286.43
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$286.43
|
| Rate for Payer: Fidelis Essential Plan QHP |
$302.35
|
| Rate for Payer: Fidelis Medicare Advantage |
$318.26
|
| Rate for Payer: Fidelis Qualified Health Plan |
$302.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$318.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$318.26
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$238.69
|
| Rate for Payer: Healthfirst Commercial |
$318.26
|
| Rate for Payer: Healthfirst Essential Plan |
$716.09
|
| Rate for Payer: Healthfirst Medicare Advantage |
$302.35
|
| Rate for Payer: Healthfirst QHP |
$318.26
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$222.78
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$318.26
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$270.52
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$222.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$318.26
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$238.69
|
| Rate for Payer: SOMOS Essential |
$238.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$318.26
|
|
|
PR REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<
|
Professional
|
Both
|
$614.46
|
|
|
Service Code
|
HCPCS 12041
|
| Min. Negotiated Rate |
$117.48 |
| Max. Negotiated Rate |
$377.62 |
| Rate for Payer: Cash Price |
$167.69
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$167.83
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$151.05
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$151.05
|
| Rate for Payer: Fidelis Essential Plan QHP |
$159.44
|
| Rate for Payer: Fidelis Medicare Advantage |
$167.83
|
| Rate for Payer: Fidelis Qualified Health Plan |
$159.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$167.83
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$167.83
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$125.87
|
| Rate for Payer: Healthfirst Commercial |
$167.83
|
| Rate for Payer: Healthfirst Essential Plan |
$377.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$159.44
|
| Rate for Payer: Healthfirst QHP |
$167.83
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$117.48
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$167.83
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$142.66
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$117.48
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$167.83
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$125.87
|
| Rate for Payer: SOMOS Essential |
$125.87
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$167.83
|
|
|
PR REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM
|
Professional
|
Both
|
$822.40
|
|
|
Service Code
|
HCPCS 12042
|
| Min. Negotiated Rate |
$157.37 |
| Max. Negotiated Rate |
$505.82 |
| Rate for Payer: Cash Price |
$225.61
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$224.81
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$202.33
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$202.33
|
| Rate for Payer: Fidelis Essential Plan QHP |
$213.57
|
| Rate for Payer: Fidelis Medicare Advantage |
$224.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$213.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$224.81
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$224.81
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$168.61
|
| Rate for Payer: Healthfirst Commercial |
$224.81
|
| Rate for Payer: Healthfirst Essential Plan |
$505.82
|
| Rate for Payer: Healthfirst Medicare Advantage |
$213.57
|
| Rate for Payer: Healthfirst QHP |
$224.81
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$157.37
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$224.81
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$191.09
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$157.37
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$224.81
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$168.61
|
| Rate for Payer: SOMOS Essential |
$168.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$224.81
|
|
|
PR REPAIR INTERMEDIATE N/H/F/XTRNL GENT >30.0 CM
|
Professional
|
Both
|
$1,587.32
|
|
|
Service Code
|
HCPCS 12047
|
| Min. Negotiated Rate |
$295.34 |
| Max. Negotiated Rate |
$949.32 |
| Rate for Payer: Cash Price |
$424.98
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$421.92
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$379.73
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$379.73
|
| Rate for Payer: Fidelis Essential Plan QHP |
$400.82
|
| Rate for Payer: Fidelis Medicare Advantage |
$421.92
|
| Rate for Payer: Fidelis Qualified Health Plan |
$400.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$421.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$421.92
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$316.44
|
| Rate for Payer: Healthfirst Commercial |
$421.92
|
| Rate for Payer: Healthfirst Essential Plan |
$949.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$400.82
|
| Rate for Payer: Healthfirst QHP |
$421.92
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$295.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$421.92
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$358.63
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$295.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$421.92
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$316.44
|
| Rate for Payer: SOMOS Essential |
$316.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$421.92
|
|
|
PR REPAIR INTERMEDIATE N/H/F/XTRNL GENT 7.6-12.5CM
|
Professional
|
Both
|
$910.95
|
|
|
Service Code
|
HCPCS 12044
|
| Min. Negotiated Rate |
$174.31 |
| Max. Negotiated Rate |
$560.29 |
| Rate for Payer: Cash Price |
$248.64
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$249.02
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$224.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$224.12
|
| Rate for Payer: Fidelis Essential Plan QHP |
$236.57
|
| Rate for Payer: Fidelis Medicare Advantage |
$249.02
|
| Rate for Payer: Fidelis Qualified Health Plan |
$236.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$249.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$249.02
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$186.76
|
| Rate for Payer: Healthfirst Commercial |
$249.02
|
| Rate for Payer: Healthfirst Essential Plan |
$560.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$236.57
|
| Rate for Payer: Healthfirst QHP |
$249.02
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$174.31
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$249.02
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$211.67
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$174.31
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$249.02
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$186.76
|
| Rate for Payer: SOMOS Essential |
$186.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$249.02
|
|
|
PR REPAIR INTERMEDIATE S/A/T/E 12.6-20.0CM
|
Professional
|
Both
|
$1,050.49
|
|
|
Service Code
|
HCPCS 12035
|
| Min. Negotiated Rate |
$197.79 |
| Max. Negotiated Rate |
$635.76 |
| Rate for Payer: Cash Price |
$283.68
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$282.56
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$254.30
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$254.30
|
| Rate for Payer: Fidelis Essential Plan QHP |
$268.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$282.56
|
| Rate for Payer: Fidelis Qualified Health Plan |
$268.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$282.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$282.56
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$211.92
|
| Rate for Payer: Healthfirst Commercial |
$282.56
|
| Rate for Payer: Healthfirst Essential Plan |
$635.76
|
| Rate for Payer: Healthfirst Medicare Advantage |
$268.43
|
| Rate for Payer: Healthfirst QHP |
$282.56
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$197.79
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$282.56
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$240.18
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$197.79
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$282.56
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$211.92
|
| Rate for Payer: SOMOS Essential |
$211.92
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$282.56
|
|
|
PR REPAIR INTERMEDIATE S/A/T/E 20.1-30.0 CM
|
Professional
|
Both
|
$1,235.47
|
|
|
Service Code
|
HCPCS 12036
|
| Min. Negotiated Rate |
$232.95 |
| Max. Negotiated Rate |
$748.78 |
| Rate for Payer: Cash Price |
$334.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$332.79
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$299.51
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$299.51
|
| Rate for Payer: Fidelis Essential Plan QHP |
$316.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$332.79
|
| Rate for Payer: Fidelis Qualified Health Plan |
$316.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$332.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$332.79
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$249.59
|
| Rate for Payer: Healthfirst Commercial |
$332.79
|
| Rate for Payer: Healthfirst Essential Plan |
$748.78
|
| Rate for Payer: Healthfirst Medicare Advantage |
$316.15
|
| Rate for Payer: Healthfirst QHP |
$332.79
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$232.95
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$332.79
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$282.87
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$232.95
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$332.79
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$249.59
|
| Rate for Payer: SOMOS Essential |
$249.59
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$332.79
|
|
