|
CHG ANGIOGRAPHY EXTREMITY UNILATERAL RS&I
|
Professional
|
$300.16
|
|
|
Service Code
|
HCPCS 75710 TC
|
| Min. Negotiated Rate |
$60.03 |
| Max. Negotiated Rate |
$484.26 |
| Rate for Payer: Cash Price |
$81.80
|
| Rate for Payer: Cash Price |
$81.80
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$77.18
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$77.18
|
| Rate for Payer: Fidelis Essential Plan QHP |
$81.47
|
| Rate for Payer: Fidelis Medicare Advantage |
$85.76
|
| Rate for Payer: Fidelis Qualified Health Plan |
$81.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$85.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$85.76
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$64.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$81.47
|
| Rate for Payer: Healthfirst QHP |
$85.76
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$60.03
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$85.76
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$72.90
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$60.03
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$85.76
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$225.12
|
| Rate for Payer: SOMOS Essential |
$225.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$85.76
|
|
|
CHG ANGIOGRAPHY EXTREMITY UNILATERAL RS&I
|
Professional
|
$645.68
|
|
|
Service Code
|
HCPCS 75710
|
| Min. Negotiated Rate |
$60.03 |
| Max. Negotiated Rate |
$484.26 |
| Rate for Payer: Cash Price |
$174.90
|
| Rate for Payer: Cash Price |
$174.90
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$166.03
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$166.03
|
| Rate for Payer: Fidelis Essential Plan QHP |
$175.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$184.48
|
| Rate for Payer: Fidelis Qualified Health Plan |
$175.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$184.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$184.48
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$138.36
|
| Rate for Payer: Healthfirst Medicare Advantage |
$175.26
|
| Rate for Payer: Healthfirst QHP |
$184.48
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$129.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$184.48
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$156.81
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$129.14
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$184.48
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$484.26
|
| Rate for Payer: SOMOS Essential |
$484.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$184.48
|
|
|
CHG ANGIOGRAPHY INTERNAL MAMMARY RS&I
|
Professional
|
$466.62
|
|
|
Service Code
|
HCPCS 75756 TC
|
| Min. Negotiated Rate |
$45.76 |
| Max. Negotiated Rate |
$521.59 |
| Rate for Payer: Cash Price |
$131.94
|
| Rate for Payer: Cash Price |
$131.94
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$119.99
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$119.99
|
| Rate for Payer: Fidelis Essential Plan QHP |
$126.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$133.32
|
| Rate for Payer: Fidelis Qualified Health Plan |
$126.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$133.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$133.32
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$99.99
|
| Rate for Payer: Healthfirst Medicare Advantage |
$126.65
|
| Rate for Payer: Healthfirst QHP |
$133.32
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$93.32
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$133.32
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$113.32
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$93.32
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$133.32
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$349.96
|
| Rate for Payer: SOMOS Essential |
$349.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$133.32
|
|
|
CHG ANGIOGRAPHY INTERNAL MAMMARY RS&I
|
Professional
|
$228.80
|
|
|
Service Code
|
HCPCS 75756 26
|
| Min. Negotiated Rate |
$45.76 |
| Max. Negotiated Rate |
$521.59 |
| Rate for Payer: Cash Price |
$60.78
|
| Rate for Payer: Cash Price |
$60.78
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$58.83
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$58.83
|
| Rate for Payer: Fidelis Essential Plan QHP |
$62.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$65.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$62.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$65.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$65.37
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$49.03
|
| Rate for Payer: Healthfirst Medicare Advantage |
$62.10
|
| Rate for Payer: Healthfirst QHP |
$65.37
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$45.76
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$65.37
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$55.56
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$45.76
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$65.37
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$171.60
|
| Rate for Payer: SOMOS Essential |
$171.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$65.37
|
|
|
CHG ANGIOGRAPHY INTERNAL MAMMARY RS&I
|
Professional
|
$695.45
|
|
|
Service Code
|
HCPCS 75756
|
| Min. Negotiated Rate |
$45.76 |
| Max. Negotiated Rate |
$521.59 |
| Rate for Payer: Cash Price |
$192.72
|
| Rate for Payer: Cash Price |
$192.72
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$178.83
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$178.83
|
| Rate for Payer: Fidelis Essential Plan QHP |
$188.76
|
| Rate for Payer: Fidelis Medicare Advantage |
$198.70
|
| Rate for Payer: Fidelis Qualified Health Plan |
$188.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$198.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$198.70
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$149.02
|
| Rate for Payer: Healthfirst Medicare Advantage |
$188.76
|
| Rate for Payer: Healthfirst QHP |
$198.70
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$139.09
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$198.70
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$168.90
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$139.09
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$198.70
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$521.59
|
| Rate for Payer: SOMOS Essential |
$521.59
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$198.70
|
|
|
CHG ANGIOGRAPHY PELVIC SLCTV/SUPRASLCTV RS&I
|
Professional
|
$397.64
|
|
|
Service Code
|
HCPCS 75736 TC
|
| Min. Negotiated Rate |
$42.94 |
| Max. Negotiated Rate |
$459.25 |
| Rate for Payer: Cash Price |
$109.54
|
| Rate for Payer: Cash Price |
$109.54
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$102.25
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$102.25
|
| Rate for Payer: Fidelis Essential Plan QHP |
$107.93
|
| Rate for Payer: Fidelis Medicare Advantage |
$113.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$107.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$113.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$113.61
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$85.21
|
| Rate for Payer: Healthfirst Medicare Advantage |
$107.93
|
| Rate for Payer: Healthfirst QHP |
$113.61
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$79.53
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$113.61
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$96.57
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$79.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$113.61
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$298.23
|
| Rate for Payer: SOMOS Essential |
$298.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$113.61
|
|
|
CHG ANGIOGRAPHY PELVIC SLCTV/SUPRASLCTV RS&I
|
Professional
|
$612.33
|
|
|
Service Code
|
HCPCS 75736
|
| Min. Negotiated Rate |
$42.94 |
| Max. Negotiated Rate |
$459.25 |
| Rate for Payer: Cash Price |
$166.71
|
| Rate for Payer: Cash Price |
$166.71
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$157.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$157.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$166.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$174.95
|
| Rate for Payer: Fidelis Qualified Health Plan |
$166.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$174.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$174.95
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$131.21
|
| Rate for Payer: Healthfirst Medicare Advantage |
$166.20
|
| Rate for Payer: Healthfirst QHP |
$174.95
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$122.46
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$174.95
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$148.71
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$122.46
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$174.95
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$459.25
|
| Rate for Payer: SOMOS Essential |
$459.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$174.95
|
|
|
CHG ANGIOGRAPHY PELVIC SLCTV/SUPRASLCTV RS&I
|
Professional
|
$214.69
|
|
|
Service Code
|
HCPCS 75736 26
|
| Min. Negotiated Rate |
$42.94 |
| Max. Negotiated Rate |
$459.25 |
| Rate for Payer: Cash Price |
$57.17
|
| Rate for Payer: Cash Price |
$57.17
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$55.21
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$55.21
|
| Rate for Payer: Fidelis Essential Plan QHP |
$58.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$61.34
|
| Rate for Payer: Fidelis Qualified Health Plan |
$58.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$61.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$61.34
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$46.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$58.27
|
| Rate for Payer: Healthfirst QHP |
$61.34
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$42.94
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$61.34
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$52.14
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$42.94
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$61.34
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$161.02
|
| Rate for Payer: SOMOS Essential |
$161.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$61.34
|
|
|
CHG ANGIOGRAPHY PULMONARY BILATERAL SLCTV RS&I
|
Professional
|
$311.19
|
|
|
Service Code
|
HCPCS 75743 26
|
| Min. Negotiated Rate |
$62.24 |
| Max. Negotiated Rate |
$469.30 |
| Rate for Payer: Cash Price |
$84.26
|
| Rate for Payer: Cash Price |
$84.26
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$80.02
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$80.02
|
| Rate for Payer: Fidelis Essential Plan QHP |
$84.46
|
| Rate for Payer: Fidelis Medicare Advantage |
$88.91
|
| Rate for Payer: Fidelis Qualified Health Plan |
$84.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$88.91
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$88.91
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$66.68
|
| Rate for Payer: Healthfirst Medicare Advantage |
$84.46
|
| Rate for Payer: Healthfirst QHP |
$88.91
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$62.24
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$88.91
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$75.57
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$62.24
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$88.91
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$233.39
|
| Rate for Payer: SOMOS Essential |
$233.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$88.91
|
|
|
CHG ANGIOGRAPHY PULMONARY BILATERAL SLCTV RS&I
|
Professional
|
$625.73
|
|
|
Service Code
|
HCPCS 75743
|
| Min. Negotiated Rate |
$62.24 |
| Max. Negotiated Rate |
$469.30 |
| Rate for Payer: Cash Price |
$169.60
|
| Rate for Payer: Cash Price |
$169.60
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$160.90
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$160.90
|
| Rate for Payer: Fidelis Essential Plan QHP |
$169.84
|
| Rate for Payer: Fidelis Medicare Advantage |
$178.78
|
| Rate for Payer: Fidelis Qualified Health Plan |
$169.84
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$178.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$178.78
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$134.08
|
| Rate for Payer: Healthfirst Medicare Advantage |
$169.84
|
| Rate for Payer: Healthfirst QHP |
$178.78
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$125.15
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$178.78
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$151.96
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$125.15
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$178.78
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$469.30
|
| Rate for Payer: SOMOS Essential |
$469.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$178.78
|
|
|
CHG ANGIOGRAPHY PULMONARY BILATERAL SLCTV RS&I
|
Professional
|
$314.55
|
|
|
Service Code
|
HCPCS 75743 TC
|
| Min. Negotiated Rate |
$62.24 |
| Max. Negotiated Rate |
$469.30 |
| Rate for Payer: Cash Price |
$85.34
|
| Rate for Payer: Cash Price |
$85.34
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$80.88
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$80.88
|
| Rate for Payer: Fidelis Essential Plan QHP |
$85.38
|
| Rate for Payer: Fidelis Medicare Advantage |
$89.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$85.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$89.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$89.87
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$67.40
|
| Rate for Payer: Healthfirst Medicare Advantage |
$85.38
|
| Rate for Payer: Healthfirst QHP |
$89.87
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$62.91
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$89.87
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$76.39
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$62.91
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$89.87
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$235.91
|
| Rate for Payer: SOMOS Essential |
$235.91
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$89.87
|
|
|
CHG ANGIOGRAPHY PULMONARY UNILATERAL SLCTV RS&I
|
Professional
|
$554.86
|
|
|
Service Code
|
HCPCS 75741
|
| Min. Negotiated Rate |
$49.21 |
| Max. Negotiated Rate |
$416.14 |
| Rate for Payer: Cash Price |
$149.62
|
| Rate for Payer: Cash Price |
$149.62
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$142.68
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$142.68
|
| Rate for Payer: Fidelis Essential Plan QHP |
$150.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$158.53
|
| Rate for Payer: Fidelis Qualified Health Plan |
$150.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$158.53
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$158.53
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$118.90
|
| Rate for Payer: Healthfirst Medicare Advantage |
$150.60
|
| Rate for Payer: Healthfirst QHP |
$158.53
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$110.97
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$158.53
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$134.75
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$110.97
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$158.53
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$416.14
|
| Rate for Payer: SOMOS Essential |
$416.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$158.53
|
|
|
CHG ANGIOGRAPHY PULMONARY UNILATERAL SLCTV RS&I
|
Professional
|
$308.77
|
|
|
Service Code
|
HCPCS 75741 TC
|
| Min. Negotiated Rate |
$49.21 |
| Max. Negotiated Rate |
$416.14 |
| Rate for Payer: Cash Price |
$83.77
|
| Rate for Payer: Cash Price |
$83.77
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$79.40
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$79.40
|
| Rate for Payer: Fidelis Essential Plan QHP |
$83.81
|
| Rate for Payer: Fidelis Medicare Advantage |
$88.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$83.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$88.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$88.22
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$66.16
|
| Rate for Payer: Healthfirst Medicare Advantage |
$83.81
|
| Rate for Payer: Healthfirst QHP |
$88.22
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$61.75
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$88.22
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$74.99
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$61.75
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$88.22
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$231.58
|
| Rate for Payer: SOMOS Essential |
$231.58
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$88.22
|
|
|
CHG ANGIOGRAPHY PULMONARY UNILATERAL SLCTV RS&I
|
Professional
|
$246.05
|
|
|
Service Code
|
HCPCS 75741 26
|
| Min. Negotiated Rate |
$49.21 |
| Max. Negotiated Rate |
$416.14 |
| Rate for Payer: Cash Price |
$65.85
|
| Rate for Payer: Cash Price |
$65.85
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$63.27
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$63.27
|
| Rate for Payer: Fidelis Essential Plan QHP |
$66.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$70.30
|
| Rate for Payer: Fidelis Qualified Health Plan |
$66.78
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$70.30
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$70.30
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$52.72
|
| Rate for Payer: Healthfirst Medicare Advantage |
$66.78
|
| Rate for Payer: Healthfirst QHP |
$70.30
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$49.21
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$70.30
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$59.76
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$49.21
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$70.30
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$184.54
|
| Rate for Payer: SOMOS Essential |
$184.54
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$70.30
|
|
|
CHG ANGIOGRAPHY SPINAL SELECTIVE RS&I
|
Professional
|
$580.20
|
|
|
Service Code
|
HCPCS 75705 TC
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$817.66 |
| Rate for Payer: Cash Price |
$160.62
|
| Rate for Payer: Cash Price |
$160.62
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$149.19
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$149.19
|
| Rate for Payer: Fidelis Essential Plan QHP |
$157.48
|
| Rate for Payer: Fidelis Medicare Advantage |
$165.77
|
| Rate for Payer: Fidelis Qualified Health Plan |
$157.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$165.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$165.77
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$124.33
|
| Rate for Payer: Healthfirst Medicare Advantage |
$157.48
|
| Rate for Payer: Healthfirst QHP |
$165.77
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$116.04
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$165.77
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$140.90
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$116.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$165.77
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$435.15
|
| Rate for Payer: SOMOS Essential |
$435.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$165.77
|
|
|
CHG ANGIOGRAPHY SPINAL SELECTIVE RS&I
|
Professional
|
$510.02
|
|
|
Service Code
|
HCPCS 75705 26
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$817.66 |
| Rate for Payer: Cash Price |
$135.78
|
| Rate for Payer: Cash Price |
$135.78
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$131.15
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$131.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$138.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$145.72
|
| Rate for Payer: Fidelis Qualified Health Plan |
$138.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$145.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$145.72
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$109.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$138.43
|
| Rate for Payer: Healthfirst QHP |
$145.72
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$102.00
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$145.72
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$123.86
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$102.00
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$145.72
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$382.52
|
| Rate for Payer: SOMOS Essential |
$382.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$145.72
|
|
|
CHG ANGIOGRAPHY SPINAL SELECTIVE RS&I
|
Professional
|
$1,090.22
|
|
|
Service Code
|
HCPCS 75705
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$817.66 |
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$280.34
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$280.34
|
| Rate for Payer: Fidelis Essential Plan QHP |
$295.92
|
| Rate for Payer: Fidelis Medicare Advantage |
$311.49
|
| Rate for Payer: Fidelis Qualified Health Plan |
$295.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$311.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$311.49
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$233.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$295.92
|
| Rate for Payer: Healthfirst QHP |
$311.49
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$218.04
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$311.49
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$264.77
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$218.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$311.49
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$817.66
|
| Rate for Payer: SOMOS Essential |
$817.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$311.49
|
|
|
CHG ANGIOGRAPHY VISCERAL SLCTV/SUPRASLCTV RS&I
|
Professional
|
$724.19
|
|
|
Service Code
|
HCPCS 75726
|
| Min. Negotiated Rate |
$67.51 |
| Max. Negotiated Rate |
$543.14 |
| Rate for Payer: Cash Price |
$194.90
|
| Rate for Payer: Cash Price |
$194.90
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$186.22
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$186.22
|
| Rate for Payer: Fidelis Essential Plan QHP |
$196.56
|
| Rate for Payer: Fidelis Medicare Advantage |
$206.91
|
| Rate for Payer: Fidelis Qualified Health Plan |
$196.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$206.91
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$206.91
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$155.18
|
| Rate for Payer: Healthfirst Medicare Advantage |
$196.56
|
| Rate for Payer: Healthfirst QHP |
$206.91
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$144.84
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$206.91
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$175.87
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$144.84
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$206.91
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$543.14
|
| Rate for Payer: SOMOS Essential |
$543.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$206.91
|
|
|
CHG ANGIOGRAPHY VISCERAL SLCTV/SUPRASLCTV RS&I
|
Professional
|
$386.65
|
|
|
Service Code
|
HCPCS 75726 26
|
| Min. Negotiated Rate |
$67.51 |
| Max. Negotiated Rate |
$543.14 |
| Rate for Payer: Cash Price |
$102.88
|
| Rate for Payer: Cash Price |
$102.88
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$99.42
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$99.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$104.95
|
| Rate for Payer: Fidelis Medicare Advantage |
$110.47
|
| Rate for Payer: Fidelis Qualified Health Plan |
$104.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$110.47
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$110.47
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$82.85
|
| Rate for Payer: Healthfirst Medicare Advantage |
$104.95
|
| Rate for Payer: Healthfirst QHP |
$110.47
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$77.33
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$110.47
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$93.90
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$77.33
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$110.47
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$289.99
|
| Rate for Payer: SOMOS Essential |
$289.99
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$110.47
|
|
|
CHG ANGIOGRAPHY VISCERAL SLCTV/SUPRASLCTV RS&I
|
Professional
|
$337.54
|
|
|
Service Code
|
HCPCS 75726 TC
|
| Min. Negotiated Rate |
$67.51 |
| Max. Negotiated Rate |
$543.14 |
| Rate for Payer: Cash Price |
$92.02
|
| Rate for Payer: Cash Price |
$92.02
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$86.80
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$86.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$91.62
|
| Rate for Payer: Fidelis Medicare Advantage |
$96.44
|
| Rate for Payer: Fidelis Qualified Health Plan |
$91.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$96.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$96.44
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$72.33
|
| Rate for Payer: Healthfirst Medicare Advantage |
$91.62
|
| Rate for Payer: Healthfirst QHP |
$96.44
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$67.51
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$96.44
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$81.97
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$67.51
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$96.44
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$253.16
|
| Rate for Payer: SOMOS Essential |
$253.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$96.44
|
|
|
CHG ANGRPH CATH F-UP STD TCAT OTHER THAN THROMBYLSIS
|
Professional
|
$398.76
|
|
|
Service Code
|
HCPCS 75898 26
|
| Min. Negotiated Rate |
$79.75 |
| Max. Negotiated Rate |
$458.78 |
| Rate for Payer: Cash Price |
$106.79
|
| Rate for Payer: Cash Price |
$106.79
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$102.54
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$102.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$108.23
|
| Rate for Payer: Fidelis Medicare Advantage |
$113.93
|
| Rate for Payer: Fidelis Qualified Health Plan |
$108.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$113.93
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$113.93
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$85.45
|
| Rate for Payer: Healthfirst Medicare Advantage |
$108.23
|
| Rate for Payer: Healthfirst QHP |
$113.93
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$79.75
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$113.93
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$96.84
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$79.75
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$113.93
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$299.07
|
| Rate for Payer: SOMOS Essential |
$299.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$113.93
|
|
|
CHG ANGRPH CATH F-UP STD TCAT OTHER THAN THROMBYLSIS
|
Professional
|
$611.70
|
|
|
Service Code
|
HCPCS 75898
|
| Min. Negotiated Rate |
$79.75 |
| Max. Negotiated Rate |
$458.78 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$458.78
|
| Rate for Payer: SOMOS Essential |
$458.78
|
|
|
CHG ANGRPH CATH F-UP STD TCAT OTHER THAN THROMBYLSIS
|
Professional
|
$212.94
|
|
|
Service Code
|
HCPCS 75898 TC
|
| Min. Negotiated Rate |
$79.75 |
| Max. Negotiated Rate |
$458.78 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$159.70
|
| Rate for Payer: SOMOS Essential |
$159.70
|
|
|
CHG ANGRPH PULMONARY NONSLCTV CATH/VEN NJX RS&I
|
Professional
|
$357.67
|
|
|
Service Code
|
HCPCS 75746 TC
|
| Min. Negotiated Rate |
$42.99 |
| Max. Negotiated Rate |
$429.48 |
| Rate for Payer: Cash Price |
$98.31
|
| Rate for Payer: Cash Price |
$98.31
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$91.97
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$91.97
|
| Rate for Payer: Fidelis Essential Plan QHP |
$97.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$102.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$97.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$102.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$102.19
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$76.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$97.08
|
| Rate for Payer: Healthfirst QHP |
$102.19
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$71.53
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$102.19
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$86.86
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$71.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$102.19
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$268.25
|
| Rate for Payer: SOMOS Essential |
$268.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$102.19
|
|
|
CHG ANGRPH PULMONARY NONSLCTV CATH/VEN NJX RS&I
|
Professional
|
$572.64
|
|
|
Service Code
|
HCPCS 75746
|
| Min. Negotiated Rate |
$42.99 |
| Max. Negotiated Rate |
$429.48 |
| Rate for Payer: Cash Price |
$155.80
|
| Rate for Payer: Cash Price |
$155.80
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$147.25
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$147.25
|
| Rate for Payer: Fidelis Essential Plan QHP |
$155.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$163.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$155.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$163.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$163.61
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$122.71
|
| Rate for Payer: Healthfirst Medicare Advantage |
$155.43
|
| Rate for Payer: Healthfirst QHP |
$163.61
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$114.53
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$163.61
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$139.07
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$114.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$163.61
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$429.48
|
| Rate for Payer: SOMOS Essential |
$429.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$163.61
|
|
