|
CHG BRAIN IMAGING <4 STATIC VIEWS W/VASCULAR FLOW
|
Professional
|
$870.91
|
|
|
Service Code
|
HCPCS 78601
|
| Min. Negotiated Rate |
$18.76 |
| Max. Negotiated Rate |
$653.18 |
| Rate for Payer: Cash Price |
$235.29
|
| Rate for Payer: Cash Price |
$235.29
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$223.95
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$223.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$236.39
|
| Rate for Payer: Fidelis Medicare Advantage |
$248.83
|
| Rate for Payer: Fidelis Qualified Health Plan |
$236.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$248.83
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$248.83
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$186.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$236.39
|
| Rate for Payer: Healthfirst QHP |
$248.83
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$174.18
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$248.83
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$211.51
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$174.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$248.83
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$653.18
|
| Rate for Payer: SOMOS Essential |
$653.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$248.83
|
|
|
CHG BRAIN IMAGING <4 STATIC VIEWS W/VASCULAR FLOW
|
Professional
|
$93.80
|
|
|
Service Code
|
HCPCS 78601 26
|
| Min. Negotiated Rate |
$18.76 |
| Max. Negotiated Rate |
$653.18 |
| Rate for Payer: Cash Price |
$25.72
|
| Rate for Payer: Cash Price |
$25.72
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$24.12
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$24.12
|
| Rate for Payer: Fidelis Essential Plan QHP |
$25.46
|
| Rate for Payer: Fidelis Medicare Advantage |
$26.80
|
| Rate for Payer: Fidelis Qualified Health Plan |
$25.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.80
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$20.10
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.46
|
| Rate for Payer: Healthfirst QHP |
$26.80
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$18.76
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$26.80
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$22.78
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$18.76
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26.80
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$70.35
|
| Rate for Payer: SOMOS Essential |
$70.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$26.80
|
|
|
CHG BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW
|
Professional
|
$1,309.56
|
|
|
Service Code
|
HCPCS 78606
|
| Min. Negotiated Rate |
$24.26 |
| Max. Negotiated Rate |
$982.17 |
| Rate for Payer: Cash Price |
$354.48
|
| Rate for Payer: Cash Price |
$354.48
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$336.74
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$336.74
|
| Rate for Payer: Fidelis Essential Plan QHP |
$355.45
|
| Rate for Payer: Fidelis Medicare Advantage |
$374.16
|
| Rate for Payer: Fidelis Qualified Health Plan |
$355.45
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$374.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$374.16
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$280.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$355.45
|
| Rate for Payer: Healthfirst QHP |
$374.16
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$261.91
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$374.16
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$318.04
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$261.91
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$374.16
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$982.17
|
| Rate for Payer: SOMOS Essential |
$982.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$374.16
|
|
|
CHG BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW
|
Professional
|
$121.28
|
|
|
Service Code
|
HCPCS 78606 26
|
| Min. Negotiated Rate |
$24.26 |
| Max. Negotiated Rate |
$982.17 |
| Rate for Payer: Cash Price |
$32.45
|
| Rate for Payer: Cash Price |
$32.45
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$31.18
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$31.18
|
| Rate for Payer: Fidelis Essential Plan QHP |
$32.92
|
| Rate for Payer: Fidelis Medicare Advantage |
$34.65
|
| Rate for Payer: Fidelis Qualified Health Plan |
$32.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$34.65
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$34.65
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$25.99
|
| Rate for Payer: Healthfirst Medicare Advantage |
$32.92
|
| Rate for Payer: Healthfirst QHP |
$34.65
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$24.26
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$34.65
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$29.45
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$24.26
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$34.65
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$90.96
|
| Rate for Payer: SOMOS Essential |
$90.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34.65
|
|
|
CHG BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW
|
Professional
|
$1,188.25
|
|
|
Service Code
|
HCPCS 78606 TC
|
| Min. Negotiated Rate |
$24.26 |
| Max. Negotiated Rate |
$982.17 |
| Rate for Payer: Cash Price |
$322.03
|
| Rate for Payer: Cash Price |
$322.03
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$305.55
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$305.55
|
| Rate for Payer: Fidelis Essential Plan QHP |
$322.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$339.50
|
| Rate for Payer: Fidelis Qualified Health Plan |
$322.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$339.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$339.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$254.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$322.52
|
| Rate for Payer: Healthfirst QHP |
$339.50
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$237.65
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$339.50
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$288.58
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$237.65
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$339.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$891.19
|
| Rate for Payer: SOMOS Essential |
$891.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$339.50
|
|
|
CHG BRAIN IMAGING MINIMUM 4 STATIC VIEWS
|
Professional
|
$709.56
|
|
|
Service Code
|
HCPCS 78605 TC
|
| Min. Negotiated Rate |
$20.93 |
| Max. Negotiated Rate |
$610.66 |
| Rate for Payer: Cash Price |
$190.72
|
| Rate for Payer: Cash Price |
$190.72
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$182.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$182.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$192.59
|
| Rate for Payer: Fidelis Medicare Advantage |
$202.73
|
| Rate for Payer: Fidelis Qualified Health Plan |
$192.59
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$202.73
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$202.73
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$152.05
|
| Rate for Payer: Healthfirst Medicare Advantage |
$192.59
|
| Rate for Payer: Healthfirst QHP |
$202.73
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$141.91
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$202.73
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$172.32
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$141.91
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$202.73
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$532.17
|
| Rate for Payer: SOMOS Essential |
$532.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$202.73
|
|
|
CHG BRAIN IMAGING MINIMUM 4 STATIC VIEWS
|
Professional
|
$814.21
|
|
|
Service Code
|
HCPCS 78605
|
| Min. Negotiated Rate |
$20.93 |
| Max. Negotiated Rate |
$610.66 |
| Rate for Payer: Cash Price |
$218.54
|
| Rate for Payer: Cash Price |
$218.54
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$209.37
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$209.37
|
| Rate for Payer: Fidelis Essential Plan QHP |
$221.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$232.63
|
| Rate for Payer: Fidelis Qualified Health Plan |
$221.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$232.63
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$232.63
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$174.47
|
| Rate for Payer: Healthfirst Medicare Advantage |
$221.00
|
| Rate for Payer: Healthfirst QHP |
$232.63
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$162.84
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$232.63
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$197.74
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$162.84
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$232.63
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$610.66
|
| Rate for Payer: SOMOS Essential |
$610.66
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$232.63
|
|
|
CHG BRAIN IMAGING MINIMUM 4 STATIC VIEWS
|
Professional
|
$104.65
|
|
|
Service Code
|
HCPCS 78605 26
|
| Min. Negotiated Rate |
$20.93 |
| Max. Negotiated Rate |
$610.66 |
| Rate for Payer: Cash Price |
$27.83
|
| Rate for Payer: Cash Price |
$27.83
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26.91
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$26.91
|
| Rate for Payer: Fidelis Essential Plan QHP |
$28.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$29.90
|
| Rate for Payer: Fidelis Qualified Health Plan |
$28.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$29.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$29.90
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$22.42
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28.40
|
| Rate for Payer: Healthfirst QHP |
$29.90
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$20.93
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$29.90
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$25.42
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$20.93
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$29.90
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$78.49
|
| Rate for Payer: SOMOS Essential |
$78.49
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$29.90
|
|
|
CHG BRAIN IMAGING PET METABOLIC EVALUATION
|
Professional
|
$6,319.08
|
|
|
Service Code
|
HCPCS 78608 TC
|
| Min. Negotiated Rate |
$54.66 |
| Max. Negotiated Rate |
$4,944.29 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$4,739.31
|
| Rate for Payer: SOMOS Essential |
$4,739.31
|
|
|
CHG BRAIN IMAGING PET METABOLIC EVALUATION
|
Professional
|
$6,592.39
|
|
|
Service Code
|
HCPCS 78608
|
| Min. Negotiated Rate |
$54.66 |
| Max. Negotiated Rate |
$4,944.29 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$4,944.29
|
| Rate for Payer: SOMOS Essential |
$4,944.29
|
|
|
CHG BRAIN IMAGING PET METABOLIC EVALUATION
|
Professional
|
$273.28
|
|
|
Service Code
|
HCPCS 78608 26
|
| Min. Negotiated Rate |
$54.66 |
| Max. Negotiated Rate |
$4,944.29 |
| Rate for Payer: Cash Price |
$74.53
|
| Rate for Payer: Cash Price |
$74.53
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$70.27
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$70.27
|
| Rate for Payer: Fidelis Essential Plan QHP |
$74.18
|
| Rate for Payer: Fidelis Medicare Advantage |
$78.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$74.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$78.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$78.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$58.56
|
| Rate for Payer: Healthfirst Medicare Advantage |
$74.18
|
| Rate for Payer: Healthfirst QHP |
$78.08
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$54.66
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$78.08
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$66.37
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$54.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$78.08
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$204.96
|
| Rate for Payer: SOMOS Essential |
$204.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$78.08
|
|
|
CHG BRAIN IMAGING VASCULAR FLOW ONLY
|
Professional
|
$711.06
|
|
|
Service Code
|
HCPCS 78610
|
| Min. Negotiated Rate |
$11.23 |
| Max. Negotiated Rate |
$533.30 |
| Rate for Payer: Cash Price |
$190.80
|
| Rate for Payer: Cash Price |
$190.80
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$182.84
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$182.84
|
| Rate for Payer: Fidelis Essential Plan QHP |
$193.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$203.16
|
| Rate for Payer: Fidelis Qualified Health Plan |
$193.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$203.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$203.16
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$152.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$193.00
|
| Rate for Payer: Healthfirst QHP |
$203.16
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$142.21
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$203.16
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$172.69
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$142.21
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$203.16
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$533.30
|
| Rate for Payer: SOMOS Essential |
$533.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$203.16
|
|
|
CHG BRAIN IMAGING VASCULAR FLOW ONLY
|
Professional
|
$56.14
|
|
|
Service Code
|
HCPCS 78610 26
|
| Min. Negotiated Rate |
$11.23 |
| Max. Negotiated Rate |
$533.30 |
| Rate for Payer: Cash Price |
$15.02
|
| Rate for Payer: Cash Price |
$15.02
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$14.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$14.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$15.24
|
| Rate for Payer: Fidelis Medicare Advantage |
$16.04
|
| Rate for Payer: Fidelis Qualified Health Plan |
$15.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$16.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$16.04
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$12.03
|
| Rate for Payer: Healthfirst Medicare Advantage |
$15.24
|
| Rate for Payer: Healthfirst QHP |
$16.04
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$11.23
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$16.04
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$13.63
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$11.23
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$16.04
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$42.10
|
| Rate for Payer: SOMOS Essential |
$42.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$16.04
|
|
|
CHG BRAIN IMAGING VASCULAR FLOW ONLY
|
Professional
|
$654.96
|
|
|
Service Code
|
HCPCS 78610 TC
|
| Min. Negotiated Rate |
$11.23 |
| Max. Negotiated Rate |
$533.30 |
| Rate for Payer: Cash Price |
$175.79
|
| Rate for Payer: Cash Price |
$175.79
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$168.42
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$168.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$177.77
|
| Rate for Payer: Fidelis Medicare Advantage |
$187.13
|
| Rate for Payer: Fidelis Qualified Health Plan |
$177.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$187.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$187.13
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$140.35
|
| Rate for Payer: Healthfirst Medicare Advantage |
$177.77
|
| Rate for Payer: Healthfirst QHP |
$187.13
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$130.99
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$187.13
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$159.06
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$130.99
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$187.13
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$491.22
|
| Rate for Payer: SOMOS Essential |
$491.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$187.13
|
|
|
CHG CARD BLOOD POOL GATED PLANAR 1 STUDY REST/STRESS
|
Professional
|
$181.13
|
|
|
Service Code
|
HCPCS 78472 26
|
| Min. Negotiated Rate |
$36.22 |
| Max. Negotiated Rate |
$680.96 |
| Rate for Payer: Cash Price |
$49.64
|
| Rate for Payer: Cash Price |
$49.64
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$46.58
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$46.58
|
| Rate for Payer: Fidelis Essential Plan QHP |
$49.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$51.75
|
| Rate for Payer: Fidelis Qualified Health Plan |
$49.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$51.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$51.75
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$38.81
|
| Rate for Payer: Healthfirst Medicare Advantage |
$49.16
|
| Rate for Payer: Healthfirst QHP |
$51.75
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$36.22
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$51.75
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$43.99
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$36.22
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$51.75
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$135.85
|
| Rate for Payer: SOMOS Essential |
$135.85
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$51.75
|
|
|
CHG CARD BLOOD POOL GATED PLANAR 1 STUDY REST/STRESS
|
Professional
|
$726.81
|
|
|
Service Code
|
HCPCS 78472 TC
|
| Min. Negotiated Rate |
$36.22 |
| Max. Negotiated Rate |
$680.96 |
| Rate for Payer: Cash Price |
$195.82
|
| Rate for Payer: Cash Price |
$195.82
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$186.89
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$186.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$197.28
|
| Rate for Payer: Fidelis Medicare Advantage |
$207.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$197.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$207.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$207.66
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$155.74
|
| Rate for Payer: Healthfirst Medicare Advantage |
$197.28
|
| Rate for Payer: Healthfirst QHP |
$207.66
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$145.36
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$207.66
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$176.51
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$145.36
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$207.66
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$545.11
|
| Rate for Payer: SOMOS Essential |
$545.11
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$207.66
|
|
|
CHG CARD BLOOD POOL GATED PLANAR 1 STUDY REST/STRESS
|
Professional
|
$907.94
|
|
|
Service Code
|
HCPCS 78472
|
| Min. Negotiated Rate |
$36.22 |
| Max. Negotiated Rate |
$680.96 |
| Rate for Payer: Cash Price |
$245.47
|
| Rate for Payer: Cash Price |
$245.47
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$233.47
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$233.47
|
| Rate for Payer: Fidelis Essential Plan QHP |
$246.44
|
| Rate for Payer: Fidelis Medicare Advantage |
$259.41
|
| Rate for Payer: Fidelis Qualified Health Plan |
$246.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$259.41
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$259.41
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$194.56
|
| Rate for Payer: Healthfirst Medicare Advantage |
$246.44
|
| Rate for Payer: Healthfirst QHP |
$259.41
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$181.59
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$259.41
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$220.50
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$181.59
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$259.41
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$680.96
|
| Rate for Payer: SOMOS Essential |
$680.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$259.41
|
|
|
CHG CARD BL POOL GATED 1 STDY REST RT VENT EJCT FRCT
|
Professional
|
$92.54
|
|
|
Service Code
|
HCPCS 78496 26
|
| Min. Negotiated Rate |
$16.36 |
| Max. Negotiated Rate |
$130.76 |
| Rate for Payer: Cash Price |
$25.37
|
| Rate for Payer: Cash Price |
$25.37
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$23.80
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$23.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$25.12
|
| Rate for Payer: Fidelis Medicare Advantage |
$26.44
|
| Rate for Payer: Fidelis Qualified Health Plan |
$25.12
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.44
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$19.83
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.12
|
| Rate for Payer: Healthfirst QHP |
$26.44
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$18.51
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$26.44
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$22.47
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$18.51
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26.44
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$69.40
|
| Rate for Payer: SOMOS Essential |
$69.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$26.44
|
|
|
CHG CARD BL POOL GATED 1 STDY REST RT VENT EJCT FRCT
|
Professional
|
$81.80
|
|
|
Service Code
|
HCPCS 78496 TC
|
| Min. Negotiated Rate |
$16.36 |
| Max. Negotiated Rate |
$130.76 |
| Rate for Payer: Cash Price |
$22.63
|
| Rate for Payer: Cash Price |
$22.63
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$21.03
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$21.03
|
| Rate for Payer: Fidelis Essential Plan QHP |
$22.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$23.37
|
| Rate for Payer: Fidelis Qualified Health Plan |
$22.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$23.37
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$23.37
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$17.53
|
| Rate for Payer: Healthfirst Medicare Advantage |
$22.20
|
| Rate for Payer: Healthfirst QHP |
$23.37
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$16.36
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$23.37
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$19.86
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$16.36
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$23.37
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$61.35
|
| Rate for Payer: SOMOS Essential |
$61.35
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$23.37
|
|
|
CHG CARD BL POOL GATED 1 STDY REST RT VENT EJCT FRCT
|
Professional
|
$174.34
|
|
|
Service Code
|
HCPCS 78496
|
| Min. Negotiated Rate |
$16.36 |
| Max. Negotiated Rate |
$130.76 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$44.83
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$44.83
|
| Rate for Payer: Fidelis Essential Plan QHP |
$47.32
|
| Rate for Payer: Fidelis Medicare Advantage |
$49.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$47.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$49.81
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$49.81
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$37.36
|
| Rate for Payer: Healthfirst Medicare Advantage |
$47.32
|
| Rate for Payer: Healthfirst QHP |
$49.81
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$34.87
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$49.81
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$42.34
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$34.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$49.81
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$130.76
|
| Rate for Payer: SOMOS Essential |
$130.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$49.81
|
|
|
CHG CARD BL POOL GATED MLT STDY WAL MOTN EJECT FRACT
|
Professional
|
$877.77
|
|
|
Service Code
|
HCPCS 78473 TC
|
| Min. Negotiated Rate |
$53.39 |
| Max. Negotiated Rate |
$858.51 |
| Rate for Payer: Cash Price |
$238.10
|
| Rate for Payer: Cash Price |
$238.10
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$225.71
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$225.71
|
| Rate for Payer: Fidelis Essential Plan QHP |
$238.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$250.79
|
| Rate for Payer: Fidelis Qualified Health Plan |
$238.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$250.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$250.79
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$188.09
|
| Rate for Payer: Healthfirst Medicare Advantage |
$238.25
|
| Rate for Payer: Healthfirst QHP |
$250.79
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$175.55
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$250.79
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$213.17
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$175.55
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$250.79
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$658.33
|
| Rate for Payer: SOMOS Essential |
$658.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$250.79
|
|
|
CHG CARD BL POOL GATED MLT STDY WAL MOTN EJECT FRACT
|
Professional
|
$266.95
|
|
|
Service Code
|
HCPCS 78473 26
|
| Min. Negotiated Rate |
$53.39 |
| Max. Negotiated Rate |
$858.51 |
| Rate for Payer: Cash Price |
$73.64
|
| Rate for Payer: Cash Price |
$73.64
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$68.64
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$68.64
|
| Rate for Payer: Fidelis Essential Plan QHP |
$72.46
|
| Rate for Payer: Fidelis Medicare Advantage |
$76.27
|
| Rate for Payer: Fidelis Qualified Health Plan |
$72.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$76.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$76.27
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$57.20
|
| Rate for Payer: Healthfirst Medicare Advantage |
$72.46
|
| Rate for Payer: Healthfirst QHP |
$76.27
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$53.39
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$76.27
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$64.83
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$53.39
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$76.27
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$200.21
|
| Rate for Payer: SOMOS Essential |
$200.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$76.27
|
|
|
CHG CARD BL POOL GATED MLT STDY WAL MOTN EJECT FRACT
|
Professional
|
$1,144.68
|
|
|
Service Code
|
HCPCS 78473
|
| Min. Negotiated Rate |
$53.39 |
| Max. Negotiated Rate |
$858.51 |
| Rate for Payer: Cash Price |
$311.75
|
| Rate for Payer: Cash Price |
$311.75
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$294.34
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$294.34
|
| Rate for Payer: Fidelis Essential Plan QHP |
$310.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$327.05
|
| Rate for Payer: Fidelis Qualified Health Plan |
$310.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$327.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$327.05
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$245.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$310.70
|
| Rate for Payer: Healthfirst QHP |
$327.05
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$228.94
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$327.05
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$277.99
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$228.94
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$327.05
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$858.51
|
| Rate for Payer: SOMOS Essential |
$858.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$327.05
|
|
|
CHG CARD BL POOL GATED SPECT REST WAL MOTN EJCT FRCT
|
Professional
|
$690.87
|
|
|
Service Code
|
HCPCS 78494 TC
|
| Min. Negotiated Rate |
$43.78 |
| Max. Negotiated Rate |
$682.34 |
| Rate for Payer: Cash Price |
$186.79
|
| Rate for Payer: Cash Price |
$186.79
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$177.65
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$177.65
|
| Rate for Payer: Fidelis Essential Plan QHP |
$187.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$197.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$187.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$197.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$197.39
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$148.04
|
| Rate for Payer: Healthfirst Medicare Advantage |
$187.52
|
| Rate for Payer: Healthfirst QHP |
$197.39
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$138.17
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$197.39
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$167.78
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$138.17
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$197.39
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$518.15
|
| Rate for Payer: SOMOS Essential |
$518.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$197.39
|
|
|
CHG CARD BL POOL GATED SPECT REST WAL MOTN EJCT FRCT
|
Professional
|
$909.79
|
|
|
Service Code
|
HCPCS 78494
|
| Min. Negotiated Rate |
$43.78 |
| Max. Negotiated Rate |
$682.34 |
| Rate for Payer: Cash Price |
$246.51
|
| Rate for Payer: Cash Price |
$246.51
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$233.95
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$233.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$246.94
|
| Rate for Payer: Fidelis Medicare Advantage |
$259.94
|
| Rate for Payer: Fidelis Qualified Health Plan |
$246.94
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$259.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$259.94
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$194.96
|
| Rate for Payer: Healthfirst Medicare Advantage |
$246.94
|
| Rate for Payer: Healthfirst QHP |
$259.94
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$181.96
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$259.94
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$220.95
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$181.96
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$259.94
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$682.34
|
| Rate for Payer: SOMOS Essential |
$682.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$259.94
|
|
