|
CHG CONSLTJ&REPRT REFERRED MATRL REQUIRING PREPJ SLD
|
Professional
|
$454.62
|
|
|
Service Code
|
HCPCS 88323
|
| Min. Negotiated Rate |
$24.41 |
| Max. Negotiated Rate |
$340.96 |
| Rate for Payer: Cash Price |
$128.17
|
| Rate for Payer: Cash Price |
$128.17
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$116.90
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$116.90
|
| Rate for Payer: Fidelis Essential Plan QHP |
$123.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$129.89
|
| Rate for Payer: Fidelis Qualified Health Plan |
$123.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$129.89
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$129.89
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$97.42
|
| Rate for Payer: Healthfirst Medicare Advantage |
$123.40
|
| Rate for Payer: Healthfirst QHP |
$129.89
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$90.92
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$129.89
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$110.41
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$90.92
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$129.89
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$340.96
|
| Rate for Payer: SOMOS Essential |
$340.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$129.89
|
|
|
CHG CONSLTJ&REPRT REFERRED MATRL REQUIRING PREPJ SLD
|
Professional
|
$332.57
|
|
|
Service Code
|
HCPCS 88323 26
|
| Min. Negotiated Rate |
$24.41 |
| Max. Negotiated Rate |
$340.96 |
| Rate for Payer: Cash Price |
$92.97
|
| Rate for Payer: Cash Price |
$92.97
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$85.52
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$85.52
|
| Rate for Payer: Fidelis Essential Plan QHP |
$90.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$95.02
|
| Rate for Payer: Fidelis Qualified Health Plan |
$90.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$95.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$95.02
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$71.26
|
| Rate for Payer: Healthfirst Medicare Advantage |
$90.27
|
| Rate for Payer: Healthfirst QHP |
$95.02
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$66.51
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$95.02
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$80.77
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$66.51
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$95.02
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$249.43
|
| Rate for Payer: SOMOS Essential |
$249.43
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$95.02
|
|
|
CHG CONSLTJ&REPRT REFERRED MATRL REQUIRING PREPJ SLD
|
Professional
|
$122.05
|
|
|
Service Code
|
HCPCS 88323 TC
|
| Min. Negotiated Rate |
$24.41 |
| Max. Negotiated Rate |
$340.96 |
| Rate for Payer: Cash Price |
$35.20
|
| Rate for Payer: Cash Price |
$35.20
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$31.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$31.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$33.13
|
| Rate for Payer: Fidelis Medicare Advantage |
$34.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$33.13
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$34.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$34.87
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$26.15
|
| Rate for Payer: Healthfirst Medicare Advantage |
$33.13
|
| Rate for Payer: Healthfirst QHP |
$34.87
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$24.41
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$34.87
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$29.64
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$24.41
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$34.87
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$91.54
|
| Rate for Payer: SOMOS Essential |
$91.54
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34.87
|
|
|
CHG CONSLTJ&REPRT REFERRED SLIDES PREPARED ELSEWHERE
|
Professional
|
$332.43
|
|
|
Service Code
|
HCPCS 88321
|
| Min. Negotiated Rate |
$66.49 |
| Max. Negotiated Rate |
$249.32 |
| Rate for Payer: Cash Price |
$90.53
|
| Rate for Payer: Cash Price |
$90.53
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$85.48
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$85.48
|
| Rate for Payer: Fidelis Essential Plan QHP |
$90.23
|
| Rate for Payer: Fidelis Medicare Advantage |
$94.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$90.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$94.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$94.98
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$71.24
|
| Rate for Payer: Healthfirst Medicare Advantage |
$90.23
|
| Rate for Payer: Healthfirst QHP |
$94.98
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$66.49
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$94.98
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$80.73
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$66.49
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$94.98
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$249.32
|
| Rate for Payer: SOMOS Essential |
$249.32
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$94.98
|
|
|
CHG CONTINUING MEDICAL PHYSICS CONSLTJ PR WK
|
Professional
|
$381.26
|
|
|
Service Code
|
HCPCS 77336
|
| Min. Negotiated Rate |
$76.25 |
| Max. Negotiated Rate |
$285.94 |
| Rate for Payer: Cash Price |
$106.77
|
| Rate for Payer: Cash Price |
$106.77
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$98.04
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$98.04
|
| Rate for Payer: Fidelis Essential Plan QHP |
$103.48
|
| Rate for Payer: Fidelis Medicare Advantage |
$108.93
|
| Rate for Payer: Fidelis Qualified Health Plan |
$103.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$108.93
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$108.93
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$81.70
|
| Rate for Payer: Healthfirst Medicare Advantage |
$103.48
|
| Rate for Payer: Healthfirst QHP |
$108.93
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$76.25
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$108.93
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$92.59
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$76.25
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$108.93
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$285.94
|
| Rate for Payer: SOMOS Essential |
$285.94
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$108.93
|
|
|
CHG CORPORA CAVERNOSOGRAPY RS&I
|
Professional
|
$209.79
|
|
|
Service Code
|
HCPCS 74445 26
|
| Min. Negotiated Rate |
$41.96 |
| Max. Negotiated Rate |
$328.31 |
| Rate for Payer: Cash Price |
$57.97
|
| Rate for Payer: Cash Price |
$57.97
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$53.95
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$53.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$56.94
|
| Rate for Payer: Fidelis Medicare Advantage |
$59.94
|
| Rate for Payer: Fidelis Qualified Health Plan |
$56.94
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$59.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$59.94
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$44.96
|
| Rate for Payer: Healthfirst Medicare Advantage |
$56.94
|
| Rate for Payer: Healthfirst QHP |
$59.94
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$41.96
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$59.94
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$50.95
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$41.96
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$59.94
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$157.34
|
| Rate for Payer: SOMOS Essential |
$157.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$59.94
|
|
|
CHG CORPORA CAVERNOSOGRAPY RS&I
|
Professional
|
$437.75
|
|
|
Service Code
|
HCPCS 74445
|
| Min. Negotiated Rate |
$41.96 |
| Max. Negotiated Rate |
$328.31 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$328.31
|
| Rate for Payer: SOMOS Essential |
$328.31
|
|
|
CHG CORPORA CAVERNOSOGRAPY RS&I
|
Professional
|
$227.96
|
|
|
Service Code
|
HCPCS 74445 TC
|
| Min. Negotiated Rate |
$41.96 |
| Max. Negotiated Rate |
$328.31 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$170.97
|
| Rate for Payer: SOMOS Essential |
$170.97
|
|
|
CHG CPLX DYNAMIC PHARYNGEAL&SP EVAL C/V REC
|
Professional
|
$293.13
|
|
|
Service Code
|
HCPCS 70371 TC
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$343.61 |
| Rate for Payer: Cash Price |
$80.78
|
| Rate for Payer: Cash Price |
$80.78
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$75.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$75.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$79.56
|
| Rate for Payer: Fidelis Medicare Advantage |
$83.75
|
| Rate for Payer: Fidelis Qualified Health Plan |
$79.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$83.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$83.75
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$62.81
|
| Rate for Payer: Healthfirst Medicare Advantage |
$79.56
|
| Rate for Payer: Healthfirst QHP |
$83.75
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$58.62
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$83.75
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$71.19
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$58.62
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$83.75
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$219.85
|
| Rate for Payer: SOMOS Essential |
$219.85
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$83.75
|
|
|
CHG CPLX DYNAMIC PHARYNGEAL&SP EVAL C/V REC
|
Professional
|
$165.03
|
|
|
Service Code
|
HCPCS 70371 26
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$343.61 |
| Rate for Payer: Cash Price |
$45.55
|
| Rate for Payer: Cash Price |
$45.55
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$42.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$42.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$44.79
|
| Rate for Payer: Fidelis Medicare Advantage |
$47.15
|
| Rate for Payer: Fidelis Qualified Health Plan |
$44.79
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$47.15
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$47.15
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$35.36
|
| Rate for Payer: Healthfirst Medicare Advantage |
$44.79
|
| Rate for Payer: Healthfirst QHP |
$47.15
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$33.00
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$47.15
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$40.08
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$33.00
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$47.15
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$123.77
|
| Rate for Payer: SOMOS Essential |
$123.77
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$47.15
|
|
|
CHG CPLX DYNAMIC PHARYNGEAL&SP EVAL C/V REC
|
Professional
|
$458.15
|
|
|
Service Code
|
HCPCS 70371
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$343.61 |
| Rate for Payer: Cash Price |
$126.33
|
| Rate for Payer: Cash Price |
$126.33
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$117.81
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$117.81
|
| Rate for Payer: Fidelis Essential Plan QHP |
$124.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$130.90
|
| Rate for Payer: Fidelis Qualified Health Plan |
$124.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$130.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$130.90
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$98.18
|
| Rate for Payer: Healthfirst Medicare Advantage |
$124.36
|
| Rate for Payer: Healthfirst QHP |
$130.90
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$91.63
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$130.90
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$111.26
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$91.63
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$130.90
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$343.61
|
| Rate for Payer: SOMOS Essential |
$343.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$130.90
|
|
|
CHG CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP
|
Professional
|
$449.86
|
|
|
Service Code
|
HCPCS 75635 26
|
| Min. Negotiated Rate |
$89.97 |
| Max. Negotiated Rate |
$912.90 |
| Rate for Payer: Cash Price |
$122.87
|
| Rate for Payer: Cash Price |
$122.87
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$115.68
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$115.68
|
| Rate for Payer: Fidelis Essential Plan QHP |
$122.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$128.53
|
| Rate for Payer: Fidelis Qualified Health Plan |
$122.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$128.53
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$128.53
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$96.40
|
| Rate for Payer: Healthfirst Medicare Advantage |
$122.10
|
| Rate for Payer: Healthfirst QHP |
$128.53
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$89.97
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$128.53
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$109.25
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$89.97
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$128.53
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$337.40
|
| Rate for Payer: SOMOS Essential |
$337.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$128.53
|
|
|
CHG CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP
|
Professional
|
$1,217.20
|
|
|
Service Code
|
HCPCS 75635
|
| Min. Negotiated Rate |
$89.97 |
| Max. Negotiated Rate |
$912.90 |
| Rate for Payer: Cash Price |
$490.25
|
| Rate for Payer: Cash Price |
$490.25
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$464.48
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$464.48
|
| Rate for Payer: Fidelis Essential Plan QHP |
$490.29
|
| Rate for Payer: Fidelis Medicare Advantage |
$516.09
|
| Rate for Payer: Fidelis Qualified Health Plan |
$490.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$516.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$516.09
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$387.07
|
| Rate for Payer: Healthfirst Medicare Advantage |
$490.29
|
| Rate for Payer: Healthfirst QHP |
$516.09
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$361.26
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$516.09
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$438.68
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$361.26
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$516.09
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$912.90
|
| Rate for Payer: SOMOS Essential |
$912.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$516.09
|
|
|
CHG CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP
|
Professional
|
$767.34
|
|
|
Service Code
|
HCPCS 75635 TC
|
| Min. Negotiated Rate |
$89.97 |
| Max. Negotiated Rate |
$912.90 |
| Rate for Payer: Cash Price |
$367.38
|
| Rate for Payer: Cash Price |
$367.38
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$348.80
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$348.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$368.17
|
| Rate for Payer: Fidelis Medicare Advantage |
$387.55
|
| Rate for Payer: Fidelis Qualified Health Plan |
$368.17
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$387.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$387.55
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$290.66
|
| Rate for Payer: Healthfirst Medicare Advantage |
$368.17
|
| Rate for Payer: Healthfirst QHP |
$387.55
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$271.28
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$387.55
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$329.42
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$271.28
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$387.55
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$575.50
|
| Rate for Payer: SOMOS Essential |
$575.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$387.55
|
|
|
CHG CT ABDOMEN & PELVIS W/CONTRAST MATERIAL
|
Professional
|
$350.18
|
|
|
Service Code
|
HCPCS 74177 26
|
| Min. Negotiated Rate |
$70.04 |
| Max. Negotiated Rate |
$1,012.81 |
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$90.04
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$90.04
|
| Rate for Payer: Fidelis Essential Plan QHP |
$95.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$100.05
|
| Rate for Payer: Fidelis Qualified Health Plan |
$95.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$100.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$100.05
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$75.04
|
| Rate for Payer: Healthfirst Medicare Advantage |
$95.05
|
| Rate for Payer: Healthfirst QHP |
$100.05
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$70.04
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$100.05
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$85.04
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$70.04
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$100.05
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$262.64
|
| Rate for Payer: SOMOS Essential |
$262.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$100.05
|
|
|
CHG CT ABDOMEN & PELVIS W/CONTRAST MATERIAL
|
Professional
|
$1,000.23
|
|
|
Service Code
|
HCPCS 74177 TC
|
| Min. Negotiated Rate |
$70.04 |
| Max. Negotiated Rate |
$1,012.81 |
| Rate for Payer: Cash Price |
$267.27
|
| Rate for Payer: Cash Price |
$267.27
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$257.20
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$257.20
|
| Rate for Payer: Fidelis Essential Plan QHP |
$271.49
|
| Rate for Payer: Fidelis Medicare Advantage |
$285.78
|
| Rate for Payer: Fidelis Qualified Health Plan |
$271.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$285.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$285.78
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$214.34
|
| Rate for Payer: Healthfirst Medicare Advantage |
$271.49
|
| Rate for Payer: Healthfirst QHP |
$285.78
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$200.05
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$285.78
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$242.91
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$200.05
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$285.78
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$750.17
|
| Rate for Payer: SOMOS Essential |
$750.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$285.78
|
|
|
CHG CT ABDOMEN & PELVIS W/CONTRAST MATERIAL
|
Professional
|
$1,350.41
|
|
|
Service Code
|
HCPCS 74177
|
| Min. Negotiated Rate |
$70.04 |
| Max. Negotiated Rate |
$1,012.81 |
| Rate for Payer: Cash Price |
$361.51
|
| Rate for Payer: Cash Price |
$361.51
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$347.25
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$347.25
|
| Rate for Payer: Fidelis Essential Plan QHP |
$366.54
|
| Rate for Payer: Fidelis Medicare Advantage |
$385.83
|
| Rate for Payer: Fidelis Qualified Health Plan |
$366.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$385.83
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$385.83
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$289.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$366.54
|
| Rate for Payer: Healthfirst QHP |
$385.83
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$270.08
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$385.83
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$327.96
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$270.08
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$385.83
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,012.81
|
| Rate for Payer: SOMOS Essential |
$1,012.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$385.83
|
|
|
CHG CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL
|
Professional
|
$464.03
|
|
|
Service Code
|
HCPCS 74176 TC
|
| Min. Negotiated Rate |
$67.17 |
| Max. Negotiated Rate |
$599.92 |
| Rate for Payer: Cash Price |
$125.81
|
| Rate for Payer: Cash Price |
$125.81
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$119.32
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$119.32
|
| Rate for Payer: Fidelis Essential Plan QHP |
$125.95
|
| Rate for Payer: Fidelis Medicare Advantage |
$132.58
|
| Rate for Payer: Fidelis Qualified Health Plan |
$125.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$132.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$132.58
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$99.44
|
| Rate for Payer: Healthfirst Medicare Advantage |
$125.95
|
| Rate for Payer: Healthfirst QHP |
$132.58
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$92.81
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$132.58
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$112.69
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$92.81
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$132.58
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$348.02
|
| Rate for Payer: SOMOS Essential |
$348.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$132.58
|
|
|
CHG CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL
|
Professional
|
$799.89
|
|
|
Service Code
|
HCPCS 74176
|
| Min. Negotiated Rate |
$67.17 |
| Max. Negotiated Rate |
$599.92 |
| Rate for Payer: Cash Price |
$216.09
|
| Rate for Payer: Cash Price |
$216.09
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$205.69
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$205.69
|
| Rate for Payer: Fidelis Essential Plan QHP |
$217.11
|
| Rate for Payer: Fidelis Medicare Advantage |
$228.54
|
| Rate for Payer: Fidelis Qualified Health Plan |
$217.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$228.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$228.54
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$171.40
|
| Rate for Payer: Healthfirst Medicare Advantage |
$217.11
|
| Rate for Payer: Healthfirst QHP |
$228.54
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$159.98
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$228.54
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$194.26
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$159.98
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$228.54
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$599.92
|
| Rate for Payer: SOMOS Essential |
$599.92
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$228.54
|
|
|
CHG CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL
|
Professional
|
$335.86
|
|
|
Service Code
|
HCPCS 74176 26
|
| Min. Negotiated Rate |
$67.17 |
| Max. Negotiated Rate |
$599.92 |
| Rate for Payer: Cash Price |
$90.28
|
| Rate for Payer: Cash Price |
$90.28
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$86.36
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$86.36
|
| Rate for Payer: Fidelis Essential Plan QHP |
$91.16
|
| Rate for Payer: Fidelis Medicare Advantage |
$95.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$91.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$95.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$95.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$71.97
|
| Rate for Payer: Healthfirst Medicare Advantage |
$91.16
|
| Rate for Payer: Healthfirst QHP |
$95.96
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$67.17
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$95.96
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$81.57
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$67.17
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$95.96
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$251.90
|
| Rate for Payer: SOMOS Essential |
$251.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$95.96
|
|
|
CHG CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE
|
Professional
|
$1,128.16
|
|
|
Service Code
|
HCPCS 74178 TC
|
| Min. Negotiated Rate |
$76.52 |
| Max. Negotiated Rate |
$1,133.08 |
| Rate for Payer: Cash Price |
$302.08
|
| Rate for Payer: Cash Price |
$302.08
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$290.10
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$290.10
|
| Rate for Payer: Fidelis Essential Plan QHP |
$306.21
|
| Rate for Payer: Fidelis Medicare Advantage |
$322.33
|
| Rate for Payer: Fidelis Qualified Health Plan |
$306.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$322.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$322.33
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$241.75
|
| Rate for Payer: Healthfirst Medicare Advantage |
$306.21
|
| Rate for Payer: Healthfirst QHP |
$322.33
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$225.63
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$322.33
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$273.98
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$225.63
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$322.33
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$846.12
|
| Rate for Payer: SOMOS Essential |
$846.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$322.33
|
|
|
CHG CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE
|
Professional
|
$1,510.78
|
|
|
Service Code
|
HCPCS 74178
|
| Min. Negotiated Rate |
$76.52 |
| Max. Negotiated Rate |
$1,133.08 |
| Rate for Payer: Cash Price |
$405.93
|
| Rate for Payer: Cash Price |
$405.93
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$388.48
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$388.48
|
| Rate for Payer: Fidelis Essential Plan QHP |
$410.07
|
| Rate for Payer: Fidelis Medicare Advantage |
$431.65
|
| Rate for Payer: Fidelis Qualified Health Plan |
$410.07
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$431.65
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$431.65
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$323.74
|
| Rate for Payer: Healthfirst Medicare Advantage |
$410.07
|
| Rate for Payer: Healthfirst QHP |
$431.65
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$302.16
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$431.65
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$366.90
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$302.16
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$431.65
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,133.08
|
| Rate for Payer: SOMOS Essential |
$1,133.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$431.65
|
|
|
CHG CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE
|
Professional
|
$382.62
|
|
|
Service Code
|
HCPCS 74178 26
|
| Min. Negotiated Rate |
$76.52 |
| Max. Negotiated Rate |
$1,133.08 |
| Rate for Payer: Cash Price |
$103.86
|
| Rate for Payer: Cash Price |
$103.86
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$98.39
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$98.39
|
| Rate for Payer: Fidelis Essential Plan QHP |
$103.85
|
| Rate for Payer: Fidelis Medicare Advantage |
$109.32
|
| Rate for Payer: Fidelis Qualified Health Plan |
$103.85
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$109.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$109.32
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$81.99
|
| Rate for Payer: Healthfirst Medicare Advantage |
$103.85
|
| Rate for Payer: Healthfirst QHP |
$109.32
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$76.52
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$109.32
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$92.92
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$76.52
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$109.32
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$286.96
|
| Rate for Payer: SOMOS Essential |
$286.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$109.32
|
|
|
CHG CT ABDOMEN W/CONTRAST MATERIAL
|
Professional
|
$1,011.68
|
|
|
Service Code
|
HCPCS 74160
|
| Min. Negotiated Rate |
$48.87 |
| Max. Negotiated Rate |
$758.76 |
| Rate for Payer: Cash Price |
$278.61
|
| Rate for Payer: Cash Price |
$278.61
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$267.54
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$267.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$282.41
|
| Rate for Payer: Fidelis Medicare Advantage |
$297.27
|
| Rate for Payer: Fidelis Qualified Health Plan |
$282.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$297.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$297.27
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$222.95
|
| Rate for Payer: Healthfirst Medicare Advantage |
$282.41
|
| Rate for Payer: Healthfirst QHP |
$297.27
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$208.09
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$297.27
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$252.68
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$208.09
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$297.27
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$758.76
|
| Rate for Payer: SOMOS Essential |
$758.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$297.27
|
|
|
CHG CT ABDOMEN W/CONTRAST MATERIAL
|
Professional
|
$767.34
|
|
|
Service Code
|
HCPCS 74160 TC
|
| Min. Negotiated Rate |
$48.87 |
| Max. Negotiated Rate |
$758.76 |
| Rate for Payer: Cash Price |
$212.26
|
| Rate for Payer: Cash Price |
$212.26
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$204.71
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$204.71
|
| Rate for Payer: Fidelis Essential Plan QHP |
$216.09
|
| Rate for Payer: Fidelis Medicare Advantage |
$227.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$216.09
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$227.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$227.46
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$170.60
|
| Rate for Payer: Healthfirst Medicare Advantage |
$216.09
|
| Rate for Payer: Healthfirst QHP |
$227.46
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$159.22
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$227.46
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$193.34
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$159.22
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$227.46
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$575.50
|
| Rate for Payer: SOMOS Essential |
$575.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.46
|
|
