|
CHG CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL
|
Professional
|
$629.34
|
|
|
Service Code
|
HCPCS 72133 TC
|
| Min. Negotiated Rate |
$48.87 |
| Max. Negotiated Rate |
$655.25 |
| Rate for Payer: Cash Price |
$169.82
|
| Rate for Payer: Cash Price |
$169.82
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$161.83
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$161.83
|
| Rate for Payer: Fidelis Essential Plan QHP |
$170.82
|
| Rate for Payer: Fidelis Medicare Advantage |
$179.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$170.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$179.81
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$179.81
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$134.86
|
| Rate for Payer: Healthfirst Medicare Advantage |
$170.82
|
| Rate for Payer: Healthfirst QHP |
$179.81
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$125.87
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$179.81
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$152.84
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$125.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$179.81
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$472.00
|
| Rate for Payer: SOMOS Essential |
$472.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$179.81
|
|
|
CHG CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL
|
Professional
|
$244.34
|
|
|
Service Code
|
HCPCS 72133 26
|
| Min. Negotiated Rate |
$48.87 |
| Max. Negotiated Rate |
$655.25 |
| Rate for Payer: Cash Price |
$65.96
|
| Rate for Payer: Cash Price |
$65.96
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$62.83
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$62.83
|
| Rate for Payer: Fidelis Essential Plan QHP |
$66.32
|
| Rate for Payer: Fidelis Medicare Advantage |
$69.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$66.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$69.81
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$69.81
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$52.36
|
| Rate for Payer: Healthfirst Medicare Advantage |
$66.32
|
| Rate for Payer: Healthfirst QHP |
$69.81
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$48.87
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$69.81
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$59.34
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$48.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$69.81
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$183.26
|
| Rate for Payer: SOMOS Essential |
$183.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$69.81
|
|
|
CHG CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL
|
Professional
|
$873.67
|
|
|
Service Code
|
HCPCS 72133
|
| Min. Negotiated Rate |
$48.87 |
| Max. Negotiated Rate |
$655.25 |
| Rate for Payer: Cash Price |
$235.78
|
| Rate for Payer: Cash Price |
$235.78
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$224.66
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$224.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$237.14
|
| Rate for Payer: Fidelis Medicare Advantage |
$249.62
|
| Rate for Payer: Fidelis Qualified Health Plan |
$237.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$249.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$249.62
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$187.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$237.14
|
| Rate for Payer: Healthfirst QHP |
$249.62
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$174.73
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$249.62
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$212.18
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$174.73
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$249.62
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$655.25
|
| Rate for Payer: SOMOS Essential |
$655.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$249.62
|
|
|
CHG CT MAXILLOFACIAL W/CONTRAST MATERIAL
|
Professional
|
$666.68
|
|
|
Service Code
|
HCPCS 70487
|
| Min. Negotiated Rate |
$43.38 |
| Max. Negotiated Rate |
$500.01 |
| Rate for Payer: Cash Price |
$180.76
|
| Rate for Payer: Cash Price |
$180.76
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$171.43
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$171.43
|
| Rate for Payer: Fidelis Essential Plan QHP |
$180.96
|
| Rate for Payer: Fidelis Medicare Advantage |
$190.48
|
| Rate for Payer: Fidelis Qualified Health Plan |
$180.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$190.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$190.48
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$142.86
|
| Rate for Payer: Healthfirst Medicare Advantage |
$180.96
|
| Rate for Payer: Healthfirst QHP |
$190.48
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$133.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$190.48
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$161.91
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$133.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$190.48
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$500.01
|
| Rate for Payer: SOMOS Essential |
$500.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$190.48
|
|
|
CHG CT MAXILLOFACIAL W/CONTRAST MATERIAL
|
Professional
|
$449.79
|
|
|
Service Code
|
HCPCS 70487 TC
|
| Min. Negotiated Rate |
$43.38 |
| Max. Negotiated Rate |
$500.01 |
| Rate for Payer: Cash Price |
$122.27
|
| Rate for Payer: Cash Price |
$122.27
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$115.66
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$115.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$122.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$128.51
|
| Rate for Payer: Fidelis Qualified Health Plan |
$122.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$128.51
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$128.51
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$96.38
|
| Rate for Payer: Healthfirst Medicare Advantage |
$122.08
|
| Rate for Payer: Healthfirst QHP |
$128.51
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$89.96
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$128.51
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$109.23
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$89.96
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$128.51
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$337.34
|
| Rate for Payer: SOMOS Essential |
$337.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$128.51
|
|
|
CHG CT MAXILLOFACIAL W/CONTRAST MATERIAL
|
Professional
|
$216.90
|
|
|
Service Code
|
HCPCS 70487 26
|
| Min. Negotiated Rate |
$43.38 |
| Max. Negotiated Rate |
$500.01 |
| Rate for Payer: Cash Price |
$58.48
|
| Rate for Payer: Cash Price |
$58.48
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$55.77
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$55.77
|
| Rate for Payer: Fidelis Essential Plan QHP |
$58.87
|
| Rate for Payer: Fidelis Medicare Advantage |
$61.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$58.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$61.97
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$61.97
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$46.48
|
| Rate for Payer: Healthfirst Medicare Advantage |
$58.87
|
| Rate for Payer: Healthfirst QHP |
$61.97
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$43.38
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$61.97
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$52.67
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$43.38
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$61.97
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$162.68
|
| Rate for Payer: SOMOS Essential |
$162.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$61.97
|
|
|
CHG CT MAXILLOFACIAL W/O CONTRAST MATERIAL
|
Professional
|
$163.42
|
|
|
Service Code
|
HCPCS 70486 26
|
| Min. Negotiated Rate |
$32.68 |
| Max. Negotiated Rate |
$422.18 |
| Rate for Payer: Cash Price |
$44.33
|
| Rate for Payer: Cash Price |
$44.33
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$42.02
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$42.02
|
| Rate for Payer: Fidelis Essential Plan QHP |
$44.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$46.69
|
| Rate for Payer: Fidelis Qualified Health Plan |
$44.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$46.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$46.69
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$35.02
|
| Rate for Payer: Healthfirst Medicare Advantage |
$44.36
|
| Rate for Payer: Healthfirst QHP |
$46.69
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$32.68
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$46.69
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$39.69
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$32.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$46.69
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$122.56
|
| Rate for Payer: SOMOS Essential |
$122.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$46.69
|
|
|
CHG CT MAXILLOFACIAL W/O CONTRAST MATERIAL
|
Professional
|
$562.91
|
|
|
Service Code
|
HCPCS 70486
|
| Min. Negotiated Rate |
$32.68 |
| Max. Negotiated Rate |
$422.18 |
| Rate for Payer: Cash Price |
$152.22
|
| Rate for Payer: Cash Price |
$152.22
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$144.75
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$144.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$152.79
|
| Rate for Payer: Fidelis Medicare Advantage |
$160.83
|
| Rate for Payer: Fidelis Qualified Health Plan |
$152.79
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$160.83
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$160.83
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$120.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$152.79
|
| Rate for Payer: Healthfirst QHP |
$160.83
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$112.58
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$160.83
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$136.71
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$112.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$160.83
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$422.18
|
| Rate for Payer: SOMOS Essential |
$422.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$160.83
|
|
|
CHG CT MAXILLOFACIAL W/O CONTRAST MATERIAL
|
Professional
|
$399.49
|
|
|
Service Code
|
HCPCS 70486 TC
|
| Min. Negotiated Rate |
$32.68 |
| Max. Negotiated Rate |
$422.18 |
| Rate for Payer: Cash Price |
$107.90
|
| Rate for Payer: Cash Price |
$107.90
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$102.73
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$102.73
|
| Rate for Payer: Fidelis Essential Plan QHP |
$108.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$114.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$108.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$114.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$114.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$85.60
|
| Rate for Payer: Healthfirst Medicare Advantage |
$108.43
|
| Rate for Payer: Healthfirst QHP |
$114.14
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$79.90
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$114.14
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$97.02
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$79.90
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$114.14
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$299.62
|
| Rate for Payer: SOMOS Essential |
$299.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$114.14
|
|
|
CHG CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL
|
Professional
|
$570.40
|
|
|
Service Code
|
HCPCS 70488 TC
|
| Min. Negotiated Rate |
$48.87 |
| Max. Negotiated Rate |
$611.08 |
| Rate for Payer: Cash Price |
$153.32
|
| Rate for Payer: Cash Price |
$153.32
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$146.67
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$146.67
|
| Rate for Payer: Fidelis Essential Plan QHP |
$154.82
|
| Rate for Payer: Fidelis Medicare Advantage |
$162.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$154.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$162.97
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$162.97
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$122.23
|
| Rate for Payer: Healthfirst Medicare Advantage |
$154.82
|
| Rate for Payer: Healthfirst QHP |
$162.97
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$114.08
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$162.97
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$138.52
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$114.08
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$162.97
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$427.80
|
| Rate for Payer: SOMOS Essential |
$427.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$162.97
|
|
|
CHG CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL
|
Professional
|
$814.77
|
|
|
Service Code
|
HCPCS 70488
|
| Min. Negotiated Rate |
$48.87 |
| Max. Negotiated Rate |
$611.08 |
| Rate for Payer: Cash Price |
$219.27
|
| Rate for Payer: Cash Price |
$219.27
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$209.51
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$209.51
|
| Rate for Payer: Fidelis Essential Plan QHP |
$221.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$232.79
|
| Rate for Payer: Fidelis Qualified Health Plan |
$221.15
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$232.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$232.79
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$174.59
|
| Rate for Payer: Healthfirst Medicare Advantage |
$221.15
|
| Rate for Payer: Healthfirst QHP |
$232.79
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$162.95
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$232.79
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$197.87
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$162.95
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$232.79
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$611.08
|
| Rate for Payer: SOMOS Essential |
$611.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$232.79
|
|
|
CHG CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL
|
Professional
|
$244.34
|
|
|
Service Code
|
HCPCS 70488 26
|
| Min. Negotiated Rate |
$48.87 |
| Max. Negotiated Rate |
$611.08 |
| Rate for Payer: Cash Price |
$65.96
|
| Rate for Payer: Cash Price |
$65.96
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$62.83
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$62.83
|
| Rate for Payer: Fidelis Essential Plan QHP |
$66.32
|
| Rate for Payer: Fidelis Medicare Advantage |
$69.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$66.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$69.81
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$69.81
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$52.36
|
| Rate for Payer: Healthfirst Medicare Advantage |
$66.32
|
| Rate for Payer: Healthfirst QHP |
$69.81
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$48.87
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$69.81
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$59.34
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$48.87
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$69.81
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$183.26
|
| Rate for Payer: SOMOS Essential |
$183.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$69.81
|
|
|
CHG CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL
|
Professional
|
$580.48
|
|
|
Service Code
|
HCPCS 70481 TC
|
| Min. Negotiated Rate |
$43.38 |
| Max. Negotiated Rate |
$598.03 |
| Rate for Payer: Cash Price |
$156.46
|
| Rate for Payer: Cash Price |
$156.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$149.26
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$149.26
|
| Rate for Payer: Fidelis Essential Plan QHP |
$157.56
|
| Rate for Payer: Fidelis Medicare Advantage |
$165.85
|
| Rate for Payer: Fidelis Qualified Health Plan |
$157.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$165.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$165.85
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$124.39
|
| Rate for Payer: Healthfirst Medicare Advantage |
$157.56
|
| Rate for Payer: Healthfirst QHP |
$165.85
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$116.10
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$165.85
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$140.97
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$116.10
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$165.85
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$435.36
|
| Rate for Payer: SOMOS Essential |
$435.36
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$165.85
|
|
|
CHG CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL
|
Professional
|
$216.90
|
|
|
Service Code
|
HCPCS 70481 26
|
| Min. Negotiated Rate |
$43.38 |
| Max. Negotiated Rate |
$598.03 |
| Rate for Payer: Cash Price |
$58.88
|
| Rate for Payer: Cash Price |
$58.88
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$55.77
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$55.77
|
| Rate for Payer: Fidelis Essential Plan QHP |
$58.87
|
| Rate for Payer: Fidelis Medicare Advantage |
$61.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$58.87
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$61.97
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$61.97
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$46.48
|
| Rate for Payer: Healthfirst Medicare Advantage |
$58.87
|
| Rate for Payer: Healthfirst QHP |
$61.97
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$43.38
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$61.97
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$52.67
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$43.38
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$61.97
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$162.68
|
| Rate for Payer: SOMOS Essential |
$162.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$61.97
|
|
|
CHG CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL
|
Professional
|
$797.37
|
|
|
Service Code
|
HCPCS 70481
|
| Min. Negotiated Rate |
$43.38 |
| Max. Negotiated Rate |
$598.03 |
| Rate for Payer: Cash Price |
$215.34
|
| Rate for Payer: Cash Price |
$215.34
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$205.04
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$205.04
|
| Rate for Payer: Fidelis Essential Plan QHP |
$216.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$227.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$216.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$227.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$227.82
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$170.86
|
| Rate for Payer: Healthfirst Medicare Advantage |
$216.43
|
| Rate for Payer: Healthfirst QHP |
$227.82
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$159.47
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$227.82
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$193.65
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$159.47
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$227.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$598.03
|
| Rate for Payer: SOMOS Essential |
$598.03
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.82
|
|
|
CHG CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL
|
Professional
|
$446.92
|
|
|
Service Code
|
HCPCS 70480 TC
|
| Min. Negotiated Rate |
$49.41 |
| Max. Negotiated Rate |
$520.46 |
| Rate for Payer: Cash Price |
$121.49
|
| Rate for Payer: Cash Price |
$121.49
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$114.92
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$114.92
|
| Rate for Payer: Fidelis Essential Plan QHP |
$121.31
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.69
|
| Rate for Payer: Fidelis Qualified Health Plan |
$121.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$127.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.69
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$95.77
|
| Rate for Payer: Healthfirst Medicare Advantage |
$121.31
|
| Rate for Payer: Healthfirst QHP |
$127.69
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$89.38
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$127.69
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$108.54
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$89.38
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.69
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$335.19
|
| Rate for Payer: SOMOS Essential |
$335.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.69
|
|
|
CHG CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL
|
Professional
|
$693.95
|
|
|
Service Code
|
HCPCS 70480
|
| Min. Negotiated Rate |
$49.41 |
| Max. Negotiated Rate |
$520.46 |
| Rate for Payer: Cash Price |
$188.58
|
| Rate for Payer: Cash Price |
$188.58
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$178.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$178.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$188.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$198.27
|
| Rate for Payer: Fidelis Qualified Health Plan |
$188.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$198.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$198.27
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$148.70
|
| Rate for Payer: Healthfirst Medicare Advantage |
$188.36
|
| Rate for Payer: Healthfirst QHP |
$198.27
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$138.79
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$198.27
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$168.53
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$138.79
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$198.27
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$520.46
|
| Rate for Payer: SOMOS Essential |
$520.46
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$198.27
|
|
|
CHG CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL
|
Professional
|
$247.03
|
|
|
Service Code
|
HCPCS 70480 26
|
| Min. Negotiated Rate |
$49.41 |
| Max. Negotiated Rate |
$520.46 |
| Rate for Payer: Cash Price |
$67.09
|
| Rate for Payer: Cash Price |
$67.09
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$63.52
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$63.52
|
| Rate for Payer: Fidelis Essential Plan QHP |
$67.05
|
| Rate for Payer: Fidelis Medicare Advantage |
$70.58
|
| Rate for Payer: Fidelis Qualified Health Plan |
$67.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$70.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$70.58
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$52.94
|
| Rate for Payer: Healthfirst Medicare Advantage |
$67.05
|
| Rate for Payer: Healthfirst QHP |
$70.58
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$49.41
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$70.58
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$59.99
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$49.41
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$70.58
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$185.27
|
| Rate for Payer: SOMOS Essential |
$185.27
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$70.58
|
|
|
CHG CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR
|
Professional
|
$242.90
|
|
|
Service Code
|
HCPCS 70482 26
|
| Min. Negotiated Rate |
$48.58 |
| Max. Negotiated Rate |
$698.38 |
| Rate for Payer: Cash Price |
$65.96
|
| Rate for Payer: Cash Price |
$65.96
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$62.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$62.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$65.93
|
| Rate for Payer: Fidelis Medicare Advantage |
$69.40
|
| Rate for Payer: Fidelis Qualified Health Plan |
$65.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$69.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$69.40
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$52.05
|
| Rate for Payer: Healthfirst Medicare Advantage |
$65.93
|
| Rate for Payer: Healthfirst QHP |
$69.40
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$48.58
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$69.40
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$58.99
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$48.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$69.40
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$182.18
|
| Rate for Payer: SOMOS Essential |
$182.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$69.40
|
|
|
CHG CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR
|
Professional
|
$931.18
|
|
|
Service Code
|
HCPCS 70482
|
| Min. Negotiated Rate |
$48.58 |
| Max. Negotiated Rate |
$698.38 |
| Rate for Payer: Cash Price |
$251.49
|
| Rate for Payer: Cash Price |
$251.49
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$239.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$239.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$252.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$266.05
|
| Rate for Payer: Fidelis Qualified Health Plan |
$252.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$266.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$266.05
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$199.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$252.75
|
| Rate for Payer: Healthfirst QHP |
$266.05
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$186.24
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$266.05
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$226.14
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$186.24
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$266.05
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$698.38
|
| Rate for Payer: SOMOS Essential |
$698.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$266.05
|
|
|
CHG CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR
|
Professional
|
$688.28
|
|
|
Service Code
|
HCPCS 70482 TC
|
| Min. Negotiated Rate |
$48.58 |
| Max. Negotiated Rate |
$698.38 |
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$176.98
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$176.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$186.82
|
| Rate for Payer: Fidelis Medicare Advantage |
$196.65
|
| Rate for Payer: Fidelis Qualified Health Plan |
$186.82
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$196.65
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$196.65
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$147.49
|
| Rate for Payer: Healthfirst Medicare Advantage |
$186.82
|
| Rate for Payer: Healthfirst QHP |
$196.65
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$137.66
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$196.65
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$167.15
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$137.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$196.65
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$516.21
|
| Rate for Payer: SOMOS Essential |
$516.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$196.65
|
|
|
CHG CT PELVIS W/CONTRAST MATERIAL
|
Professional
|
$222.08
|
|
|
Service Code
|
HCPCS 72193 26
|
| Min. Negotiated Rate |
$44.42 |
| Max. Negotiated Rate |
$742.06 |
| Rate for Payer: Cash Price |
$60.32
|
| Rate for Payer: Cash Price |
$60.32
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$57.10
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$57.10
|
| Rate for Payer: Fidelis Essential Plan QHP |
$60.28
|
| Rate for Payer: Fidelis Medicare Advantage |
$63.45
|
| Rate for Payer: Fidelis Qualified Health Plan |
$60.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$63.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$63.45
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$47.59
|
| Rate for Payer: Healthfirst Medicare Advantage |
$60.28
|
| Rate for Payer: Healthfirst QHP |
$63.45
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$44.42
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$63.45
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$53.93
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$44.42
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$63.45
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$166.56
|
| Rate for Payer: SOMOS Essential |
$166.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$63.45
|
|
|
CHG CT PELVIS W/CONTRAST MATERIAL
|
Professional
|
$767.34
|
|
|
Service Code
|
HCPCS 72193 TC
|
| Min. Negotiated Rate |
$44.42 |
| Max. Negotiated Rate |
$742.06 |
| Rate for Payer: Cash Price |
$213.43
|
| Rate for Payer: Cash Price |
$213.43
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$205.82
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$205.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$217.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$228.69
|
| Rate for Payer: Fidelis Qualified Health Plan |
$217.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$228.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$228.69
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$171.52
|
| Rate for Payer: Healthfirst Medicare Advantage |
$217.26
|
| Rate for Payer: Healthfirst QHP |
$228.69
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$160.08
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$228.69
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$194.39
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$160.08
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$228.69
|
| 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 |
$228.69
|
|
|
CHG CT PELVIS W/CONTRAST MATERIAL
|
Professional
|
$989.42
|
|
|
Service Code
|
HCPCS 72193
|
| Min. Negotiated Rate |
$44.42 |
| Max. Negotiated Rate |
$742.06 |
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Cash Price |
$273.75
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$262.93
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$262.93
|
| Rate for Payer: Fidelis Essential Plan QHP |
$277.53
|
| Rate for Payer: Fidelis Medicare Advantage |
$292.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$277.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$292.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$292.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$219.10
|
| Rate for Payer: Healthfirst Medicare Advantage |
$277.53
|
| Rate for Payer: Healthfirst QHP |
$292.14
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$204.50
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$292.14
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$248.32
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$204.50
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$292.14
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$742.06
|
| Rate for Payer: SOMOS Essential |
$742.06
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$292.14
|
|
|
CHG CT PELVIS W/O CONTRAST MATERIAL
|
Professional
|
$582.61
|
|
|
Service Code
|
HCPCS 72192
|
| Min. Negotiated Rate |
$41.80 |
| Max. Negotiated Rate |
$436.96 |
| Rate for Payer: Cash Price |
$157.52
|
| Rate for Payer: Cash Price |
$157.52
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$149.81
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$149.81
|
| Rate for Payer: Fidelis Essential Plan QHP |
$158.14
|
| Rate for Payer: Fidelis Medicare Advantage |
$166.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$158.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$166.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$166.46
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$124.84
|
| Rate for Payer: Healthfirst Medicare Advantage |
$158.14
|
| Rate for Payer: Healthfirst QHP |
$166.46
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$116.52
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$166.46
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$141.49
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$116.52
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$166.46
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$436.96
|
| Rate for Payer: SOMOS Essential |
$436.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$166.46
|
|
