|
CHG LIVER & SPLEEN IMAGING W/VASCULAR FLOW
|
Professional
|
$108.22
|
|
|
Service Code
|
HCPCS 78216 26
|
| Min. Negotiated Rate |
$21.64 |
| Max. Negotiated Rate |
$414.96 |
| Rate for Payer: Cash Price |
$27.81
|
| Rate for Payer: Cash Price |
$27.81
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$27.83
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$27.83
|
| Rate for Payer: Fidelis Essential Plan QHP |
$29.37
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.92
|
| Rate for Payer: Fidelis Qualified Health Plan |
$29.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$30.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.92
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$23.19
|
| Rate for Payer: Healthfirst Medicare Advantage |
$29.37
|
| Rate for Payer: Healthfirst QHP |
$30.92
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$21.64
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$30.92
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$26.28
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$21.64
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.92
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$81.16
|
| Rate for Payer: SOMOS Essential |
$81.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$30.92
|
|
|
CHG LIVER & SPLEEN IMAGING W/VASCULAR FLOW
|
Professional
|
$445.06
|
|
|
Service Code
|
HCPCS 78216 TC
|
| Min. Negotiated Rate |
$21.64 |
| Max. Negotiated Rate |
$414.96 |
| Rate for Payer: Cash Price |
$121.79
|
| Rate for Payer: Cash Price |
$121.79
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$114.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$114.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$120.80
|
| Rate for Payer: Fidelis Medicare Advantage |
$127.16
|
| Rate for Payer: Fidelis Qualified Health Plan |
$120.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$127.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$127.16
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$95.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$120.80
|
| Rate for Payer: Healthfirst QHP |
$127.16
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$89.01
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$127.16
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$108.09
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$89.01
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$127.16
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$333.80
|
| Rate for Payer: SOMOS Essential |
$333.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$127.16
|
|
|
CHG LYMPHANGIOGRAPHY EXTREMITY ONLY BILATERAL RS&I
|
Professional
|
$1,320.59
|
|
|
Service Code
|
HCPCS 75803
|
| Min. Negotiated Rate |
$44.95 |
| Max. Negotiated Rate |
$990.44 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$990.44
|
| Rate for Payer: SOMOS Essential |
$990.44
|
|
|
CHG LYMPHANGIOGRAPHY EXTREMITY ONLY BILATERAL RS&I
|
Professional
|
$1,095.82
|
|
|
Service Code
|
HCPCS 75803 TC
|
| Min. Negotiated Rate |
$44.95 |
| Max. Negotiated Rate |
$990.44 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$821.86
|
| Rate for Payer: SOMOS Essential |
$821.86
|
|
|
CHG LYMPHANGIOGRAPHY EXTREMITY ONLY BILATERAL RS&I
|
Professional
|
$224.77
|
|
|
Service Code
|
HCPCS 75803 26
|
| Min. Negotiated Rate |
$44.95 |
| Max. Negotiated Rate |
$990.44 |
| Rate for Payer: Cash Price |
$61.06
|
| Rate for Payer: Cash Price |
$61.06
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$57.80
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$57.80
|
| Rate for Payer: Fidelis Essential Plan QHP |
$61.01
|
| Rate for Payer: Fidelis Medicare Advantage |
$64.22
|
| Rate for Payer: Fidelis Qualified Health Plan |
$61.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$64.22
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$64.22
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$48.16
|
| Rate for Payer: Healthfirst Medicare Advantage |
$61.01
|
| Rate for Payer: Healthfirst QHP |
$64.22
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$44.95
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$64.22
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$54.59
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$44.95
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$64.22
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$168.58
|
| Rate for Payer: SOMOS Essential |
$168.58
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$64.22
|
|
|
CHG LYMPHANGIOGRAPHY EXTREMITY ONLY UNILATERAL RS&I
|
Professional
|
$180.29
|
|
|
Service Code
|
HCPCS 75801 26
|
| Min. Negotiated Rate |
$36.06 |
| Max. Negotiated Rate |
$957.08 |
| Rate for Payer: Cash Price |
$48.96
|
| Rate for Payer: Cash Price |
$48.96
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$46.36
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$46.36
|
| Rate for Payer: Fidelis Essential Plan QHP |
$48.93
|
| Rate for Payer: Fidelis Medicare Advantage |
$51.51
|
| Rate for Payer: Fidelis Qualified Health Plan |
$48.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$51.51
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$51.51
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$38.63
|
| Rate for Payer: Healthfirst Medicare Advantage |
$48.93
|
| Rate for Payer: Healthfirst QHP |
$51.51
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$36.06
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$51.51
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$43.78
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$36.06
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$51.51
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$135.22
|
| Rate for Payer: SOMOS Essential |
$135.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$51.51
|
|
|
CHG LYMPHANGIOGRAPHY EXTREMITY ONLY UNILATERAL RS&I
|
Professional
|
$1,276.10
|
|
|
Service Code
|
HCPCS 75801
|
| Min. Negotiated Rate |
$36.06 |
| Max. Negotiated Rate |
$957.08 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$957.08
|
| Rate for Payer: SOMOS Essential |
$957.08
|
|
|
CHG LYMPHANGIOGRAPHY EXTREMITY ONLY UNILATERAL RS&I
|
Professional
|
$1,095.82
|
|
|
Service Code
|
HCPCS 75801 TC
|
| Min. Negotiated Rate |
$36.06 |
| Max. Negotiated Rate |
$957.08 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$821.86
|
| Rate for Payer: SOMOS Essential |
$821.86
|
|
|
CHG LYMPHANGIOGRAPHY PELVIC/ABDOMINAL BILATERAL RS&I
|
Professional
|
$1,238.65
|
|
|
Service Code
|
HCPCS 75807
|
| Min. Negotiated Rate |
$42.60 |
| Max. Negotiated Rate |
$928.99 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$928.99
|
| Rate for Payer: SOMOS Essential |
$928.99
|
|
|
CHG LYMPHANGIOGRAPHY PELVIC/ABDOMINAL BILATERAL RS&I
|
Professional
|
$212.98
|
|
|
Service Code
|
HCPCS 75807 26
|
| Min. Negotiated Rate |
$42.60 |
| Max. Negotiated Rate |
$928.99 |
| Rate for Payer: Cash Price |
$57.59
|
| Rate for Payer: Cash Price |
$57.59
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$54.76
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$54.76
|
| Rate for Payer: Fidelis Essential Plan QHP |
$57.81
|
| Rate for Payer: Fidelis Medicare Advantage |
$60.85
|
| Rate for Payer: Fidelis Qualified Health Plan |
$57.81
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$60.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$60.85
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$45.64
|
| Rate for Payer: Healthfirst Medicare Advantage |
$57.81
|
| Rate for Payer: Healthfirst QHP |
$60.85
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$42.60
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$60.85
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$51.72
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$42.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$60.85
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$159.74
|
| Rate for Payer: SOMOS Essential |
$159.74
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$60.85
|
|
|
CHG LYMPHANGIOGRAPHY PELVIC/ABDOMINAL BILATERAL RS&I
|
Professional
|
$1,025.68
|
|
|
Service Code
|
HCPCS 75807 TC
|
| Min. Negotiated Rate |
$42.60 |
| Max. Negotiated Rate |
$928.99 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$769.26
|
| Rate for Payer: SOMOS Essential |
$769.26
|
|
|
CHG LYMPHANGIOGRAPHY PELVIC/ABDOMINAL UNILAT RS&I
|
Professional
|
$155.51
|
|
|
Service Code
|
HCPCS 75805 26
|
| Min. Negotiated Rate |
$31.10 |
| Max. Negotiated Rate |
$1,043.57 |
| Rate for Payer: Cash Price |
$42.14
|
| Rate for Payer: Cash Price |
$42.14
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$39.99
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$39.99
|
| Rate for Payer: Fidelis Essential Plan QHP |
$42.21
|
| Rate for Payer: Fidelis Medicare Advantage |
$44.43
|
| Rate for Payer: Fidelis Qualified Health Plan |
$42.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$44.43
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$44.43
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$33.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$42.21
|
| Rate for Payer: Healthfirst QHP |
$44.43
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$31.10
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$44.43
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$37.77
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$31.10
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$44.43
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$116.63
|
| Rate for Payer: SOMOS Essential |
$116.63
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$44.43
|
|
|
CHG LYMPHANGIOGRAPHY PELVIC/ABDOMINAL UNILAT RS&I
|
Professional
|
$1,235.92
|
|
|
Service Code
|
HCPCS 75805 TC
|
| Min. Negotiated Rate |
$31.10 |
| Max. Negotiated Rate |
$1,043.57 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$926.94
|
| Rate for Payer: SOMOS Essential |
$926.94
|
|
|
CHG LYMPHANGIOGRAPHY PELVIC/ABDOMINAL UNILAT RS&I
|
Professional
|
$1,391.43
|
|
|
Service Code
|
HCPCS 75805
|
| Min. Negotiated Rate |
$31.10 |
| Max. Negotiated Rate |
$1,043.57 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,043.57
|
| Rate for Payer: SOMOS Essential |
$1,043.57
|
|
|
CHG LYMPHATICS & LYMPH NODES IMAGING
|
Professional
|
$1,186.82
|
|
|
Service Code
|
HCPCS 78195 TC
|
| Min. Negotiated Rate |
$44.56 |
| Max. Negotiated Rate |
$1,057.19 |
| Rate for Payer: Cash Price |
$318.49
|
| Rate for Payer: Cash Price |
$318.49
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$305.18
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$305.18
|
| Rate for Payer: Fidelis Essential Plan QHP |
$322.14
|
| Rate for Payer: Fidelis Medicare Advantage |
$339.09
|
| Rate for Payer: Fidelis Qualified Health Plan |
$322.14
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$339.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$339.09
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$254.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$322.14
|
| Rate for Payer: Healthfirst QHP |
$339.09
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$237.36
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$339.09
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$288.23
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$237.36
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$339.09
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$890.12
|
| Rate for Payer: SOMOS Essential |
$890.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$339.09
|
|
|
CHG LYMPHATICS & LYMPH NODES IMAGING
|
Professional
|
$222.78
|
|
|
Service Code
|
HCPCS 78195 26
|
| Min. Negotiated Rate |
$44.56 |
| Max. Negotiated Rate |
$1,057.19 |
| Rate for Payer: Cash Price |
$60.53
|
| Rate for Payer: Cash Price |
$60.53
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$57.28
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$57.28
|
| Rate for Payer: Fidelis Essential Plan QHP |
$60.47
|
| Rate for Payer: Fidelis Medicare Advantage |
$63.65
|
| Rate for Payer: Fidelis Qualified Health Plan |
$60.47
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$63.65
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$63.65
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$47.74
|
| Rate for Payer: Healthfirst Medicare Advantage |
$60.47
|
| Rate for Payer: Healthfirst QHP |
$63.65
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$44.56
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$63.65
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$54.10
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$44.56
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$63.65
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$167.08
|
| Rate for Payer: SOMOS Essential |
$167.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$63.65
|
|
|
CHG LYMPHATICS & LYMPH NODES IMAGING
|
Professional
|
$1,409.59
|
|
|
Service Code
|
HCPCS 78195
|
| Min. Negotiated Rate |
$44.56 |
| Max. Negotiated Rate |
$1,057.19 |
| Rate for Payer: Cash Price |
$379.02
|
| Rate for Payer: Cash Price |
$379.02
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$362.47
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$362.47
|
| Rate for Payer: Fidelis Essential Plan QHP |
$382.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$402.74
|
| Rate for Payer: Fidelis Qualified Health Plan |
$382.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$402.74
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$402.74
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$302.06
|
| Rate for Payer: Healthfirst Medicare Advantage |
$382.60
|
| Rate for Payer: Healthfirst QHP |
$402.74
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$281.92
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$402.74
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$342.33
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$281.92
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$402.74
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,057.19
|
| Rate for Payer: SOMOS Essential |
$1,057.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$402.74
|
|
|
CHG MAGNETIC RESONANCE ELASTOGRAPHY
|
Professional
|
$899.96
|
|
|
Service Code
|
HCPCS 76391
|
| Min. Negotiated Rate |
$42.34 |
| Max. Negotiated Rate |
$674.97 |
| Rate for Payer: Cash Price |
$240.62
|
| Rate for Payer: Cash Price |
$240.62
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$231.42
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$231.42
|
| Rate for Payer: Fidelis Essential Plan QHP |
$244.27
|
| Rate for Payer: Fidelis Medicare Advantage |
$257.13
|
| Rate for Payer: Fidelis Qualified Health Plan |
$244.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$257.13
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$257.13
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$192.85
|
| Rate for Payer: Healthfirst Medicare Advantage |
$244.27
|
| Rate for Payer: Healthfirst QHP |
$257.13
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$179.99
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$257.13
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$218.56
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$179.99
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$257.13
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$674.97
|
| Rate for Payer: SOMOS Essential |
$674.97
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$257.13
|
|
|
CHG MAGNETIC RESONANCE ELASTOGRAPHY
|
Professional
|
$211.68
|
|
|
Service Code
|
HCPCS 76391 26
|
| Min. Negotiated Rate |
$42.34 |
| Max. Negotiated Rate |
$674.97 |
| Rate for Payer: Cash Price |
$57.44
|
| Rate for Payer: Cash Price |
$57.44
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$54.43
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$54.43
|
| Rate for Payer: Fidelis Essential Plan QHP |
$57.46
|
| Rate for Payer: Fidelis Medicare Advantage |
$60.48
|
| Rate for Payer: Fidelis Qualified Health Plan |
$57.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$60.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$60.48
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$45.36
|
| Rate for Payer: Healthfirst Medicare Advantage |
$57.46
|
| Rate for Payer: Healthfirst QHP |
$60.48
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$42.34
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$60.48
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$51.41
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$42.34
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$60.48
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$158.76
|
| Rate for Payer: SOMOS Essential |
$158.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$60.48
|
|
|
CHG MAGNETIC RESONANCE ELASTOGRAPHY
|
Professional
|
$688.28
|
|
|
Service Code
|
HCPCS 76391 TC
|
| Min. Negotiated Rate |
$42.34 |
| Max. Negotiated Rate |
$674.97 |
| Rate for Payer: Cash Price |
$183.18
|
| Rate for Payer: Cash Price |
$183.18
|
| 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 MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPLE
|
Professional
|
$293.13
|
|
|
Service Code
|
HCPCS 77054
|
| Min. Negotiated Rate |
$16.97 |
| Max. Negotiated Rate |
$219.85 |
| Rate for Payer: Cash Price |
$80.44
|
| Rate for Payer: Cash Price |
$80.44
|
| 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 MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPLE
|
Professional
|
$84.84
|
|
|
Service Code
|
HCPCS 77054 26
|
| Min. Negotiated Rate |
$16.97 |
| Max. Negotiated Rate |
$219.85 |
| Rate for Payer: Cash Price |
$23.23
|
| Rate for Payer: Cash Price |
$23.23
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$21.82
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$21.82
|
| Rate for Payer: Fidelis Essential Plan QHP |
$23.03
|
| Rate for Payer: Fidelis Medicare Advantage |
$24.24
|
| Rate for Payer: Fidelis Qualified Health Plan |
$23.03
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.24
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.24
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18.18
|
| Rate for Payer: Healthfirst Medicare Advantage |
$23.03
|
| Rate for Payer: Healthfirst QHP |
$24.24
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$16.97
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$24.24
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$20.60
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$16.97
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$24.24
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$63.63
|
| Rate for Payer: SOMOS Essential |
$63.63
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$24.24
|
|
|
CHG MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPLE
|
Professional
|
$208.29
|
|
|
Service Code
|
HCPCS 77054 TC
|
| Min. Negotiated Rate |
$16.97 |
| Max. Negotiated Rate |
$219.85 |
| Rate for Payer: Cash Price |
$57.21
|
| Rate for Payer: Cash Price |
$57.21
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$53.56
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$53.56
|
| Rate for Payer: Fidelis Essential Plan QHP |
$56.53
|
| Rate for Payer: Fidelis Medicare Advantage |
$59.51
|
| Rate for Payer: Fidelis Qualified Health Plan |
$56.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$59.51
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$59.51
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$44.63
|
| Rate for Payer: Healthfirst Medicare Advantage |
$56.53
|
| Rate for Payer: Healthfirst QHP |
$59.51
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$41.66
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$59.51
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$50.58
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$41.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$59.51
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$156.22
|
| Rate for Payer: SOMOS Essential |
$156.22
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$59.51
|
|
|
CHG MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE
|
Professional
|
$157.99
|
|
|
Service Code
|
HCPCS 77053 TC
|
| Min. Negotiated Rate |
$13.85 |
| Max. Negotiated Rate |
$170.42 |
| Rate for Payer: Cash Price |
$43.85
|
| Rate for Payer: Cash Price |
$43.85
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$40.63
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$40.63
|
| Rate for Payer: Fidelis Essential Plan QHP |
$42.88
|
| Rate for Payer: Fidelis Medicare Advantage |
$45.14
|
| Rate for Payer: Fidelis Qualified Health Plan |
$42.88
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$45.14
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$45.14
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$33.86
|
| Rate for Payer: Healthfirst Medicare Advantage |
$42.88
|
| Rate for Payer: Healthfirst QHP |
$45.14
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$31.60
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$45.14
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$38.37
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$31.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$45.14
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$118.49
|
| Rate for Payer: SOMOS Essential |
$118.49
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$45.14
|
|
|
CHG MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE
|
Professional
|
$227.22
|
|
|
Service Code
|
HCPCS 77053
|
| Min. Negotiated Rate |
$13.85 |
| Max. Negotiated Rate |
$170.42 |
| Rate for Payer: Cash Price |
$62.76
|
| Rate for Payer: Cash Price |
$62.76
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$58.43
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$58.43
|
| Rate for Payer: Fidelis Essential Plan QHP |
$61.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$64.92
|
| Rate for Payer: Fidelis Qualified Health Plan |
$61.67
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$64.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$64.92
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$48.69
|
| Rate for Payer: Healthfirst Medicare Advantage |
$61.67
|
| Rate for Payer: Healthfirst QHP |
$64.92
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$45.44
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$64.92
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$55.18
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$45.44
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$64.92
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$170.42
|
| Rate for Payer: SOMOS Essential |
$170.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$64.92
|
|
