|
CHG MRI BREAST W/OUT&WITH CONTRAST W/CAD UNILATERAL
|
Professional
|
$402.36
|
|
|
Service Code
|
HCPCS 77048 26
|
| Min. Negotiated Rate |
$80.47 |
| Max. Negotiated Rate |
$1,121.82 |
| Rate for Payer: Cash Price |
$109.19
|
| Rate for Payer: Cash Price |
$109.19
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$103.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$103.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$109.21
|
| Rate for Payer: Fidelis Medicare Advantage |
$114.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$109.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$114.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$114.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$86.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$109.21
|
| Rate for Payer: Healthfirst QHP |
$114.96
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$80.47
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$114.96
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$97.72
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$80.47
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$114.96
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$301.77
|
| Rate for Payer: SOMOS Essential |
$301.77
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$114.96
|
|
|
CHG MRI CHEST W/CONTRAST MATERIAL
|
Professional
|
$1,675.24
|
|
|
Service Code
|
HCPCS 71551
|
| Min. Negotiated Rate |
$66.63 |
| Max. Negotiated Rate |
$1,256.43 |
| Rate for Payer: Cash Price |
$448.20
|
| Rate for Payer: Cash Price |
$448.20
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$430.78
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$430.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$454.71
|
| Rate for Payer: Fidelis Medicare Advantage |
$478.64
|
| Rate for Payer: Fidelis Qualified Health Plan |
$454.71
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$478.64
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$478.64
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$358.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$454.71
|
| Rate for Payer: Healthfirst QHP |
$478.64
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$335.05
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$478.64
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$406.84
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$335.05
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$478.64
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,256.43
|
| Rate for Payer: SOMOS Essential |
$1,256.43
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$478.64
|
|
|
CHG MRI CHEST W/CONTRAST MATERIAL
|
Professional
|
$333.17
|
|
|
Service Code
|
HCPCS 71551 26
|
| Min. Negotiated Rate |
$66.63 |
| Max. Negotiated Rate |
$1,256.43 |
| Rate for Payer: Cash Price |
$89.93
|
| Rate for Payer: Cash Price |
$89.93
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$85.67
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$85.67
|
| Rate for Payer: Fidelis Essential Plan QHP |
$90.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$95.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$90.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$95.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$95.19
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$71.39
|
| Rate for Payer: Healthfirst Medicare Advantage |
$90.43
|
| Rate for Payer: Healthfirst QHP |
$95.19
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$66.63
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$95.19
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$80.91
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$66.63
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$95.19
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$249.88
|
| Rate for Payer: SOMOS Essential |
$249.88
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$95.19
|
|
|
CHG MRI CHEST W/CONTRAST MATERIAL
|
Professional
|
$1,342.08
|
|
|
Service Code
|
HCPCS 71551 TC
|
| Min. Negotiated Rate |
$66.63 |
| Max. Negotiated Rate |
$1,256.43 |
| Rate for Payer: Cash Price |
$358.27
|
| Rate for Payer: Cash Price |
$358.27
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$345.10
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$345.10
|
| Rate for Payer: Fidelis Essential Plan QHP |
$364.28
|
| Rate for Payer: Fidelis Medicare Advantage |
$383.45
|
| Rate for Payer: Fidelis Qualified Health Plan |
$364.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$383.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$383.45
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$287.59
|
| Rate for Payer: Healthfirst Medicare Advantage |
$364.28
|
| Rate for Payer: Healthfirst QHP |
$383.45
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$268.42
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$383.45
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$325.93
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$268.42
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$383.45
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,006.56
|
| Rate for Payer: SOMOS Essential |
$1,006.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$383.45
|
|
|
CHG MRI CHEST W/O CONTRAST MATERIAL
|
Professional
|
$1,275.26
|
|
|
Service Code
|
HCPCS 71550
|
| Min. Negotiated Rate |
$56.19 |
| Max. Negotiated Rate |
$956.44 |
| Rate for Payer: Cash Price |
$405.93
|
| Rate for Payer: Cash Price |
$405.93
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$389.99
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$389.99
|
| Rate for Payer: Fidelis Essential Plan QHP |
$411.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$433.32
|
| Rate for Payer: Fidelis Qualified Health Plan |
$411.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$433.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$433.32
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$324.99
|
| Rate for Payer: Healthfirst Medicare Advantage |
$411.65
|
| Rate for Payer: Healthfirst QHP |
$433.32
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$303.32
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$433.32
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$368.32
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$303.32
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$433.32
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$956.44
|
| Rate for Payer: SOMOS Essential |
$956.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$433.32
|
|
|
CHG MRI CHEST W/O CONTRAST MATERIAL
|
Professional
|
$280.95
|
|
|
Service Code
|
HCPCS 71550 26
|
| Min. Negotiated Rate |
$56.19 |
| Max. Negotiated Rate |
$956.44 |
| Rate for Payer: Cash Price |
$75.96
|
| Rate for Payer: Cash Price |
$75.96
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$72.24
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$72.24
|
| Rate for Payer: Fidelis Essential Plan QHP |
$76.26
|
| Rate for Payer: Fidelis Medicare Advantage |
$80.27
|
| Rate for Payer: Fidelis Qualified Health Plan |
$76.26
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$80.27
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$80.27
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$60.20
|
| Rate for Payer: Healthfirst Medicare Advantage |
$76.26
|
| Rate for Payer: Healthfirst QHP |
$80.27
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$56.19
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$80.27
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$68.23
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$56.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$80.27
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$210.71
|
| Rate for Payer: SOMOS Essential |
$210.71
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$80.27
|
|
|
CHG MRI CHEST W/O CONTRAST MATERIAL
|
Professional
|
$994.32
|
|
|
Service Code
|
HCPCS 71550 TC
|
| Min. Negotiated Rate |
$56.19 |
| Max. Negotiated Rate |
$956.44 |
| Rate for Payer: Cash Price |
$329.97
|
| Rate for Payer: Cash Price |
$329.97
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$317.74
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$317.74
|
| Rate for Payer: Fidelis Essential Plan QHP |
$335.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$353.05
|
| Rate for Payer: Fidelis Qualified Health Plan |
$335.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$353.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$353.05
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$264.79
|
| Rate for Payer: Healthfirst Medicare Advantage |
$335.40
|
| Rate for Payer: Healthfirst QHP |
$353.05
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$247.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$353.05
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$300.09
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$247.14
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$353.05
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$745.74
|
| Rate for Payer: SOMOS Essential |
$745.74
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$353.05
|
|
|
CHG MRI CHEST W/O & W/CONTRAST MATERIAL
|
Professional
|
$433.76
|
|
|
Service Code
|
HCPCS 71552 26
|
| Min. Negotiated Rate |
$86.75 |
| Max. Negotiated Rate |
$1,502.21 |
| Rate for Payer: Cash Price |
$117.36
|
| Rate for Payer: Cash Price |
$117.36
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$111.54
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$111.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$117.73
|
| Rate for Payer: Fidelis Medicare Advantage |
$123.93
|
| Rate for Payer: Fidelis Qualified Health Plan |
$117.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$123.93
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$123.93
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$92.95
|
| Rate for Payer: Healthfirst Medicare Advantage |
$117.73
|
| Rate for Payer: Healthfirst QHP |
$123.93
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$86.75
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$123.93
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$105.34
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$86.75
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$123.93
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$325.32
|
| Rate for Payer: SOMOS Essential |
$325.32
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$123.93
|
|
|
CHG MRI CHEST W/O & W/CONTRAST MATERIAL
|
Professional
|
$1,569.19
|
|
|
Service Code
|
HCPCS 71552 TC
|
| Min. Negotiated Rate |
$86.75 |
| Max. Negotiated Rate |
$1,502.21 |
| Rate for Payer: Cash Price |
$448.09
|
| Rate for Payer: Cash Price |
$448.09
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$431.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$431.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$455.57
|
| Rate for Payer: Fidelis Medicare Advantage |
$479.55
|
| Rate for Payer: Fidelis Qualified Health Plan |
$455.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$479.55
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$479.55
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$359.66
|
| Rate for Payer: Healthfirst Medicare Advantage |
$455.57
|
| Rate for Payer: Healthfirst QHP |
$479.55
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$335.68
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$479.55
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$407.62
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$335.68
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$479.55
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,176.89
|
| Rate for Payer: SOMOS Essential |
$1,176.89
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$479.55
|
|
|
CHG MRI CHEST W/O & W/CONTRAST MATERIAL
|
Professional
|
$2,002.95
|
|
|
Service Code
|
HCPCS 71552
|
| Min. Negotiated Rate |
$86.75 |
| Max. Negotiated Rate |
$1,502.21 |
| Rate for Payer: Cash Price |
$565.45
|
| Rate for Payer: Cash Price |
$565.45
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$543.14
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$543.14
|
| Rate for Payer: Fidelis Essential Plan QHP |
$573.32
|
| Rate for Payer: Fidelis Medicare Advantage |
$603.49
|
| Rate for Payer: Fidelis Qualified Health Plan |
$573.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$603.49
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$603.49
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$452.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$573.32
|
| Rate for Payer: Healthfirst QHP |
$603.49
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$422.44
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$603.49
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$512.97
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$422.44
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$603.49
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,502.21
|
| Rate for Payer: SOMOS Essential |
$1,502.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$603.49
|
|
|
CHG MRI GUIDANCE FOR PARENCHYMAL TISSUE ABLATION
|
Professional
|
$3,335.40
|
|
|
Service Code
|
HCPCS 77022
|
| Min. Negotiated Rate |
$163.02 |
| Max. Negotiated Rate |
$2,501.55 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$2,501.55
|
| Rate for Payer: SOMOS Essential |
$2,501.55
|
|
|
CHG MRI GUIDANCE FOR PARENCHYMAL TISSUE ABLATION
|
Professional
|
$815.08
|
|
|
Service Code
|
HCPCS 77022 26
|
| Min. Negotiated Rate |
$163.02 |
| Max. Negotiated Rate |
$2,501.55 |
| Rate for Payer: Cash Price |
$216.64
|
| Rate for Payer: Cash Price |
$216.64
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$209.59
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$209.59
|
| Rate for Payer: Fidelis Essential Plan QHP |
$221.24
|
| Rate for Payer: Fidelis Medicare Advantage |
$232.88
|
| Rate for Payer: Fidelis Qualified Health Plan |
$221.24
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$232.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$232.88
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$174.66
|
| Rate for Payer: Healthfirst Medicare Advantage |
$221.24
|
| Rate for Payer: Healthfirst QHP |
$232.88
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$163.02
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$232.88
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$197.95
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$163.02
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$232.88
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$611.31
|
| Rate for Payer: SOMOS Essential |
$611.31
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$232.88
|
|
|
CHG MRI GUIDANCE FOR PARENCHYMAL TISSUE ABLATION
|
Professional
|
$2,520.32
|
|
|
Service Code
|
HCPCS 77022 TC
|
| Min. Negotiated Rate |
$163.02 |
| Max. Negotiated Rate |
$2,501.55 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,890.24
|
| Rate for Payer: SOMOS Essential |
$1,890.24
|
|
|
CHG MRI GUIDANCE NEEDLE PLACEMENT RS&I
|
Professional
|
$1,550.78
|
|
|
Service Code
|
HCPCS 77021 TC
|
| Min. Negotiated Rate |
$56.36 |
| Max. Negotiated Rate |
$1,374.43 |
| Rate for Payer: Cash Price |
$419.72
|
| Rate for Payer: Cash Price |
$419.72
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$398.77
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$398.77
|
| Rate for Payer: Fidelis Essential Plan QHP |
$420.93
|
| Rate for Payer: Fidelis Medicare Advantage |
$443.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$420.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$443.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$443.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$332.31
|
| Rate for Payer: Healthfirst Medicare Advantage |
$420.93
|
| Rate for Payer: Healthfirst QHP |
$443.08
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$310.16
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$443.08
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$376.62
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$310.16
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$443.08
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,163.08
|
| Rate for Payer: SOMOS Essential |
$1,163.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$443.08
|
|
|
CHG MRI GUIDANCE NEEDLE PLACEMENT RS&I
|
Professional
|
$1,832.57
|
|
|
Service Code
|
HCPCS 77021
|
| Min. Negotiated Rate |
$56.36 |
| Max. Negotiated Rate |
$1,374.43 |
| Rate for Payer: Cash Price |
$496.61
|
| Rate for Payer: Cash Price |
$496.61
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$471.23
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$471.23
|
| Rate for Payer: Fidelis Essential Plan QHP |
$497.41
|
| Rate for Payer: Fidelis Medicare Advantage |
$523.59
|
| Rate for Payer: Fidelis Qualified Health Plan |
$497.41
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$523.59
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$523.59
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$392.69
|
| Rate for Payer: Healthfirst Medicare Advantage |
$497.41
|
| Rate for Payer: Healthfirst QHP |
$523.59
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$366.51
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$523.59
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$445.05
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$366.51
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$523.59
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,374.43
|
| Rate for Payer: SOMOS Essential |
$1,374.43
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$523.59
|
|
|
CHG MRI GUIDANCE NEEDLE PLACEMENT RS&I
|
Professional
|
$281.79
|
|
|
Service Code
|
HCPCS 77021 26
|
| Min. Negotiated Rate |
$56.36 |
| Max. Negotiated Rate |
$1,374.43 |
| Rate for Payer: Cash Price |
$76.89
|
| Rate for Payer: Cash Price |
$76.89
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$72.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$72.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$76.48
|
| Rate for Payer: Fidelis Medicare Advantage |
$80.51
|
| Rate for Payer: Fidelis Qualified Health Plan |
$76.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$80.51
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$80.51
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$60.38
|
| Rate for Payer: Healthfirst Medicare Advantage |
$76.48
|
| Rate for Payer: Healthfirst QHP |
$80.51
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$56.36
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$80.51
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$68.43
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$56.36
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$80.51
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$211.34
|
| Rate for Payer: SOMOS Essential |
$211.34
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$80.51
|
|
|
CHG MRI LOWER EXTREM OTH/THN JT W/CONTRAST MATRL
|
Professional
|
$309.61
|
|
|
Service Code
|
HCPCS 73719 26
|
| Min. Negotiated Rate |
$61.92 |
| Max. Negotiated Rate |
$873.47 |
| Rate for Payer: Cash Price |
$83.90
|
| Rate for Payer: Cash Price |
$83.90
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$79.61
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$79.61
|
| Rate for Payer: Fidelis Essential Plan QHP |
$84.04
|
| Rate for Payer: Fidelis Medicare Advantage |
$88.46
|
| Rate for Payer: Fidelis Qualified Health Plan |
$84.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$88.46
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$88.46
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$66.34
|
| Rate for Payer: Healthfirst Medicare Advantage |
$84.04
|
| Rate for Payer: Healthfirst QHP |
$88.46
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$61.92
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$88.46
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$75.19
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$61.92
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$88.46
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$232.21
|
| Rate for Payer: SOMOS Essential |
$232.21
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$88.46
|
|
|
CHG MRI LOWER EXTREM OTH/THN JT W/CONTRAST MATRL
|
Professional
|
$1,164.63
|
|
|
Service Code
|
HCPCS 73719
|
| Min. Negotiated Rate |
$61.92 |
| Max. Negotiated Rate |
$873.47 |
| Rate for Payer: Cash Price |
$314.46
|
| Rate for Payer: Cash Price |
$314.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$299.48
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$299.48
|
| Rate for Payer: Fidelis Essential Plan QHP |
$316.11
|
| Rate for Payer: Fidelis Medicare Advantage |
$332.75
|
| Rate for Payer: Fidelis Qualified Health Plan |
$316.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$332.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$332.75
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$249.56
|
| Rate for Payer: Healthfirst Medicare Advantage |
$316.11
|
| Rate for Payer: Healthfirst QHP |
$332.75
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$232.92
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$332.75
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$282.84
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$232.92
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$332.75
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$873.47
|
| Rate for Payer: SOMOS Essential |
$873.47
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$332.75
|
|
|
CHG MRI LOWER EXTREM OTH/THN JT W/CONTRAST MATRL
|
Professional
|
$855.02
|
|
|
Service Code
|
HCPCS 73719 TC
|
| Min. Negotiated Rate |
$61.92 |
| Max. Negotiated Rate |
$873.47 |
| Rate for Payer: Cash Price |
$230.56
|
| Rate for Payer: Cash Price |
$230.56
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$219.86
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$219.86
|
| Rate for Payer: Fidelis Essential Plan QHP |
$232.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$244.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$232.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$244.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$244.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$183.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$232.08
|
| Rate for Payer: Healthfirst QHP |
$244.29
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$171.00
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$244.29
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$207.65
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$171.00
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$244.29
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$641.26
|
| Rate for Payer: SOMOS Essential |
$641.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$244.29
|
|
|
CHG MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL
|
Professional
|
$734.27
|
|
|
Service Code
|
HCPCS 73718 TC
|
| Min. Negotiated Rate |
$51.74 |
| Max. Negotiated Rate |
$744.71 |
| Rate for Payer: Cash Price |
$196.93
|
| Rate for Payer: Cash Price |
$196.93
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$188.81
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$188.81
|
| Rate for Payer: Fidelis Essential Plan QHP |
$199.30
|
| Rate for Payer: Fidelis Medicare Advantage |
$209.79
|
| Rate for Payer: Fidelis Qualified Health Plan |
$199.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$209.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$209.79
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$157.34
|
| Rate for Payer: Healthfirst Medicare Advantage |
$199.30
|
| Rate for Payer: Healthfirst QHP |
$209.79
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$146.85
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$209.79
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$178.32
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$146.85
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$209.79
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$550.70
|
| Rate for Payer: SOMOS Essential |
$550.70
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$209.79
|
|
|
CHG MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL
|
Professional
|
$992.95
|
|
|
Service Code
|
HCPCS 73718
|
| Min. Negotiated Rate |
$51.74 |
| Max. Negotiated Rate |
$744.71 |
| Rate for Payer: Cash Price |
$266.86
|
| Rate for Payer: Cash Price |
$266.86
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$255.33
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$255.33
|
| Rate for Payer: Fidelis Essential Plan QHP |
$269.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$283.70
|
| Rate for Payer: Fidelis Qualified Health Plan |
$269.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$283.70
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$283.70
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$212.78
|
| Rate for Payer: Healthfirst Medicare Advantage |
$269.52
|
| Rate for Payer: Healthfirst QHP |
$283.70
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$198.59
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$283.70
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$241.14
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$198.59
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$283.70
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$744.71
|
| Rate for Payer: SOMOS Essential |
$744.71
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$283.70
|
|
|
CHG MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL
|
Professional
|
$258.69
|
|
|
Service Code
|
HCPCS 73718 26
|
| Min. Negotiated Rate |
$51.74 |
| Max. Negotiated Rate |
$744.71 |
| Rate for Payer: Cash Price |
$69.93
|
| Rate for Payer: Cash Price |
$69.93
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$66.52
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$66.52
|
| Rate for Payer: Fidelis Essential Plan QHP |
$70.21
|
| Rate for Payer: Fidelis Medicare Advantage |
$73.91
|
| Rate for Payer: Fidelis Qualified Health Plan |
$70.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$73.91
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$73.91
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$55.43
|
| Rate for Payer: Healthfirst Medicare Advantage |
$70.21
|
| Rate for Payer: Healthfirst QHP |
$73.91
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$51.74
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$73.91
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$62.82
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$51.74
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$73.91
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$194.02
|
| Rate for Payer: SOMOS Essential |
$194.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$73.91
|
|
|
CHG MRI LOWER EXTREM OTH/THN JT W/O & W/CONTR MATR
|
Professional
|
$1,089.06
|
|
|
Service Code
|
HCPCS 73720 TC
|
| Min. Negotiated Rate |
$82.30 |
| Max. Negotiated Rate |
$1,125.42 |
| Rate for Payer: Cash Price |
$291.07
|
| Rate for Payer: Cash Price |
$291.07
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$280.04
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$280.04
|
| Rate for Payer: Fidelis Essential Plan QHP |
$295.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$311.16
|
| Rate for Payer: Fidelis Qualified Health Plan |
$295.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$311.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$311.16
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$233.37
|
| Rate for Payer: Healthfirst Medicare Advantage |
$295.60
|
| Rate for Payer: Healthfirst QHP |
$311.16
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$217.81
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$311.16
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$264.49
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$217.81
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$311.16
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$816.80
|
| Rate for Payer: SOMOS Essential |
$816.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$311.16
|
|
|
CHG MRI LOWER EXTREM OTH/THN JT W/O & W/CONTR MATR
|
Professional
|
$411.50
|
|
|
Service Code
|
HCPCS 73720 26
|
| Min. Negotiated Rate |
$82.30 |
| Max. Negotiated Rate |
$1,125.42 |
| Rate for Payer: Cash Price |
$111.33
|
| Rate for Payer: Cash Price |
$111.33
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$105.81
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$105.81
|
| Rate for Payer: Fidelis Essential Plan QHP |
$111.69
|
| Rate for Payer: Fidelis Medicare Advantage |
$117.57
|
| Rate for Payer: Fidelis Qualified Health Plan |
$111.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$117.57
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$117.57
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$88.18
|
| Rate for Payer: Healthfirst Medicare Advantage |
$111.69
|
| Rate for Payer: Healthfirst QHP |
$117.57
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$82.30
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$117.57
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$99.93
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$82.30
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$117.57
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$308.62
|
| Rate for Payer: SOMOS Essential |
$308.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$117.57
|
|
|
CHG MRI LOWER EXTREM OTH/THN JT W/O & W/CONTR MATR
|
Professional
|
$1,500.56
|
|
|
Service Code
|
HCPCS 73720
|
| Min. Negotiated Rate |
$82.30 |
| Max. Negotiated Rate |
$1,125.42 |
| Rate for Payer: Cash Price |
$402.40
|
| Rate for Payer: Cash Price |
$402.40
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$385.86
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$385.86
|
| Rate for Payer: Fidelis Essential Plan QHP |
$407.29
|
| Rate for Payer: Fidelis Medicare Advantage |
$428.73
|
| Rate for Payer: Fidelis Qualified Health Plan |
$407.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$428.73
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$428.73
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$321.55
|
| Rate for Payer: Healthfirst Medicare Advantage |
$407.29
|
| Rate for Payer: Healthfirst QHP |
$428.73
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$300.11
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$428.73
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$364.42
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$300.11
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$428.73
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,125.42
|
| Rate for Payer: SOMOS Essential |
$1,125.42
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$428.73
|
|
