|
CHG PATHOLOGY CLINICAL CONSULTATION MOD MDM 21-40MIN
|
Professional
|
$189.60
|
|
|
Service Code
|
HCPCS 80504
|
| Min. Negotiated Rate |
$37.92 |
| Max. Negotiated Rate |
$142.20 |
| Rate for Payer: Cash Price |
$52.15
|
| Rate for Payer: Cash Price |
$52.15
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$48.75
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$48.75
|
| Rate for Payer: Fidelis Essential Plan QHP |
$51.46
|
| Rate for Payer: Fidelis Medicare Advantage |
$54.17
|
| Rate for Payer: Fidelis Qualified Health Plan |
$51.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$54.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$54.17
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$40.63
|
| Rate for Payer: Healthfirst Medicare Advantage |
$51.46
|
| Rate for Payer: Healthfirst QHP |
$54.17
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$37.92
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$54.17
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$46.04
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$37.92
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$54.17
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$142.20
|
| Rate for Payer: SOMOS Essential |
$142.20
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$54.17
|
|
|
CHG PATHOLOGY CLINICAL CONSULTATION SF MDM 5-20 MIN
|
Professional
|
$88.10
|
|
|
Service Code
|
HCPCS 80503
|
| Min. Negotiated Rate |
$17.62 |
| Max. Negotiated Rate |
$66.08 |
| Rate for Payer: Cash Price |
$24.11
|
| Rate for Payer: Cash Price |
$24.11
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$22.65
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$22.65
|
| Rate for Payer: Fidelis Essential Plan QHP |
$23.91
|
| Rate for Payer: Fidelis Medicare Advantage |
$25.17
|
| Rate for Payer: Fidelis Qualified Health Plan |
$23.91
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$25.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$25.17
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$18.88
|
| Rate for Payer: Healthfirst Medicare Advantage |
$23.91
|
| Rate for Payer: Healthfirst QHP |
$25.17
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$17.62
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$25.17
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$21.39
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$17.62
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$25.17
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$66.08
|
| Rate for Payer: SOMOS Essential |
$66.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$25.17
|
|
|
CHG PATHOLOGY CONSULTATION DURING SURGERY
|
Professional
|
$142.31
|
|
|
Service Code
|
HCPCS 88329
|
| Min. Negotiated Rate |
$28.46 |
| Max. Negotiated Rate |
$106.73 |
| Rate for Payer: Cash Price |
$38.44
|
| Rate for Payer: Cash Price |
$38.44
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$36.59
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$36.59
|
| Rate for Payer: Fidelis Essential Plan QHP |
$38.63
|
| Rate for Payer: Fidelis Medicare Advantage |
$40.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$38.63
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$40.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$40.66
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$30.50
|
| Rate for Payer: Healthfirst Medicare Advantage |
$38.63
|
| Rate for Payer: Healthfirst QHP |
$40.66
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$28.46
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$40.66
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$34.56
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$28.46
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$40.66
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$106.73
|
| Rate for Payer: SOMOS Essential |
$106.73
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$40.66
|
|
|
CHG PELVIMETRY W/WOPLACENTAL LOCALIZATION
|
Professional
|
$104.79
|
|
|
Service Code
|
HCPCS 74710 TC
|
| Min. Negotiated Rate |
$13.06 |
| Max. Negotiated Rate |
$127.58 |
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$26.95
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$26.95
|
| Rate for Payer: Fidelis Essential Plan QHP |
$28.44
|
| Rate for Payer: Fidelis Medicare Advantage |
$29.94
|
| Rate for Payer: Fidelis Qualified Health Plan |
$28.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$29.94
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$29.94
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$22.46
|
| Rate for Payer: Healthfirst Medicare Advantage |
$28.44
|
| Rate for Payer: Healthfirst QHP |
$29.94
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$20.96
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$29.94
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$25.45
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$20.96
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$29.94
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$78.59
|
| Rate for Payer: SOMOS Essential |
$78.59
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$29.94
|
|
|
CHG PELVIMETRY W/WOPLACENTAL LOCALIZATION
|
Professional
|
$170.10
|
|
|
Service Code
|
HCPCS 74710
|
| Min. Negotiated Rate |
$13.06 |
| Max. Negotiated Rate |
$127.58 |
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$43.74
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$43.74
|
| Rate for Payer: Fidelis Essential Plan QHP |
$46.17
|
| Rate for Payer: Fidelis Medicare Advantage |
$48.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$46.17
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$48.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$48.60
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$36.45
|
| Rate for Payer: Healthfirst Medicare Advantage |
$46.17
|
| Rate for Payer: Healthfirst QHP |
$48.60
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$34.02
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$48.60
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$41.31
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$34.02
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$48.60
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$127.58
|
| Rate for Payer: SOMOS Essential |
$127.58
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$48.60
|
|
|
CHG PELVIMETRY W/WOPLACENTAL LOCALIZATION
|
Professional
|
$65.31
|
|
|
Service Code
|
HCPCS 74710 26
|
| Min. Negotiated Rate |
$13.06 |
| Max. Negotiated Rate |
$127.58 |
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.79
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$16.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$17.73
|
| Rate for Payer: Fidelis Medicare Advantage |
$18.66
|
| Rate for Payer: Fidelis Qualified Health Plan |
$17.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.66
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.66
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$14.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$17.73
|
| Rate for Payer: Healthfirst QHP |
$18.66
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$13.06
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$18.66
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$15.86
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$13.06
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$18.66
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$48.98
|
| Rate for Payer: SOMOS Essential |
$48.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18.66
|
|
|
CHG PERCUTANEOUS PLACEMENT ENTEROCLYSIS TUBE RS&I
|
Professional
|
$146.37
|
|
|
Service Code
|
HCPCS 74355 26
|
| Min. Negotiated Rate |
$29.27 |
| Max. Negotiated Rate |
$507.78 |
| Rate for Payer: Cash Price |
$39.62
|
| Rate for Payer: Cash Price |
$39.62
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$37.64
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$37.64
|
| Rate for Payer: Fidelis Essential Plan QHP |
$39.73
|
| Rate for Payer: Fidelis Medicare Advantage |
$41.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$39.73
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$41.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$41.82
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$31.36
|
| Rate for Payer: Healthfirst Medicare Advantage |
$39.73
|
| Rate for Payer: Healthfirst QHP |
$41.82
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$29.27
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$41.82
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$35.55
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$29.27
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$41.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$109.78
|
| Rate for Payer: SOMOS Essential |
$109.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$41.82
|
|
|
CHG PERCUTANEOUS PLACEMENT ENTEROCLYSIS TUBE RS&I
|
Professional
|
$677.04
|
|
|
Service Code
|
HCPCS 74355
|
| Min. Negotiated Rate |
$29.27 |
| Max. Negotiated Rate |
$507.78 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$507.78
|
| Rate for Payer: SOMOS Essential |
$507.78
|
|
|
CHG PERCUTANEOUS PLACEMENT ENTEROCLYSIS TUBE RS&I
|
Professional
|
$530.67
|
|
|
Service Code
|
HCPCS 74355 TC
|
| Min. Negotiated Rate |
$29.27 |
| Max. Negotiated Rate |
$507.78 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$398.00
|
| Rate for Payer: SOMOS Essential |
$398.00
|
|
|
CHG PERINEOGRAM
|
Professional
|
$416.78
|
|
|
Service Code
|
HCPCS 74775
|
| Min. Negotiated Rate |
$24.33 |
| Max. Negotiated Rate |
$312.58 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$312.58
|
| Rate for Payer: SOMOS Essential |
$312.58
|
|
|
CHG PERINEOGRAM
|
Professional
|
$295.12
|
|
|
Service Code
|
HCPCS 74775 TC
|
| Min. Negotiated Rate |
$24.33 |
| Max. Negotiated Rate |
$312.58 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$221.34
|
| Rate for Payer: SOMOS Essential |
$221.34
|
|
|
CHG PERINEOGRAM
|
Professional
|
$121.66
|
|
|
Service Code
|
HCPCS 74775 26
|
| Min. Negotiated Rate |
$24.33 |
| Max. Negotiated Rate |
$312.58 |
| Rate for Payer: Cash Price |
$32.14
|
| Rate for Payer: Cash Price |
$32.14
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$31.28
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$31.28
|
| Rate for Payer: Fidelis Essential Plan QHP |
$33.02
|
| Rate for Payer: Fidelis Medicare Advantage |
$34.76
|
| Rate for Payer: Fidelis Qualified Health Plan |
$33.02
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$34.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$34.76
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$26.07
|
| Rate for Payer: Healthfirst Medicare Advantage |
$33.02
|
| Rate for Payer: Healthfirst QHP |
$34.76
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$24.33
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$34.76
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$29.55
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$24.33
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$34.76
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$91.24
|
| Rate for Payer: SOMOS Essential |
$91.24
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$34.76
|
|
|
CHG PERITONEAL-VENOUS SHUNT PATENCY TEST
|
Professional
|
$884.94
|
|
|
Service Code
|
HCPCS 78291 TC
|
| Min. Negotiated Rate |
$33.43 |
| Max. Negotiated Rate |
$789.08 |
| Rate for Payer: Cash Price |
$238.10
|
| Rate for Payer: Cash Price |
$238.10
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$227.56
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$227.56
|
| Rate for Payer: Fidelis Essential Plan QHP |
$240.20
|
| Rate for Payer: Fidelis Medicare Advantage |
$252.84
|
| Rate for Payer: Fidelis Qualified Health Plan |
$240.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$252.84
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$252.84
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$189.63
|
| Rate for Payer: Healthfirst Medicare Advantage |
$240.20
|
| Rate for Payer: Healthfirst QHP |
$252.84
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$176.99
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$252.84
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$214.91
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$176.99
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$252.84
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$663.70
|
| Rate for Payer: SOMOS Essential |
$663.70
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$252.84
|
|
|
CHG PERITONEAL-VENOUS SHUNT PATENCY TEST
|
Professional
|
$1,052.10
|
|
|
Service Code
|
HCPCS 78291
|
| Min. Negotiated Rate |
$33.43 |
| Max. Negotiated Rate |
$789.08 |
| Rate for Payer: Cash Price |
$284.10
|
| Rate for Payer: Cash Price |
$284.10
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$270.54
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$270.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$285.57
|
| Rate for Payer: Fidelis Medicare Advantage |
$300.60
|
| Rate for Payer: Fidelis Qualified Health Plan |
$285.57
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$300.60
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$300.60
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$225.45
|
| Rate for Payer: Healthfirst Medicare Advantage |
$285.57
|
| Rate for Payer: Healthfirst QHP |
$300.60
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$210.42
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$300.60
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$255.51
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$210.42
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$300.60
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$789.08
|
| Rate for Payer: SOMOS Essential |
$789.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$300.60
|
|
|
CHG PERITONEAL-VENOUS SHUNT PATENCY TEST
|
Professional
|
$167.16
|
|
|
Service Code
|
HCPCS 78291 26
|
| Min. Negotiated Rate |
$33.43 |
| Max. Negotiated Rate |
$789.08 |
| Rate for Payer: Cash Price |
$46.00
|
| Rate for Payer: Cash Price |
$46.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$42.98
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$42.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$45.37
|
| Rate for Payer: Fidelis Medicare Advantage |
$47.76
|
| Rate for Payer: Fidelis Qualified Health Plan |
$45.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$47.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$47.76
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$35.82
|
| Rate for Payer: Healthfirst Medicare Advantage |
$45.37
|
| Rate for Payer: Healthfirst QHP |
$47.76
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$33.43
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$47.76
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$40.60
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$33.43
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$47.76
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$125.37
|
| Rate for Payer: SOMOS Essential |
$125.37
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$47.76
|
|
|
CHG PERITONEOGRAM RS&I
|
Professional
|
$264.32
|
|
|
Service Code
|
HCPCS 74190 TC
|
| Min. Negotiated Rate |
$18.24 |
| Max. Negotiated Rate |
$266.62 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$198.24
|
| Rate for Payer: SOMOS Essential |
$198.24
|
|
|
CHG PERITONEOGRAM RS&I
|
Professional
|
$355.50
|
|
|
Service Code
|
HCPCS 74190
|
| Min. Negotiated Rate |
$18.24 |
| Max. Negotiated Rate |
$266.62 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$266.62
|
| Rate for Payer: SOMOS Essential |
$266.62
|
|
|
CHG PERITONEOGRAM RS&I
|
Professional
|
$91.18
|
|
|
Service Code
|
HCPCS 74190 26
|
| Min. Negotiated Rate |
$18.24 |
| Max. Negotiated Rate |
$266.62 |
| Rate for Payer: Cash Price |
$24.12
|
| Rate for Payer: Cash Price |
$24.12
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$23.44
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$23.44
|
| Rate for Payer: Fidelis Essential Plan QHP |
$24.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$26.05
|
| Rate for Payer: Fidelis Qualified Health Plan |
$24.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.05
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$19.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$24.75
|
| Rate for Payer: Healthfirst QHP |
$26.05
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$18.24
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$26.05
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$22.14
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$18.24
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26.05
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$68.38
|
| Rate for Payer: SOMOS Essential |
$68.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$26.05
|
|
|
CHG PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH
|
Professional
|
$6,319.08
|
|
|
Service Code
|
HCPCS 78815 TC
|
| Min. Negotiated Rate |
$90.43 |
| Max. Negotiated Rate |
$5,078.43 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$4,739.31
|
| Rate for Payer: SOMOS Essential |
$4,739.31
|
|
|
CHG PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH
|
Professional
|
$6,771.24
|
|
|
Service Code
|
HCPCS 78815
|
| Min. Negotiated Rate |
$90.43 |
| Max. Negotiated Rate |
$5,078.43 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$5,078.43
|
| Rate for Payer: SOMOS Essential |
$5,078.43
|
|
|
CHG PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH
|
Professional
|
$452.13
|
|
|
Service Code
|
HCPCS 78815 26
|
| Min. Negotiated Rate |
$90.43 |
| Max. Negotiated Rate |
$5,078.43 |
| Rate for Payer: Cash Price |
$122.62
|
| Rate for Payer: Cash Price |
$122.62
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$116.26
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$116.26
|
| Rate for Payer: Fidelis Essential Plan QHP |
$122.72
|
| Rate for Payer: Fidelis Medicare Advantage |
$129.18
|
| Rate for Payer: Fidelis Qualified Health Plan |
$122.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$129.18
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$129.18
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$96.88
|
| Rate for Payer: Healthfirst Medicare Advantage |
$122.72
|
| Rate for Payer: Healthfirst QHP |
$129.18
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$90.43
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$129.18
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$109.80
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$90.43
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$129.18
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$339.10
|
| Rate for Payer: SOMOS Essential |
$339.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$129.18
|
|
|
CHG PET IMAGING CT FOR ATTENUATION LIMITED AREA
|
Professional
|
$407.86
|
|
|
Service Code
|
HCPCS 78814 26
|
| Min. Negotiated Rate |
$81.57 |
| Max. Negotiated Rate |
$5,045.20 |
| Rate for Payer: Cash Price |
$110.09
|
| Rate for Payer: Cash Price |
$110.09
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$104.88
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$104.88
|
| Rate for Payer: Fidelis Essential Plan QHP |
$110.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$116.53
|
| Rate for Payer: Fidelis Qualified Health Plan |
$110.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$116.53
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$116.53
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$87.40
|
| Rate for Payer: Healthfirst Medicare Advantage |
$110.70
|
| Rate for Payer: Healthfirst QHP |
$116.53
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$81.57
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$116.53
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$99.05
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$81.57
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$116.53
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$305.90
|
| Rate for Payer: SOMOS Essential |
$305.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$116.53
|
|
|
CHG PET IMAGING CT FOR ATTENUATION LIMITED AREA
|
Professional
|
$6,726.93
|
|
|
Service Code
|
HCPCS 78814
|
| Min. Negotiated Rate |
$81.57 |
| Max. Negotiated Rate |
$5,045.20 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$5,045.20
|
| Rate for Payer: SOMOS Essential |
$5,045.20
|
|
|
CHG PET IMAGING CT FOR ATTENUATION LIMITED AREA
|
Professional
|
$6,319.08
|
|
|
Service Code
|
HCPCS 78814 TC
|
| Min. Negotiated Rate |
$81.57 |
| Max. Negotiated Rate |
$5,045.20 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$4,739.31
|
| Rate for Payer: SOMOS Essential |
$4,739.31
|
|
|
CHG PET IMAGING FOR CT ATTENUATION WHOLE BODY
|
Professional
|
$6,319.08
|
|
|
Service Code
|
HCPCS 78816 TC
|
| Min. Negotiated Rate |
$90.52 |
| Max. Negotiated Rate |
$5,078.78 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$4,739.31
|
| Rate for Payer: SOMOS Essential |
$4,739.31
|
|
