|
CHG PLMT PROX XTN PRSTH EVASC DESC THORAC AORTA RS&I
|
Professional
|
$1,585.89
|
|
|
Service Code
|
HCPCS 75958 TC
|
| Min. Negotiated Rate |
$164.53 |
| Max. Negotiated Rate |
$1,806.40 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,189.42
|
| Rate for Payer: SOMOS Essential |
$1,189.42
|
|
|
CHG PLMT PROX XTN PRSTH EVASC DESC THORAC AORTA RS&I
|
Professional
|
$822.64
|
|
|
Service Code
|
HCPCS 75958 26
|
| Min. Negotiated Rate |
$164.53 |
| Max. Negotiated Rate |
$1,806.40 |
| Rate for Payer: Cash Price |
$216.28
|
| Rate for Payer: Cash Price |
$216.28
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$211.54
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$211.54
|
| Rate for Payer: Fidelis Essential Plan QHP |
$223.29
|
| Rate for Payer: Fidelis Medicare Advantage |
$235.04
|
| Rate for Payer: Fidelis Qualified Health Plan |
$223.29
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.04
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$176.28
|
| Rate for Payer: Healthfirst Medicare Advantage |
$223.29
|
| Rate for Payer: Healthfirst QHP |
$235.04
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$164.53
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$235.04
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$199.78
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$164.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$235.04
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$616.98
|
| Rate for Payer: SOMOS Essential |
$616.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$235.04
|
|
|
CHG PLMT PROX XTN PRSTH EVASC DESC THORAC AORTA RS&I
|
Professional
|
$2,408.53
|
|
|
Service Code
|
HCPCS 75958
|
| Min. Negotiated Rate |
$164.53 |
| Max. Negotiated Rate |
$1,806.40 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,806.40
|
| Rate for Payer: SOMOS Essential |
$1,806.40
|
|
|
CHG PROTEIN ELECTROP FXJ&QUAN OTH FLUS CONCENTRATI
|
Professional
|
$69.20
|
|
|
Service Code
|
HCPCS 84166 26
|
| Min. Negotiated Rate |
$13.84 |
| Max. Negotiated Rate |
$51.90 |
| Rate for Payer: Cash Price |
$19.03
|
| Rate for Payer: Cash Price |
$19.03
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$17.79
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$17.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$18.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$19.77
|
| Rate for Payer: Fidelis Qualified Health Plan |
$18.78
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.77
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$14.83
|
| Rate for Payer: Healthfirst Medicare Advantage |
$18.78
|
| Rate for Payer: Healthfirst QHP |
$19.77
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$13.84
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$19.77
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$16.80
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$13.84
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$19.77
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$51.90
|
| Rate for Payer: SOMOS Essential |
$51.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.77
|
|
|
CHG PROTEIN ELECTROPHORETIC FRACTJ&QUANTJ SERUM
|
Professional
|
$69.20
|
|
|
Service Code
|
HCPCS 84165 26
|
| Min. Negotiated Rate |
$13.84 |
| Max. Negotiated Rate |
$51.90 |
| Rate for Payer: Cash Price |
$19.03
|
| Rate for Payer: Cash Price |
$19.03
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$17.79
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$17.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$18.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$19.77
|
| Rate for Payer: Fidelis Qualified Health Plan |
$18.78
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.77
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$14.83
|
| Rate for Payer: Healthfirst Medicare Advantage |
$18.78
|
| Rate for Payer: Healthfirst QHP |
$19.77
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$13.84
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$19.77
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$16.80
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$13.84
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$19.77
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$51.90
|
| Rate for Payer: SOMOS Essential |
$51.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.77
|
|
|
CHG PROTEIN WESTRN BLOT BLOOD/OTH FLU IMMUNOLOGICAL
|
Professional
|
$69.20
|
|
|
Service Code
|
HCPCS 84182 26
|
| Min. Negotiated Rate |
$13.84 |
| Max. Negotiated Rate |
$51.90 |
| Rate for Payer: Cash Price |
$19.03
|
| Rate for Payer: Cash Price |
$19.03
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$17.79
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$17.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$18.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$19.77
|
| Rate for Payer: Fidelis Qualified Health Plan |
$18.78
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.77
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$14.83
|
| Rate for Payer: Healthfirst Medicare Advantage |
$18.78
|
| Rate for Payer: Healthfirst QHP |
$19.77
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$13.84
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$19.77
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$16.80
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$13.84
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$19.77
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$51.90
|
| Rate for Payer: SOMOS Essential |
$51.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.77
|
|
|
CHG PROTEIN WESTRN BLOT I&R BLOOD/OTHER FLUID
|
Professional
|
$69.20
|
|
|
Service Code
|
HCPCS 84181 26
|
| Min. Negotiated Rate |
$13.84 |
| Max. Negotiated Rate |
$51.90 |
| Rate for Payer: Cash Price |
$19.03
|
| Rate for Payer: Cash Price |
$19.03
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$17.79
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$17.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$18.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$19.77
|
| Rate for Payer: Fidelis Qualified Health Plan |
$18.78
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$19.77
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$19.77
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$14.83
|
| Rate for Payer: Healthfirst Medicare Advantage |
$18.78
|
| Rate for Payer: Healthfirst QHP |
$19.77
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$13.84
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$19.77
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$16.80
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$13.84
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$19.77
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$51.90
|
| Rate for Payer: SOMOS Essential |
$51.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$19.77
|
|
|
CHG PROTHROMBIN TIME
|
Professional
|
$10.72
|
|
|
Service Code
|
HCPCS 85610
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$8.04 |
| Rate for Payer: Cash Price |
$4.29
|
| Rate for Payer: Cash Price |
$4.29
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$3.86
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$3.86
|
| Rate for Payer: Fidelis Essential Plan QHP |
$4.08
|
| Rate for Payer: Fidelis Medicare Advantage |
$4.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$4.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$3.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$4.08
|
| Rate for Payer: Healthfirst QHP |
$4.29
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$3.00
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$4.29
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$3.65
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$3.00
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$4.29
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$8.04
|
| Rate for Payer: SOMOS Essential |
$8.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4.29
|
|
|
CHG PROTON TX DELIVERY COMPLEX
|
Professional
|
$4,177.78
|
|
|
Service Code
|
HCPCS 77525
|
| Min. Negotiated Rate |
$3,133.34 |
| Max. Negotiated Rate |
$3,133.34 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$3,133.34
|
| Rate for Payer: SOMOS Essential |
$3,133.34
|
|
|
CHG PROTON TX DELIVERY INTERMEDIATE
|
Professional
|
$3,924.10
|
|
|
Service Code
|
HCPCS 77523
|
| Min. Negotiated Rate |
$2,943.08 |
| Max. Negotiated Rate |
$2,943.08 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$2,943.08
|
| Rate for Payer: SOMOS Essential |
$2,943.08
|
|
|
CHG PROTON TX DELIVERY SIMPLE W/COMPENSATION
|
Professional
|
$3,308.13
|
|
|
Service Code
|
HCPCS 77522
|
| Min. Negotiated Rate |
$2,481.10 |
| Max. Negotiated Rate |
$2,481.10 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$2,481.10
|
| Rate for Payer: SOMOS Essential |
$2,481.10
|
|
|
CHG PROTON TX DELIVERY SIMPLE W/O COMPENSATION
|
Professional
|
$3,221.51
|
|
|
Service Code
|
HCPCS 77520
|
| Min. Negotiated Rate |
$2,416.13 |
| Max. Negotiated Rate |
$2,416.13 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$2,416.13
|
| Rate for Payer: SOMOS Essential |
$2,416.13
|
|
|
CHG PRQ TRANSHEPATC DILAT BILIARY DUCT STRICTRE RS&I
|
Professional
|
$1,023.16
|
|
|
Service Code
|
HCPCS 74363 TC
|
| Min. Negotiated Rate |
$33.14 |
| Max. Negotiated Rate |
$891.66 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$767.37
|
| Rate for Payer: SOMOS Essential |
$767.37
|
|
|
CHG PRQ TRANSHEPATC DILAT BILIARY DUCT STRICTRE RS&I
|
Professional
|
$1,188.88
|
|
|
Service Code
|
HCPCS 74363
|
| Min. Negotiated Rate |
$33.14 |
| Max. Negotiated Rate |
$891.66 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$891.66
|
| Rate for Payer: SOMOS Essential |
$891.66
|
|
|
CHG PRQ TRANSHEPATC DILAT BILIARY DUCT STRICTRE RS&I
|
Professional
|
$165.73
|
|
|
Service Code
|
HCPCS 74363 26
|
| Min. Negotiated Rate |
$33.14 |
| Max. Negotiated Rate |
$891.66 |
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$42.62
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$42.62
|
| Rate for Payer: Fidelis Essential Plan QHP |
$44.98
|
| Rate for Payer: Fidelis Medicare Advantage |
$47.35
|
| Rate for Payer: Fidelis Qualified Health Plan |
$44.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$47.35
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$47.35
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$35.51
|
| Rate for Payer: Healthfirst Medicare Advantage |
$44.98
|
| Rate for Payer: Healthfirst QHP |
$47.35
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$33.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$47.35
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$40.25
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$33.14
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$47.35
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$124.30
|
| Rate for Payer: SOMOS Essential |
$124.30
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$47.35
|
|
|
CHG PRQ TRANSHEPATC PORTOGRAPY HEMODYN EVAL RS&I
|
Professional
|
$576.87
|
|
|
Service Code
|
HCPCS 75885
|
| Min. Negotiated Rate |
$52.47 |
| Max. Negotiated Rate |
$432.65 |
| Rate for Payer: Cash Price |
$157.14
|
| Rate for Payer: Cash Price |
$157.14
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$148.34
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$148.34
|
| Rate for Payer: Fidelis Essential Plan QHP |
$156.58
|
| Rate for Payer: Fidelis Medicare Advantage |
$164.82
|
| Rate for Payer: Fidelis Qualified Health Plan |
$156.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$164.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$164.82
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$123.62
|
| Rate for Payer: Healthfirst Medicare Advantage |
$156.58
|
| Rate for Payer: Healthfirst QHP |
$164.82
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$115.37
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$164.82
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$140.10
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$115.37
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$164.82
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$432.65
|
| Rate for Payer: SOMOS Essential |
$432.65
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$164.82
|
|
|
CHG PRQ TRANSHEPATC PORTOGRAPY HEMODYN EVAL RS&I
|
Professional
|
$314.55
|
|
|
Service Code
|
HCPCS 75885 TC
|
| Min. Negotiated Rate |
$52.47 |
| Max. Negotiated Rate |
$432.65 |
| Rate for Payer: Cash Price |
$85.73
|
| Rate for Payer: Cash Price |
$85.73
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$80.88
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$80.88
|
| Rate for Payer: Fidelis Essential Plan QHP |
$85.38
|
| Rate for Payer: Fidelis Medicare Advantage |
$89.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$85.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$89.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$89.87
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$67.40
|
| Rate for Payer: Healthfirst Medicare Advantage |
$85.38
|
| Rate for Payer: Healthfirst QHP |
$89.87
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$62.91
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$89.87
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$76.39
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$62.91
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$89.87
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$235.91
|
| Rate for Payer: SOMOS Essential |
$235.91
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$89.87
|
|
|
CHG PRQ TRANSHEPATC PORTOGRAPY HEMODYN EVAL RS&I
|
Professional
|
$262.36
|
|
|
Service Code
|
HCPCS 75885 26
|
| Min. Negotiated Rate |
$52.47 |
| Max. Negotiated Rate |
$432.65 |
| Rate for Payer: Cash Price |
$71.41
|
| Rate for Payer: Cash Price |
$71.41
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$67.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$67.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$71.21
|
| Rate for Payer: Fidelis Medicare Advantage |
$74.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$71.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$74.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$74.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$56.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$71.21
|
| Rate for Payer: Healthfirst QHP |
$74.96
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$52.47
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$74.96
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$63.72
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$52.47
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$74.96
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$196.77
|
| Rate for Payer: SOMOS Essential |
$196.77
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$74.96
|
|
|
CHG PRQ TRANSHEPATC PORTOGRAPY W/O HEMODYN EVL INTRP
|
Professional
|
$318.85
|
|
|
Service Code
|
HCPCS 75887 TC
|
| Min. Negotiated Rate |
$53.33 |
| Max. Negotiated Rate |
$439.14 |
| Rate for Payer: Cash Price |
$86.52
|
| Rate for Payer: Cash Price |
$86.52
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$81.99
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$81.99
|
| Rate for Payer: Fidelis Essential Plan QHP |
$86.54
|
| Rate for Payer: Fidelis Medicare Advantage |
$91.10
|
| Rate for Payer: Fidelis Qualified Health Plan |
$86.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$91.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$91.10
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$68.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$86.54
|
| Rate for Payer: Healthfirst QHP |
$91.10
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$63.77
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$91.10
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$77.44
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$63.77
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$91.10
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$239.14
|
| Rate for Payer: SOMOS Essential |
$239.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$91.10
|
|
|
CHG PRQ TRANSHEPATC PORTOGRAPY W/O HEMODYN EVL INTRP
|
Professional
|
$585.52
|
|
|
Service Code
|
HCPCS 75887
|
| Min. Negotiated Rate |
$53.33 |
| Max. Negotiated Rate |
$439.14 |
| Rate for Payer: Cash Price |
$158.32
|
| Rate for Payer: Cash Price |
$158.32
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$150.56
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$150.56
|
| Rate for Payer: Fidelis Essential Plan QHP |
$158.93
|
| Rate for Payer: Fidelis Medicare Advantage |
$167.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$158.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$167.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$167.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$125.47
|
| Rate for Payer: Healthfirst Medicare Advantage |
$158.93
|
| Rate for Payer: Healthfirst QHP |
$167.29
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$117.10
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$167.29
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$142.20
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$117.10
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$167.29
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$439.14
|
| Rate for Payer: SOMOS Essential |
$439.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$167.29
|
|
|
CHG PRQ TRANSHEPATC PORTOGRAPY W/O HEMODYN EVL INTRP
|
Professional
|
$266.67
|
|
|
Service Code
|
HCPCS 75887 26
|
| Min. Negotiated Rate |
$53.33 |
| Max. Negotiated Rate |
$439.14 |
| Rate for Payer: Cash Price |
$71.80
|
| Rate for Payer: Cash Price |
$71.80
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$68.57
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$68.57
|
| Rate for Payer: Fidelis Essential Plan QHP |
$72.38
|
| Rate for Payer: Fidelis Medicare Advantage |
$76.19
|
| Rate for Payer: Fidelis Qualified Health Plan |
$72.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$76.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$76.19
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$57.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$72.38
|
| Rate for Payer: Healthfirst QHP |
$76.19
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$53.33
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$76.19
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$64.76
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$53.33
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$76.19
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$200.00
|
| Rate for Payer: SOMOS Essential |
$200.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$76.19
|
|
|
CHG PULMONARY PERFUSION IMAGING PARTICULATE
|
Professional
|
$948.33
|
|
|
Service Code
|
HCPCS 78580
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$711.25 |
| Rate for Payer: Cash Price |
$254.00
|
| Rate for Payer: Cash Price |
$254.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$243.86
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$243.86
|
| Rate for Payer: Fidelis Essential Plan QHP |
$257.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$270.95
|
| Rate for Payer: Fidelis Qualified Health Plan |
$257.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$270.95
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$270.95
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$203.21
|
| Rate for Payer: Healthfirst Medicare Advantage |
$257.40
|
| Rate for Payer: Healthfirst QHP |
$270.95
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$189.66
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$270.95
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$230.31
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$189.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$270.95
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$711.25
|
| Rate for Payer: SOMOS Essential |
$711.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$270.95
|
|
|
CHG PULMONARY PERFUSION IMAGING PARTICULATE
|
Professional
|
$808.75
|
|
|
Service Code
|
HCPCS 78580 TC
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$711.25 |
| Rate for Payer: Cash Price |
$216.26
|
| Rate for Payer: Cash Price |
$216.26
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$207.96
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$207.96
|
| Rate for Payer: Fidelis Essential Plan QHP |
$219.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$231.07
|
| Rate for Payer: Fidelis Qualified Health Plan |
$219.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$231.07
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$231.07
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$173.30
|
| Rate for Payer: Healthfirst Medicare Advantage |
$219.52
|
| Rate for Payer: Healthfirst QHP |
$231.07
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$161.75
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$231.07
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$196.41
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$161.75
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$231.07
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$606.56
|
| Rate for Payer: SOMOS Essential |
$606.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$231.07
|
|
|
CHG PULMONARY PERFUSION IMAGING PARTICULATE
|
Professional
|
$139.58
|
|
|
Service Code
|
HCPCS 78580 26
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$711.25 |
| Rate for Payer: Cash Price |
$37.74
|
| Rate for Payer: Cash Price |
$37.74
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$35.89
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$35.89
|
| Rate for Payer: Fidelis Essential Plan QHP |
$37.89
|
| Rate for Payer: Fidelis Medicare Advantage |
$39.88
|
| Rate for Payer: Fidelis Qualified Health Plan |
$37.89
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$39.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$39.88
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$29.91
|
| Rate for Payer: Healthfirst Medicare Advantage |
$37.89
|
| Rate for Payer: Healthfirst QHP |
$39.88
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$27.92
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$39.88
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$33.90
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$27.92
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$39.88
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$104.68
|
| Rate for Payer: SOMOS Essential |
$104.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$39.88
|
|
|
CHG PULMONARY VENTILATION IMAGING
|
Professional
|
$666.44
|
|
|
Service Code
|
HCPCS 78579 TC
|
| Min. Negotiated Rate |
$18.26 |
| Max. Negotiated Rate |
$568.29 |
| Rate for Payer: Cash Price |
$177.52
|
| Rate for Payer: Cash Price |
$177.52
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$171.37
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$171.37
|
| Rate for Payer: Fidelis Essential Plan QHP |
$180.89
|
| Rate for Payer: Fidelis Medicare Advantage |
$190.41
|
| Rate for Payer: Fidelis Qualified Health Plan |
$180.89
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$190.41
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$190.41
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$142.81
|
| Rate for Payer: Healthfirst Medicare Advantage |
$180.89
|
| Rate for Payer: Healthfirst QHP |
$190.41
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$133.29
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$190.41
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$161.85
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$133.29
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$190.41
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$499.83
|
| Rate for Payer: SOMOS Essential |
$499.83
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$190.41
|
|
