|
CHG US INTRAUTERINE FTL TFUJ/CORDOCNTS IMG S&I
|
Professional
|
$561.86
|
|
|
Service Code
|
HCPCS 76941
|
| Min. Negotiated Rate |
$50.71 |
| Max. Negotiated Rate |
$421.40 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$421.40
|
| Rate for Payer: SOMOS Essential |
$421.40
|
|
|
CHG US LMTD JT/FCL EVAL NONVASC XTR STRUX R-T W/IMG
|
Professional
|
$133.32
|
|
|
Service Code
|
HCPCS 76882 26
|
| Min. Negotiated Rate |
$8.31 |
| Max. Negotiated Rate |
$131.14 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$34.28
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$34.28
|
| Rate for Payer: Fidelis Essential Plan QHP |
$36.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$38.09
|
| Rate for Payer: Fidelis Qualified Health Plan |
$36.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$38.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$38.09
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$28.57
|
| Rate for Payer: Healthfirst Medicare Advantage |
$36.19
|
| Rate for Payer: Healthfirst QHP |
$38.09
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$26.66
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$38.09
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$32.38
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$26.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$38.09
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$99.99
|
| Rate for Payer: SOMOS Essential |
$99.99
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$38.09
|
|
|
CHG US LMTD JT/FCL EVAL NONVASC XTR STRUX R-T W/IMG
|
Professional
|
$41.55
|
|
|
Service Code
|
HCPCS 76882 TC
|
| Min. Negotiated Rate |
$8.31 |
| Max. Negotiated Rate |
$131.14 |
| Rate for Payer: Cash Price |
$36.78
|
| Rate for Payer: Cash Price |
$36.78
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$10.68
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$10.68
|
| Rate for Payer: Fidelis Essential Plan QHP |
$11.28
|
| Rate for Payer: Fidelis Medicare Advantage |
$11.87
|
| Rate for Payer: Fidelis Qualified Health Plan |
$11.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.87
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.87
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$8.90
|
| Rate for Payer: Healthfirst Medicare Advantage |
$11.28
|
| Rate for Payer: Healthfirst QHP |
$11.87
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$8.31
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$11.87
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$10.09
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$8.31
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$11.87
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$31.16
|
| Rate for Payer: SOMOS Essential |
$31.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11.87
|
|
|
CHG US LMTD JT/FCL EVAL NONVASC XTR STRUX R-T W/IMG
|
Professional
|
$174.86
|
|
|
Service Code
|
HCPCS 76882
|
| Min. Negotiated Rate |
$8.31 |
| Max. Negotiated Rate |
$131.14 |
| Rate for Payer: Cash Price |
$72.77
|
| Rate for Payer: Cash Price |
$72.77
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$44.96
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$44.96
|
| Rate for Payer: Fidelis Essential Plan QHP |
$47.46
|
| Rate for Payer: Fidelis Medicare Advantage |
$49.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$47.46
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$49.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$49.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$37.47
|
| Rate for Payer: Healthfirst Medicare Advantage |
$47.46
|
| Rate for Payer: Healthfirst QHP |
$49.96
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$34.97
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$49.96
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$42.47
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$34.97
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$49.96
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$131.14
|
| Rate for Payer: SOMOS Essential |
$131.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$49.96
|
|
|
CHG US &MNTR PARENCHYMAL TISSUE ABLATION
|
Professional
|
$361.45
|
|
|
Service Code
|
HCPCS 76940 TC
|
| Min. Negotiated Rate |
$84.43 |
| Max. Negotiated Rate |
$587.68 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$271.09
|
| Rate for Payer: SOMOS Essential |
$271.09
|
|
|
CHG US &MNTR PARENCHYMAL TISSUE ABLATION
|
Professional
|
$422.14
|
|
|
Service Code
|
HCPCS 76940 26
|
| Min. Negotiated Rate |
$84.43 |
| Max. Negotiated Rate |
$587.68 |
| Rate for Payer: Cash Price |
$113.75
|
| Rate for Payer: Cash Price |
$113.75
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$108.55
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$108.55
|
| Rate for Payer: Fidelis Essential Plan QHP |
$114.58
|
| Rate for Payer: Fidelis Medicare Advantage |
$120.61
|
| Rate for Payer: Fidelis Qualified Health Plan |
$114.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$120.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$120.61
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$90.46
|
| Rate for Payer: Healthfirst Medicare Advantage |
$114.58
|
| Rate for Payer: Healthfirst QHP |
$120.61
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$84.43
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$120.61
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$102.52
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$84.43
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$120.61
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$316.60
|
| Rate for Payer: SOMOS Essential |
$316.60
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$120.61
|
|
|
CHG US &MNTR PARENCHYMAL TISSUE ABLATION
|
Professional
|
$783.58
|
|
|
Service Code
|
HCPCS 76940
|
| Min. Negotiated Rate |
$84.43 |
| Max. Negotiated Rate |
$587.68 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$587.68
|
| Rate for Payer: SOMOS Essential |
$587.68
|
|
|
CHG US NRV&ACC STRUX 1 XTR COMPRE W/IMG PR EXTREMITY
|
Professional
|
$295.75
|
|
|
Service Code
|
HCPCS 76883
|
| Min. Negotiated Rate |
$12.91 |
| Max. Negotiated Rate |
$221.81 |
| Rate for Payer: Cash Price |
$80.37
|
| Rate for Payer: Cash Price |
$80.37
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$76.05
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$76.05
|
| Rate for Payer: Fidelis Essential Plan QHP |
$80.28
|
| Rate for Payer: Fidelis Medicare Advantage |
$84.50
|
| Rate for Payer: Fidelis Qualified Health Plan |
$80.28
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$84.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$84.50
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$63.38
|
| Rate for Payer: Healthfirst Medicare Advantage |
$80.28
|
| Rate for Payer: Healthfirst QHP |
$84.50
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$59.15
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$84.50
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$71.82
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$59.15
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$84.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$221.81
|
| Rate for Payer: SOMOS Essential |
$221.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$84.50
|
|
|
CHG US NRV&ACC STRUX 1 XTR COMPRE W/IMG PR EXTREMITY
|
Professional
|
$64.54
|
|
|
Service Code
|
HCPCS 76883 TC
|
| Min. Negotiated Rate |
$12.91 |
| Max. Negotiated Rate |
$221.81 |
| Rate for Payer: Cash Price |
$17.13
|
| Rate for Payer: Cash Price |
$17.13
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$16.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$16.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$17.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$18.44
|
| Rate for Payer: Fidelis Qualified Health Plan |
$17.52
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$18.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$18.44
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$13.83
|
| Rate for Payer: Healthfirst Medicare Advantage |
$17.52
|
| Rate for Payer: Healthfirst QHP |
$18.44
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$12.91
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$18.44
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$15.67
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$12.91
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$18.44
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$48.40
|
| Rate for Payer: SOMOS Essential |
$48.40
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$18.44
|
|
|
CHG US NRV&ACC STRUX 1 XTR COMPRE W/IMG PR EXTREMITY
|
Professional
|
$231.21
|
|
|
Service Code
|
HCPCS 76883 26
|
| Min. Negotiated Rate |
$12.91 |
| Max. Negotiated Rate |
$221.81 |
| Rate for Payer: Cash Price |
$63.24
|
| Rate for Payer: Cash Price |
$63.24
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$59.45
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$59.45
|
| Rate for Payer: Fidelis Essential Plan QHP |
$62.76
|
| Rate for Payer: Fidelis Medicare Advantage |
$66.06
|
| Rate for Payer: Fidelis Qualified Health Plan |
$62.76
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$66.06
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$66.06
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$49.54
|
| Rate for Payer: Healthfirst Medicare Advantage |
$62.76
|
| Rate for Payer: Healthfirst QHP |
$66.06
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$46.24
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$66.06
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$56.15
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$46.24
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$66.06
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$173.41
|
| Rate for Payer: SOMOS Essential |
$173.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$66.06
|
|
|
CHG US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U
|
Professional
|
$93.98
|
|
|
Service Code
|
HCPCS 76857 26
|
| Min. Negotiated Rate |
$18.80 |
| Max. Negotiated Rate |
$153.38 |
| Rate for Payer: Cash Price |
$25.37
|
| Rate for Payer: Cash Price |
$25.37
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$24.16
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$24.16
|
| Rate for Payer: Fidelis Essential Plan QHP |
$25.51
|
| Rate for Payer: Fidelis Medicare Advantage |
$26.85
|
| Rate for Payer: Fidelis Qualified Health Plan |
$25.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.85
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.85
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$20.14
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.51
|
| Rate for Payer: Healthfirst QHP |
$26.85
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$18.80
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$26.85
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$22.82
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$18.80
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26.85
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$70.48
|
| Rate for Payer: SOMOS Essential |
$70.48
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$26.85
|
|
|
CHG US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U
|
Professional
|
$110.57
|
|
|
Service Code
|
HCPCS 76857 TC
|
| Min. Negotiated Rate |
$18.80 |
| Max. Negotiated Rate |
$153.38 |
| Rate for Payer: Cash Price |
$31.27
|
| Rate for Payer: Cash Price |
$31.27
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$28.43
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$28.43
|
| Rate for Payer: Fidelis Essential Plan QHP |
$30.01
|
| Rate for Payer: Fidelis Medicare Advantage |
$31.59
|
| Rate for Payer: Fidelis Qualified Health Plan |
$30.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$31.59
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$31.59
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$23.69
|
| Rate for Payer: Healthfirst Medicare Advantage |
$30.01
|
| Rate for Payer: Healthfirst QHP |
$31.59
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$22.11
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$31.59
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$26.85
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$22.11
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$31.59
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$82.93
|
| Rate for Payer: SOMOS Essential |
$82.93
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$31.59
|
|
|
CHG US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U
|
Professional
|
$204.51
|
|
|
Service Code
|
HCPCS 76857
|
| Min. Negotiated Rate |
$18.80 |
| Max. Negotiated Rate |
$153.38 |
| Rate for Payer: Cash Price |
$56.64
|
| Rate for Payer: Cash Price |
$56.64
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$52.59
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$52.59
|
| Rate for Payer: Fidelis Essential Plan QHP |
$55.51
|
| Rate for Payer: Fidelis Medicare Advantage |
$58.43
|
| Rate for Payer: Fidelis Qualified Health Plan |
$55.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$58.43
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$58.43
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$43.82
|
| Rate for Payer: Healthfirst Medicare Advantage |
$55.51
|
| Rate for Payer: Healthfirst QHP |
$58.43
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$40.90
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$58.43
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$49.67
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$40.90
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$58.43
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$153.38
|
| Rate for Payer: SOMOS Essential |
$153.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$58.43
|
|
|
CHG US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE
|
Professional
|
$450.84
|
|
|
Service Code
|
HCPCS 76856
|
| Min. Negotiated Rate |
$26.66 |
| Max. Negotiated Rate |
$338.13 |
| Rate for Payer: Cash Price |
$122.05
|
| Rate for Payer: Cash Price |
$122.05
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$115.93
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$115.93
|
| Rate for Payer: Fidelis Essential Plan QHP |
$122.37
|
| Rate for Payer: Fidelis Medicare Advantage |
$128.81
|
| Rate for Payer: Fidelis Qualified Health Plan |
$122.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$128.81
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$128.81
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$96.61
|
| Rate for Payer: Healthfirst Medicare Advantage |
$122.37
|
| Rate for Payer: Healthfirst QHP |
$128.81
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$90.17
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$128.81
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$109.49
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$90.17
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$128.81
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$338.13
|
| Rate for Payer: SOMOS Essential |
$338.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$128.81
|
|
|
CHG US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE
|
Professional
|
$133.32
|
|
|
Service Code
|
HCPCS 76856 26
|
| Min. Negotiated Rate |
$26.66 |
| Max. Negotiated Rate |
$338.13 |
| Rate for Payer: Cash Price |
$35.37
|
| Rate for Payer: Cash Price |
$35.37
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$34.28
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$34.28
|
| Rate for Payer: Fidelis Essential Plan QHP |
$36.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$38.09
|
| Rate for Payer: Fidelis Qualified Health Plan |
$36.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$38.09
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$38.09
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$28.57
|
| Rate for Payer: Healthfirst Medicare Advantage |
$36.19
|
| Rate for Payer: Healthfirst QHP |
$38.09
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$26.66
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$38.09
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$32.38
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$26.66
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$38.09
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$99.99
|
| Rate for Payer: SOMOS Essential |
$99.99
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$38.09
|
|
|
CHG US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE
|
Professional
|
$317.56
|
|
|
Service Code
|
HCPCS 76856 TC
|
| Min. Negotiated Rate |
$26.66 |
| Max. Negotiated Rate |
$338.13 |
| Rate for Payer: Cash Price |
$86.68
|
| Rate for Payer: Cash Price |
$86.68
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$81.66
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$81.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$86.19
|
| Rate for Payer: Fidelis Medicare Advantage |
$90.73
|
| Rate for Payer: Fidelis Qualified Health Plan |
$86.19
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$90.73
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$90.73
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$68.05
|
| Rate for Payer: Healthfirst Medicare Advantage |
$86.19
|
| Rate for Payer: Healthfirst QHP |
$90.73
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$63.51
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$90.73
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$77.12
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$63.51
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$90.73
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$238.17
|
| Rate for Payer: SOMOS Essential |
$238.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$90.73
|
|
|
CHG US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT
|
Professional
|
$308.91
|
|
|
Service Code
|
HCPCS 76801 TC
|
| Min. Negotiated Rate |
$37.62 |
| Max. Negotiated Rate |
$372.78 |
| Rate for Payer: Cash Price |
$83.93
|
| Rate for Payer: Cash Price |
$83.93
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$79.43
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$79.43
|
| Rate for Payer: Fidelis Essential Plan QHP |
$83.85
|
| Rate for Payer: Fidelis Medicare Advantage |
$88.26
|
| Rate for Payer: Fidelis Qualified Health Plan |
$83.85
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$88.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$88.26
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$66.20
|
| Rate for Payer: Healthfirst Medicare Advantage |
$83.85
|
| Rate for Payer: Healthfirst QHP |
$88.26
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$61.78
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$88.26
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$75.02
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$61.78
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$88.26
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$231.68
|
| Rate for Payer: SOMOS Essential |
$231.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$88.26
|
|
|
CHG US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT
|
Professional
|
$497.04
|
|
|
Service Code
|
HCPCS 76801
|
| Min. Negotiated Rate |
$37.62 |
| Max. Negotiated Rate |
$372.78 |
| Rate for Payer: Cash Price |
$135.10
|
| Rate for Payer: Cash Price |
$135.10
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$127.81
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$127.81
|
| Rate for Payer: Fidelis Essential Plan QHP |
$134.91
|
| Rate for Payer: Fidelis Medicare Advantage |
$142.01
|
| Rate for Payer: Fidelis Qualified Health Plan |
$134.91
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$142.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$142.01
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$106.51
|
| Rate for Payer: Healthfirst Medicare Advantage |
$134.91
|
| Rate for Payer: Healthfirst QHP |
$142.01
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$99.41
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$142.01
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$120.71
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$99.41
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$142.01
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$372.78
|
| Rate for Payer: SOMOS Essential |
$372.78
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$142.01
|
|
|
CHG US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT
|
Professional
|
$188.13
|
|
|
Service Code
|
HCPCS 76801 26
|
| Min. Negotiated Rate |
$37.62 |
| Max. Negotiated Rate |
$372.78 |
| Rate for Payer: Cash Price |
$51.17
|
| Rate for Payer: Cash Price |
$51.17
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$48.38
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$48.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$51.06
|
| Rate for Payer: Fidelis Medicare Advantage |
$53.75
|
| Rate for Payer: Fidelis Qualified Health Plan |
$51.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$53.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$53.75
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$40.31
|
| Rate for Payer: Healthfirst Medicare Advantage |
$51.06
|
| Rate for Payer: Healthfirst QHP |
$53.75
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$37.62
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$53.75
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$45.69
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$37.62
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$53.75
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$141.10
|
| Rate for Payer: SOMOS Essential |
$141.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$53.75
|
|
|
CHG US PREGNANT UTERUS LIMITED 1/> FETUSES
|
Professional
|
$346.64
|
|
|
Service Code
|
HCPCS 76815
|
| Min. Negotiated Rate |
$25.37 |
| Max. Negotiated Rate |
$259.98 |
| Rate for Payer: Cash Price |
$93.54
|
| Rate for Payer: Cash Price |
$93.54
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$89.14
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$89.14
|
| Rate for Payer: Fidelis Essential Plan QHP |
$94.09
|
| Rate for Payer: Fidelis Medicare Advantage |
$99.04
|
| Rate for Payer: Fidelis Qualified Health Plan |
$94.09
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$99.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$99.04
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$74.28
|
| Rate for Payer: Healthfirst Medicare Advantage |
$94.09
|
| Rate for Payer: Healthfirst QHP |
$99.04
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$69.33
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$99.04
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$84.18
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$69.33
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$99.04
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$259.98
|
| Rate for Payer: SOMOS Essential |
$259.98
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$99.04
|
|
|
CHG US PREGNANT UTERUS LIMITED 1/> FETUSES
|
Professional
|
$219.80
|
|
|
Service Code
|
HCPCS 76815 TC
|
| Min. Negotiated Rate |
$25.37 |
| Max. Negotiated Rate |
$259.98 |
| Rate for Payer: Cash Price |
$59.96
|
| Rate for Payer: Cash Price |
$59.96
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$56.52
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$56.52
|
| Rate for Payer: Fidelis Essential Plan QHP |
$59.66
|
| Rate for Payer: Fidelis Medicare Advantage |
$62.80
|
| Rate for Payer: Fidelis Qualified Health Plan |
$59.66
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$62.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$62.80
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$47.10
|
| Rate for Payer: Healthfirst Medicare Advantage |
$59.66
|
| Rate for Payer: Healthfirst QHP |
$62.80
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$43.96
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$62.80
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$53.38
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$43.96
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$62.80
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$164.85
|
| Rate for Payer: SOMOS Essential |
$164.85
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$62.80
|
|
|
CHG US PREGNANT UTERUS LIMITED 1/> FETUSES
|
Professional
|
$126.84
|
|
|
Service Code
|
HCPCS 76815 26
|
| Min. Negotiated Rate |
$25.37 |
| Max. Negotiated Rate |
$259.98 |
| Rate for Payer: Cash Price |
$33.58
|
| Rate for Payer: Cash Price |
$33.58
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$32.62
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$32.62
|
| Rate for Payer: Fidelis Essential Plan QHP |
$34.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$36.24
|
| Rate for Payer: Fidelis Qualified Health Plan |
$34.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$36.24
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$36.24
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$27.18
|
| Rate for Payer: Healthfirst Medicare Advantage |
$34.43
|
| Rate for Payer: Healthfirst QHP |
$36.24
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$25.37
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$36.24
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$30.80
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$25.37
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$36.24
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$95.13
|
| Rate for Payer: SOMOS Essential |
$95.13
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$36.24
|
|
|
CHG US PREG UTERUS 14 WK TRANSABDL EACH GESTATION
|
Professional
|
$160.90
|
|
|
Service Code
|
HCPCS 76802 26
|
| Min. Negotiated Rate |
$18.40 |
| Max. Negotiated Rate |
$189.68 |
| Rate for Payer: Cash Price |
$43.00
|
| Rate for Payer: Cash Price |
$43.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$41.37
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$41.37
|
| Rate for Payer: Fidelis Essential Plan QHP |
$43.67
|
| Rate for Payer: Fidelis Medicare Advantage |
$45.97
|
| Rate for Payer: Fidelis Qualified Health Plan |
$43.67
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$45.97
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$45.97
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$34.48
|
| Rate for Payer: Healthfirst Medicare Advantage |
$43.67
|
| Rate for Payer: Healthfirst QHP |
$45.97
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$32.18
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$45.97
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$39.07
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$32.18
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$45.97
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$120.68
|
| Rate for Payer: SOMOS Essential |
$120.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$45.97
|
|
|
CHG US PREG UTERUS 14 WK TRANSABDL EACH GESTATION
|
Professional
|
$92.02
|
|
|
Service Code
|
HCPCS 76802 TC
|
| Min. Negotiated Rate |
$18.40 |
| Max. Negotiated Rate |
$189.68 |
| Rate for Payer: Cash Price |
$24.75
|
| Rate for Payer: Cash Price |
$24.75
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$23.66
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$23.66
|
| Rate for Payer: Fidelis Essential Plan QHP |
$24.98
|
| Rate for Payer: Fidelis Medicare Advantage |
$26.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$24.98
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$26.29
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$26.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$19.72
|
| Rate for Payer: Healthfirst Medicare Advantage |
$24.98
|
| Rate for Payer: Healthfirst QHP |
$26.29
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$18.40
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$26.29
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$22.35
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$18.40
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$26.29
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$69.02
|
| Rate for Payer: SOMOS Essential |
$69.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$26.29
|
|
|
CHG US PREG UTERUS 14 WK TRANSABDL EACH GESTATION
|
Professional
|
$252.91
|
|
|
Service Code
|
HCPCS 76802
|
| Min. Negotiated Rate |
$18.40 |
| Max. Negotiated Rate |
$189.68 |
| Rate for Payer: Cash Price |
$67.76
|
| Rate for Payer: Cash Price |
$67.76
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$65.03
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$65.03
|
| Rate for Payer: Fidelis Essential Plan QHP |
$68.65
|
| Rate for Payer: Fidelis Medicare Advantage |
$72.26
|
| Rate for Payer: Fidelis Qualified Health Plan |
$68.65
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$72.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$72.26
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$54.20
|
| Rate for Payer: Healthfirst Medicare Advantage |
$68.65
|
| Rate for Payer: Healthfirst QHP |
$72.26
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$50.58
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$72.26
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$61.42
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$50.58
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$72.26
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$189.68
|
| Rate for Payer: SOMOS Essential |
$189.68
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$72.26
|
|
