2010-06-07_(2).pdf - 19318.8K - BridgeportCT.gov

Customer Name Bridgeport City
BOE
Administrative Services Only Agreement
The Urgent Care case rate
excluding radiology and laboratory services is 115
The CMG CareToday CMG low acuity clinics visit rate is
59 Lab tests
performed at the CMG CareToday
facilities are 10 per service A complete CMG CareToday fee schedule is available on request
ASC Ambulatory surgical center group rates based on 2006 Medicare for fadIity component of outpatient
surgery services
Group 1 485
Group 2 650
Group 3 740
Group 4 900
Group 5 950
Group 6 1100
Group 7 1420
Group 8 1400
Group 9 1200
Unlisted 740
Cigna Medical Group pharmacy
fee schedule
Brand Name AWP 15 2 75
dispensing fee
Generic IfMAC pricing is available then MAC 2 75
Ifno MAC price available then AWP 15 2 75 dispensing fee
Plan charges are reduced by any applicable copayment coinsurance and or deductible for service
Services
not identified by CPT code or codes without established RVUs are billed at the 50th Percentile ofthe Arizona
Regional
Medicode Schedule
Notes
Incorrectly reflected as 798 42 rather than 807 18 in prior CMG Fee Schedule dated 3 12007 807 18 charge
as of 3 12 07 As of 6 12008 charge reduced to 485 00 facility charge and 552 18 total charge
Incorrectly reflected as 857 26 rather than 888 35 in prior CMG Fee Schedule dated 31 2007 888 35 charge
as of 3 12007 As of 6 12008 charge remains 888 35
was effective
was effective
Incorrectly reflected as 2 50 rather than 2 75 in prior CMG Fee Schedule dated 3 12007 2 75 has been correct charge
since inception ofOAP product
OS 2120I 0
32