Tier 2
Basic+
$150
per visit
- Office Visit
- Lab Test (Basic) (1)
- Medication (Basic)(Up to 2)
- Wound Care (Basic)
- Splinting (Basic)
Tier 3
Intermediate
$200
per visit
- Office Visit
- Lab Test (Basic) (Up to 2)
- Medication (Intermediate)(Up to 2)
- Wound Care (Basic)
- Splinting (Basic)
- OR Lab Test (Intermediate)(1)
Tier 4
Intermediate+
$250
per visit
- Office Visit
- Lab Test (Basic)(Up to 3)
- Medication (Intermediate) (Up to 2)
- Wound Care (Advanced)
- Splinting (Advanced)
- OR Lab Test (Intermediate)(2)
- OR Lab Test (Advanced)(1)
Tier 5
Advanced
$300
per visit
- Office Visit
- Lab Test (Basic)(Up to 3)
- Medication (Intermediate) (Up to 2)
- Wound Care (Advanced)
- Splinting (Advanced)
- OR Lab Test (Intermediate)(2)
- OR Lab Test (Advanced)(1)
Tier 6
Advanced+
$350
per visit
- Office Visit
- Lab Test (Basic)(Up to 3)
- Medication (Intermediate) (Up to 3)
- Wound Care (Advanced)
- Splinting (Advanced)
- OR Lab Test (Intermediate)(3)
- OR Lab Test (Advanced)(1)
- Cardiac Monitoring
Forms
Excellus BCBS
Fidelis
Humana
Martin’s Point
Medicaid
Medicare
MVP
Tricare
United