|
OMNIPAQUE 300MG/ML -100ML 1ML
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41658018
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
|
|
OMNIPAQUE 300MG/ML -100ML 1ML
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41658018
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.58
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.15
|
| Rate for Payer: SOMOS Essential |
$0.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
OMNIPAQUE 300MG/ML - 150ML 1ML
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41648019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
|
|
OMNIPAQUE 300MG/ML - 150ML 1ML
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41648019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.58
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.15
|
| Rate for Payer: SOMOS Essential |
$0.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
OMNIPAQUE 300MG/ML - 50ML PER 1ML
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41658017
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.58
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.15
|
| Rate for Payer: SOMOS Essential |
$0.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
OMNIPAQUE 300MG/ML - 50ML PER 1ML
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41658017
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
|
|
OMNIPAQUE 300ML - 150ML 1ML
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41658019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
|
|
OMNIPAQUE 300ML - 150ML 1ML
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41658019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.58
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.15
|
| Rate for Payer: SOMOS Essential |
$0.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
OMNIPAQUE 300ML/ML -50ML PER 1ML
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41648017
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
|
|
OMNIPAQUE 300ML/ML -50ML PER 1ML
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41648017
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.55
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.58
|
| Rate for Payer: Group Health Inc Commercial |
$0.50
|
| Rate for Payer: Group Health Inc Medicare |
$0.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.50
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.15
|
| Rate for Payer: SOMOS Essential |
$0.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.65
|
|
|
OMNIPAQUE 350/100ML PER ML
|
Facility
|
OP
|
$1.96
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41563109
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$1.47
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.57
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.33
|
| Rate for Payer: Group Health Inc Commercial |
$0.98
|
| Rate for Payer: Group Health Inc Medicare |
$0.69
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.98
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$0.14
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$0.15
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$0.15
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$0.15
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.27
|
|
|
OMNIQAQUE 240 50ML ORAL - 1 ML
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
41658425
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.06
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.34
|
| Rate for Payer: Aetna Government |
$0.34
|
| Rate for Payer: Brighton Health Commercial |
$0.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.08
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.05
|
| Rate for Payer: Group Health Inc Medicare |
$0.04
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.05
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$0.39
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$0.41
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$0.41
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$0.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.07
|
|
|
OMT 5-6 REGIONS
|
Facility
|
OP
|
$140.40
|
|
|
Service Code
|
HCPCS 98927
|
| Hospital Charge Code |
30106423
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$874.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$694.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.00
|
| Rate for Payer: Aetna Government |
$30.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$21.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$21.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$21.00
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$30.00
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$30.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$747.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$635.21
|
| Rate for Payer: Elderplan Medicare Advantage |
$30.00
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$25.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$26.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$26.70
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$70.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$30.00
|
| Rate for Payer: Humana Medicare |
$30.60
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$30.00
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.00
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$30.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$24.00
|
| Rate for Payer: Wellcare Medicare |
$28.50
|
|
|
OMT 5-6 REGIONS
|
Facility
|
IP
|
$140.40
|
|
|
Service Code
|
HCPCS 98927
|
| Hospital Charge Code |
30106423
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$30.00
|
|
|
OMT 5-6 REGIONS
|
Facility
|
IP
|
$140.40
|
|
|
Service Code
|
HCPCS 98927
|
| Hospital Charge Code |
30304036
|
|
Hospital Revenue Code
|
530
|
| Rate for Payer: Cash Price |
$30.00
|
|
|
OMT 5-6 REGIONS
|
Facility
|
OP
|
$140.40
|
|
|
Service Code
|
HCPCS 98927
|
| Hospital Charge Code |
30304036
|
|
Hospital Revenue Code
|
530
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$112.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$77.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.00
|
| Rate for Payer: Aetna Government |
$30.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$21.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$21.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$21.00
|
| Rate for Payer: Brighton Health Commercial |
$105.30
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$30.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$112.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$95.47
|
| Rate for Payer: Elderplan Medicare Advantage |
$30.00
|
| Rate for Payer: EmblemHealth Commercial |
$30.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$25.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$26.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$26.70
|
| Rate for Payer: Group Health Inc Commercial |
$30.00
|
| Rate for Payer: Group Health Inc Medicare |
$30.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$70.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.50
|
| Rate for Payer: Healthfirst QHP |
$30.00
|
| Rate for Payer: Humana Medicare |
$30.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$30.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$24.00
|
| Rate for Payer: Wellcare Medicare |
$28.50
|
|
|
OMT 7-8 REGION
|
Facility
|
IP
|
$164.83
|
|
|
Service Code
|
HCPCS 98928
|
| Hospital Charge Code |
30106424
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$30.00
|
|
|
OMT 7-8 REGION
|
Facility
|
OP
|
$164.83
|
|
|
Service Code
|
HCPCS 98928
|
| Hospital Charge Code |
30106424
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$874.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$694.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.00
|
| Rate for Payer: Aetna Government |
$30.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$21.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$21.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$21.00
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$30.00
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$30.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$747.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$635.21
|
| Rate for Payer: Elderplan Medicare Advantage |
$30.00
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$25.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$26.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$26.70
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$82.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$30.00
|
| Rate for Payer: Humana Medicare |
$30.60
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$30.00
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.00
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$30.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$24.00
|
| Rate for Payer: Wellcare Medicare |
$28.50
|
|
|
OMT 7-8 REGIONS
|
Facility
|
IP
|
$164.83
|
|
|
Service Code
|
HCPCS 98928
|
| Hospital Charge Code |
30304037
|
|
Hospital Revenue Code
|
530
|
| Rate for Payer: Cash Price |
$30.00
|
|
|
OMT 7-8 REGIONS
|
Facility
|
OP
|
$164.83
|
|
|
Service Code
|
HCPCS 98928
|
| Hospital Charge Code |
30304037
|
|
Hospital Revenue Code
|
530
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$131.86 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$90.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.00
|
| Rate for Payer: Aetna Government |
$30.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$21.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$21.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$21.00
|
| Rate for Payer: Brighton Health Commercial |
$123.62
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$30.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$131.86
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$112.08
|
| Rate for Payer: Elderplan Medicare Advantage |
$30.00
|
| Rate for Payer: EmblemHealth Commercial |
$30.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$25.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$26.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$26.70
|
| Rate for Payer: Group Health Inc Commercial |
$30.00
|
| Rate for Payer: Group Health Inc Medicare |
$30.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$82.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.50
|
| Rate for Payer: Healthfirst QHP |
$30.00
|
| Rate for Payer: Humana Medicare |
$30.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$30.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$24.00
|
| Rate for Payer: Wellcare Medicare |
$28.50
|
|
|
OMT 9 OR MORE REGIONS
|
Facility
|
IP
|
$189.23
|
|
|
Service Code
|
HCPCS 98929
|
| Hospital Charge Code |
30106425
|
|
Hospital Revenue Code
|
450
|
| Rate for Payer: Cash Price |
$30.00
|
|
|
OMT 9 OR MORE REGIONS
|
Facility
|
IP
|
$189.23
|
|
|
Service Code
|
HCPCS 98929
|
| Hospital Charge Code |
30304038
|
|
Hospital Revenue Code
|
530
|
| Rate for Payer: Cash Price |
$30.00
|
|
|
OMT 9 OR MORE REGIONS
|
Facility
|
OP
|
$189.23
|
|
|
Service Code
|
HCPCS 98929
|
| Hospital Charge Code |
30304038
|
|
Hospital Revenue Code
|
530
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$151.38 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$104.08
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.00
|
| Rate for Payer: Aetna Government |
$30.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$21.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$21.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$21.00
|
| Rate for Payer: Brighton Health Commercial |
$141.92
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$30.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$151.38
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$128.68
|
| Rate for Payer: Elderplan Medicare Advantage |
$30.00
|
| Rate for Payer: EmblemHealth Commercial |
$30.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$25.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$26.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$26.70
|
| Rate for Payer: Group Health Inc Commercial |
$30.00
|
| Rate for Payer: Group Health Inc Medicare |
$30.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$94.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$25.50
|
| Rate for Payer: Healthfirst QHP |
$30.00
|
| Rate for Payer: Humana Medicare |
$30.60
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$30.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$24.00
|
| Rate for Payer: Wellcare Medicare |
$28.50
|
|
|
OMT 9 OR MORE REGIONS
|
Facility
|
OP
|
$189.23
|
|
|
Service Code
|
HCPCS 98929
|
| Hospital Charge Code |
30106425
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$874.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$694.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$30.00
|
| Rate for Payer: Aetna Government |
$30.00
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$21.00
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$21.00
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$21.00
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$30.00
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$30.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$747.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$635.21
|
| Rate for Payer: Elderplan Medicare Advantage |
$30.00
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$25.50
|
| Rate for Payer: Fidelis Essential Plan QHP |
$26.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$30.00
|
| Rate for Payer: Fidelis Qualified Health Plan |
$26.70
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$94.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$30.00
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$30.00
|
| Rate for Payer: Humana Medicare |
$30.60
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$30.00
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$30.00
|
| Rate for Payer: United Healthcare Commercial |
$569.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$30.00
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$24.00
|
| Rate for Payer: Wellcare Medicare |
$28.50
|
|
|
ONABOTULINUMTOXINA 100 UNITS IJ SOLR [100610]
|
Facility
|
OP
|
$760.80
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
00023114501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$608.64 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$418.44
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$6.33
|
| Rate for Payer: Aetna Government |
$6.33
|
| Rate for Payer: Affinity Essential Plan 1&2 |
$4.43
|
| Rate for Payer: Affinity Essential Plan 3&4 |
$4.43
|
| Rate for Payer: Affinity Medicaid/CHP/HARP |
$4.43
|
| Rate for Payer: Brighton Health Commercial |
$570.60
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$6.33
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$608.64
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$517.34
|
| Rate for Payer: Elderplan Medicare Advantage |
$6.33
|
| Rate for Payer: EmblemHealth Commercial |
$6.33
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$5.38
|
| Rate for Payer: Fidelis Essential Plan QHP |
$5.63
|
| Rate for Payer: Fidelis Medicare Advantage |
$6.33
|
| Rate for Payer: Fidelis Qualified Health Plan |
$5.63
|
| Rate for Payer: Group Health Inc Commercial |
$6.33
|
| Rate for Payer: Group Health Inc Medicare |
$6.33
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$380.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6.33
|
| Rate for Payer: Healthfirst Medicare Advantage |
$5.38
|
| Rate for Payer: Healthfirst QHP |
$6.33
|
| Rate for Payer: Humana Medicare |
$6.45
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$6.32
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$6.70
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$6.70
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$6.70
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$6.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.33
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$494.52
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$5.06
|
| Rate for Payer: Wellcare Medicare |
$6.01
|
|
