|
IODOFORM GAUZE 6 SIZE
|
Facility
|
OP
|
$15.24
|
|
| Hospital Charge Code |
40202601
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.33 |
| Max. Negotiated Rate |
$12.19 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.38
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$7.62
|
| Rate for Payer: Aetna Government |
$7.62
|
| Rate for Payer: Brighton Health Commercial |
$11.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$12.19
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10.36
|
| Rate for Payer: Group Health Inc Commercial |
$7.62
|
| Rate for Payer: Group Health Inc Medicare |
$5.33
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$7.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$7.62
|
|
|
IOHEXOL 12 MG/ML PO SOLN [163073]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 00407141612
|
| Hospital Charge Code |
00407141612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.01
|
| Rate for Payer: Aetna Government |
$0.01
|
| Rate for Payer: Brighton Health Commercial |
$0.02
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.02
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.02
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.02
|
|
|
IOHEXOL 180 MG/10ML VIAL
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS Q9965
|
| Hospital Charge Code |
41647019
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.84
|
| Rate for Payer: Aetna Government |
$0.84
|
| Rate for Payer: Brighton Health Commercial |
$6.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.44
|
| Rate for Payer: Group Health Inc Commercial |
$4.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.00
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1.02
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1.08
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1.08
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.20
|
|
|
IOHEXOL 180MG/ML, 10ML VIAL
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS Q9965
|
| Hospital Charge Code |
41657019
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.84
|
| Rate for Payer: Aetna Government |
$0.84
|
| Rate for Payer: Brighton Health Commercial |
$6.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5.44
|
| Rate for Payer: Group Health Inc Commercial |
$4.00
|
| Rate for Payer: Group Health Inc Medicare |
$2.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4.00
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1.02
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1.08
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1.08
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5.20
|
|
|
IOHEXOL 180 MG/ML IJ SOLN [10319]
|
Facility
|
OP
|
$4.81
|
|
|
Service Code
|
HCPCS Q9965
|
| Hospital Charge Code |
00407141110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.64
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.84
|
| Rate for Payer: Aetna Government |
$0.84
|
| Rate for Payer: Brighton Health Commercial |
$3.60
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.84
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3.27
|
| Rate for Payer: Group Health Inc Commercial |
$2.40
|
| Rate for Payer: Group Health Inc Medicare |
$1.68
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.40
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.40
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$1.02
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$1.08
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$1.08
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$1.08
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3.12
|
|
|
IOHEXOL 240MG/ML
|
Facility
|
IP
|
$22.63
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
41650396
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$11.32 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.32
|
|
|
IOHEXOL 240MG/ML
|
Facility
|
OP
|
$22.63
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
41640396
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$14.71 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.34
|
| Rate for Payer: Aetna Government |
$0.34
|
| Rate for Payer: Brighton Health Commercial |
$13.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.01
|
| Rate for Payer: Group Health Inc Commercial |
$11.32
|
| Rate for Payer: Group Health Inc Medicare |
$7.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.32
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.41
|
| Rate for Payer: SOMOS Essential |
$0.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14.71
|
|
|
IOHEXOL 240MG/ML
|
Facility
|
IP
|
$22.63
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
41640396
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$11.32 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.32
|
|
|
IOHEXOL 240MG/ML
|
Facility
|
OP
|
$22.63
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
41650396
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$14.71 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12.45
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.34
|
| Rate for Payer: Aetna Government |
$0.34
|
| Rate for Payer: Brighton Health Commercial |
$13.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.01
|
| Rate for Payer: Group Health Inc Commercial |
$11.32
|
| Rate for Payer: Group Health Inc Medicare |
$7.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11.32
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$0.41
|
| Rate for Payer: SOMOS Essential |
$0.41
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14.71
|
|
|
IOHEXOL 240 MG/ML IJ SOLN [119843]
|
Facility
|
OP
|
$2.76
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
00407141220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.52
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.34
|
| Rate for Payer: Aetna Government |
$0.34
|
| Rate for Payer: Brighton Health Commercial |
$2.07
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2.21
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.88
|
| Rate for Payer: Group Health Inc Commercial |
$1.38
|
| Rate for Payer: Group Health Inc Medicare |
$0.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1.38
|
| 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 |
$1.79
|
|
|
IOHEXOL 240 MG/ML IJ SOLN [119843]
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
00407141230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.52
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.34
|
| Rate for Payer: Aetna Government |
$0.34
|
| Rate for Payer: Brighton Health Commercial |
$0.71
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.64
|
| Rate for Payer: Group Health Inc Commercial |
$0.47
|
| Rate for Payer: Group Health Inc Medicare |
$0.33
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.47
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.47
|
| 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 |
$0.61
|
|
|
IOHEXOL 300 MG/ML IJ SOLN [119842]
|
Facility
|
OP
|
$1.11
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407141361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.83
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.89
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.76
|
| Rate for Payer: Group Health Inc Commercial |
$0.56
|
| Rate for Payer: Group Health Inc Medicare |
$0.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.56
|
| 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 |
$0.72
|
|
|
IOHEXOL 300 MG/ML IJ SOLN [119842]
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407141363
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.60
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.82
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.87
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.74
|
| Rate for Payer: Group Health Inc Commercial |
$0.54
|
| Rate for Payer: Group Health Inc Medicare |
$0.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.54
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.54
|
| 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 |
$0.71
|
|
|
IOHEXOL 300 MG/ML IJ SOLN [119842]
|
Facility
|
OP
|
$1.06
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407141365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.58
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.79
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.85
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.72
|
| Rate for Payer: Group Health Inc Commercial |
$0.53
|
| Rate for Payer: Group Health Inc Medicare |
$0.37
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.53
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.53
|
| 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 |
$0.69
|
|
|
IOHEXOL 350MG/ ML, 150ML VIAL
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41647024
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.99
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$1.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.22
|
| Rate for Payer: Group Health Inc Commercial |
$0.90
|
| Rate for Payer: Group Health Inc Medicare |
$0.63
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.90
|
| 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 |
$1.17
|
|
|
IOHEXOL 350MG/ ML, 150ML VIAL
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41657024
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.99
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$1.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.22
|
| Rate for Payer: Group Health Inc Commercial |
$0.90
|
| Rate for Payer: Group Health Inc Medicare |
$0.63
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.90
|
| 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 |
$1.17
|
|
|
IOHEXOL 350MG/ML, 50ML VIAL
|
Facility
|
OP
|
$1.96
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
41657020
|
|
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
|
|
|
IOHEXOL 350 MG/ML IV SOLN [10323]
|
Facility
|
OP
|
$1.21
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407141491
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.67
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.61
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.70
|
| Rate for Payer: EmblemHealth Commercial |
$0.61
|
| Rate for Payer: Fidelis Medicare Advantage |
$1.27
|
| Rate for Payer: Group Health Inc Commercial |
$0.61
|
| Rate for Payer: Group Health Inc Medicare |
$0.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.79
|
|
|
IOHEXOL 350 MG/ML IV SOLN [10323]
|
Facility
|
OP
|
$1.03
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407141472
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.57
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.62
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.52
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.59
|
| Rate for Payer: EmblemHealth Commercial |
$0.52
|
| Rate for Payer: Fidelis Medicare Advantage |
$1.08
|
| Rate for Payer: Group Health Inc Commercial |
$0.52
|
| Rate for Payer: Group Health Inc Medicare |
$0.36
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.52
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.67
|
|
|
IOHEXOL 350 MG/ML IV SOLN [10323]
|
Facility
|
IP
|
$1.21
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407141489
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.61
|
|
|
IOHEXOL 350 MG/ML IV SOLN [10323]
|
Facility
|
IP
|
$1.11
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407141493
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.56
|
|
|
IOHEXOL 350 MG/ML IV SOLN [10323]
|
Facility
|
OP
|
$1.11
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407141493
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.61
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.67
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.56
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.64
|
| Rate for Payer: EmblemHealth Commercial |
$0.56
|
| Rate for Payer: Fidelis Medicare Advantage |
$1.17
|
| Rate for Payer: Group Health Inc Commercial |
$0.56
|
| Rate for Payer: Group Health Inc Medicare |
$0.39
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.56
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.72
|
|
|
IOHEXOL 350 MG/ML IV SOLN [10323]
|
Facility
|
IP
|
$1.03
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407141472
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.52
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.52
|
|
|
IOHEXOL 350 MG/ML IV SOLN [10323]
|
Facility
|
OP
|
$1.21
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407141489
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.67
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.73
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.61
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.70
|
| Rate for Payer: EmblemHealth Commercial |
$0.61
|
| Rate for Payer: Fidelis Medicare Advantage |
$1.27
|
| Rate for Payer: Group Health Inc Commercial |
$0.61
|
| Rate for Payer: Group Health Inc Medicare |
$0.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.61
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.79
|
|
|
IOHEXOL 350 MG/ML IV SOLN [10323]
|
Facility
|
IP
|
$1.21
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
00407141491
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.61
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.61
|
|
