Questions & corrections

Northeastern Health System Sequoyah · Ct abd & pelvis w/contrast

$2,733.75

Source file dated 2026-02-10 · both

Source note: Covered Service by Facility, contract rate is lesser of 1. facility's aggregate eligible charges, or 2. the aggregate applicable contract rate determined by Sections 2.2, 2.3, 3 and/or 4. For outpatient covered services, services are reimbursed at defined rates based on UHC OPG Exhibit as outlined in the contract. The categorical group number is determined by a combination of the revenue code and the HCPCS/CPT code for items that are listed as eligible. The rates are as follows in pairs group number:per case rate and seperated by commas - 0:76, 1:480, 2:640, 3:739, 4:913, 5:1039, 6:1100, 7:1442, 8:1500, 9:1940, 10:1940, Unlisted:250. The first procedure will be paid at the highest contract rate as defined in the OPG, and the second procedure will be paid at 50% of the contract rate listed in the OPG. No additional payments for any additional outpatient procedures performed will be made, instead such additional outpatient procedures are included in the contract rate for the first two outpatient procedures. If the Customer receives any Covered Services for which a Per Case Payment Method applies, all Covered Services during a single Outpatient Encounter that would otherwise have a contract rate pursuant to a Per Visit, Per Unit via Facility Fee Schedule, Payment Method will instead be included in the Per Case contract rate.