|
ZZ BALLOON/UT/DIAMOND/4-2-120
|
Facility
OP
|
$574.09
|
|
| Hospital Charge Code |
41569110
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$200.93 |
| Max. Negotiated Rate |
$459.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$315.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$287.04
|
| Rate for Payer: Aetna Government |
$287.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$459.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$390.38
|
| Rate for Payer: Group Health Inc Commercial |
$287.04
|
| Rate for Payer: Group Health Inc Medicare |
$200.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$287.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$287.04
|
|
|
ZZ BALLOON/UT/DIAMOND/4-4-75
|
Facility
OP
|
$574.09
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569111
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$602.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$315.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.85
|
| Rate for Payer: Aetna Government |
$44.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$287.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$330.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$602.79
|
| Rate for Payer: Group Health Inc Commercial |
$287.04
|
| Rate for Payer: Group Health Inc Medicare |
$200.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$287.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$287.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$373.16
|
|
|
ZZ BALLOON/UT/DIAMOND/4-4-75
|
Facility
IP
|
$574.09
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569111
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$287.04 |
| Max. Negotiated Rate |
$287.04 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$287.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$287.04
|
|
|
ZZ BALLOON/UT/DIAMOND 4X2X75
|
Facility
OP
|
$578.34
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569685
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$607.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$318.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.85
|
| Rate for Payer: Aetna Government |
$44.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$289.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$332.55
|
| Rate for Payer: Fidelis Medicare Advantage |
$607.26
|
| Rate for Payer: Group Health Inc Commercial |
$289.17
|
| Rate for Payer: Group Health Inc Medicare |
$202.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$289.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$289.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$375.92
|
|
|
ZZ BALLOON/UT/DIAMOND 4X2X75
|
Facility
IP
|
$578.34
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569685
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$289.17 |
| Max. Negotiated Rate |
$289.17 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$289.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$289.17
|
|
|
ZZ BALLOON/UT/DIAMOND/5-2-120
|
Facility
OP
|
$574.09
|
|
| Hospital Charge Code |
41569112
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$200.93 |
| Max. Negotiated Rate |
$459.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$315.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$287.04
|
| Rate for Payer: Aetna Government |
$287.04
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$459.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$390.38
|
| Rate for Payer: Group Health Inc Commercial |
$287.04
|
| Rate for Payer: Group Health Inc Medicare |
$200.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$287.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$287.04
|
|
|
ZZ BALLOON/UT/DIAMOND/5-2-75
|
Facility
OP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569113
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$569.31 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$298.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.85
|
| Rate for Payer: Aetna Government |
$44.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$271.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$311.76
|
| Rate for Payer: Fidelis Medicare Advantage |
$569.31
|
| Rate for Payer: Group Health Inc Commercial |
$271.10
|
| Rate for Payer: Group Health Inc Medicare |
$189.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$271.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$271.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$352.43
|
|
|
ZZ BALLOON/UT/DIAMOND/5-2-75
|
Facility
IP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569113
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$271.10 |
| Max. Negotiated Rate |
$271.10 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$271.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$271.10
|
|
|
ZZ BALLOON/UT/DIAMOND/5-4-120
|
Facility
OP
|
$574.09
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569114
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$602.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$315.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.85
|
| Rate for Payer: Aetna Government |
$44.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$287.04
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$330.10
|
| Rate for Payer: Fidelis Medicare Advantage |
$602.79
|
| Rate for Payer: Group Health Inc Commercial |
$287.04
|
| Rate for Payer: Group Health Inc Medicare |
$200.93
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$287.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$287.04
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$373.16
|
|
|
ZZ BALLOON/UT/DIAMOND/5-4-120
|
Facility
IP
|
$574.09
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569114
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$287.04 |
| Max. Negotiated Rate |
$287.04 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$287.04
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$287.04
|
|
|
ZZ BALLOON/UT/DIAMOND/5-4-75
|
Facility
IP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569115
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$271.10 |
| Max. Negotiated Rate |
$271.10 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$271.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$271.10
|
|
|
ZZ BALLOON/UT/DIAMOND/5-4-75
|
Facility
OP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569115
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$569.31 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$298.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.85
|
| Rate for Payer: Aetna Government |
$44.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$271.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$311.76
|
| Rate for Payer: Fidelis Medicare Advantage |
$569.31
|
| Rate for Payer: Group Health Inc Commercial |
$271.10
|
| Rate for Payer: Group Health Inc Medicare |
$189.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$271.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$271.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$352.43
|
|
|
ZZ BALLOON/UT/DIAMOND 5X2X40
|
Facility
IP
|
$578.34
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$289.17 |
| Max. Negotiated Rate |
$289.17 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$289.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$289.17
|
|
|
ZZ BALLOON/UT/DIAMOND 5X2X40
|
Facility
OP
|
$578.34
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$607.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$318.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.85
|
| Rate for Payer: Aetna Government |
$44.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$289.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$332.55
|
| Rate for Payer: Fidelis Medicare Advantage |
$607.26
|
| Rate for Payer: Group Health Inc Commercial |
$289.17
|
| Rate for Payer: Group Health Inc Medicare |
$202.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$289.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$289.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$375.92
|
|
|
ZZ BALLOON/UT/DIAMOND/6-2-120
|
Facility
IP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569116
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$271.10 |
| Max. Negotiated Rate |
$271.10 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$271.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$271.10
|
|
|
ZZ BALLOON/UT/DIAMOND/6-2-120
|
Facility
OP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569116
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$569.31 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$298.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.85
|
| Rate for Payer: Aetna Government |
$44.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$271.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$311.76
|
| Rate for Payer: Fidelis Medicare Advantage |
$569.31
|
| Rate for Payer: Group Health Inc Commercial |
$271.10
|
| Rate for Payer: Group Health Inc Medicare |
$189.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$271.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$271.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$352.43
|
|
|
ZZ BALLOON/UT/DIAMOND 6X2X75
|
Facility
OP
|
$578.34
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$607.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$318.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.85
|
| Rate for Payer: Aetna Government |
$44.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$289.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$332.55
|
| Rate for Payer: Fidelis Medicare Advantage |
$607.26
|
| Rate for Payer: Group Health Inc Commercial |
$289.17
|
| Rate for Payer: Group Health Inc Medicare |
$202.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$289.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$289.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$375.92
|
|
|
ZZ BALLOON/UT/DIAMOND 6X2X75
|
Facility
IP
|
$578.34
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$289.17 |
| Max. Negotiated Rate |
$289.17 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$289.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$289.17
|
|
|
ZZ BALLOON UT/DIAMOND 6X4
|
Facility
OP
|
$578.34
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569627
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$607.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$318.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.85
|
| Rate for Payer: Aetna Government |
$44.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$289.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$332.55
|
| Rate for Payer: Fidelis Medicare Advantage |
$607.26
|
| Rate for Payer: Group Health Inc Commercial |
$289.17
|
| Rate for Payer: Group Health Inc Medicare |
$202.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$289.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$289.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$375.92
|
|
|
ZZ BALLOON UT/DIAMOND 6X4
|
Facility
IP
|
$578.34
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569627
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$289.17 |
| Max. Negotiated Rate |
$289.17 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$289.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$289.17
|
|
|
ZZ BALLOON/UT/DIAMOND 6X4X120
|
Facility
OP
|
$578.34
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$607.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$318.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.85
|
| Rate for Payer: Aetna Government |
$44.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$289.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$332.55
|
| Rate for Payer: Fidelis Medicare Advantage |
$607.26
|
| Rate for Payer: Group Health Inc Commercial |
$289.17
|
| Rate for Payer: Group Health Inc Medicare |
$202.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$289.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$289.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$375.92
|
|
|
ZZ BALLOON/UT/DIAMOND 6X4X120
|
Facility
IP
|
$578.34
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$289.17 |
| Max. Negotiated Rate |
$289.17 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$289.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$289.17
|
|
|
ZZ BALLOON/UT/DIAMOND 6X4X40
|
Facility
OP
|
$578.34
|
|
| Hospital Charge Code |
41569688
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$202.42 |
| Max. Negotiated Rate |
$462.67 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$318.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$289.17
|
| Rate for Payer: Aetna Government |
$289.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$462.67
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$393.27
|
| Rate for Payer: Group Health Inc Commercial |
$289.17
|
| Rate for Payer: Group Health Inc Medicare |
$202.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$289.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$289.17
|
|
|
ZZ BALLOON/UT/DIAMOND 6X4X75
|
Facility
OP
|
$578.34
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$607.26 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$318.09
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$44.85
|
| Rate for Payer: Aetna Government |
$44.85
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$289.17
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$332.55
|
| Rate for Payer: Fidelis Medicare Advantage |
$607.26
|
| Rate for Payer: Group Health Inc Commercial |
$289.17
|
| Rate for Payer: Group Health Inc Medicare |
$202.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$289.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$289.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$375.92
|
|
|
ZZ BALLOON/UT/DIAMOND 6X4X75
|
Facility
IP
|
$578.34
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$289.17 |
| Max. Negotiated Rate |
$289.17 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$289.17
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$289.17
|
|
