|
ZZ BALLOON/UT/DIAMOND/7-2-75
|
Facility
OP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569436
|
|
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/7-2-75
|
Facility
IP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569436
|
|
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/7-4-120
|
Facility
IP
|
$574.09
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569437
|
|
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/7-4-120
|
Facility
OP
|
$574.09
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569437
|
|
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/7-4-75
|
Facility
OP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569438
|
|
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/7-4-75
|
Facility
IP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569438
|
|
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/8-2-120
|
Facility
IP
|
$574.09
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569439
|
|
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/8-2-120
|
Facility
OP
|
$574.09
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569439
|
|
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/8-2-75
|
Facility
IP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569440
|
|
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/8-2-75
|
Facility
OP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569440
|
|
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/8-3-120
|
Facility
IP
|
$574.09
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569441
|
|
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/8-3-120
|
Facility
OP
|
$574.09
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569441
|
|
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/8-3-40
|
Facility
OP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569442
|
|
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/8-3-40
|
Facility
IP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569442
|
|
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/8-3-75
|
Facility
IP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569443
|
|
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/8-3-75
|
Facility
OP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569443
|
|
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/8-4-120
|
Facility
IP
|
$574.09
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569444
|
|
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/8-4-120
|
Facility
OP
|
$574.09
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569444
|
|
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/8-4-75
|
Facility
OP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569445
|
|
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/8-4-75
|
Facility
IP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569445
|
|
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/9-2-75
|
Facility
IP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569446
|
|
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/9-2-75
|
Facility
OP
|
$542.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569446
|
|
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/9-4-120
|
Facility
OP
|
$574.09
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569447
|
|
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/9-4-120
|
Facility
IP
|
$574.09
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569447
|
|
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/XXL/12-4-120
|
Facility
OP
|
$657.02
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
41569448
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$689.87 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$361.36
|
| 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 |
$328.51
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$377.79
|
| Rate for Payer: Fidelis Medicare Advantage |
$689.87
|
| Rate for Payer: Group Health Inc Commercial |
$328.51
|
| Rate for Payer: Group Health Inc Medicare |
$229.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$328.51
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$328.51
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$427.06
|
|
