|
CC BS QUANT MAV 2.25MM X 8MM
|
Facility
IP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522049
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
|
|
CC BS QUANT MAV 2.25MM X 8MM
|
Facility
OP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522049
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$493.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$258.50
|
| 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 |
$235.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$493.50
|
| Rate for Payer: Group Health Inc Commercial |
$235.00
|
| Rate for Payer: Group Health Inc Medicare |
$164.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$305.50
|
|
|
CC BS QUANT MAV 2.5MM X 12MM BALL
|
Facility
IP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
|
|
CC BS QUANT MAV 2.5MM X 12MM BALL
|
Facility
OP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$493.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$258.50
|
| 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 |
$235.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$493.50
|
| Rate for Payer: Group Health Inc Commercial |
$235.00
|
| Rate for Payer: Group Health Inc Medicare |
$164.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$305.50
|
|
|
CC BS QUANT MAV 2.5MM X 15MM BALL
|
Facility
IP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522053
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
|
|
CC BS QUANT MAV 2.5MM X 15MM BALL
|
Facility
OP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522053
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$493.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$258.50
|
| 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 |
$235.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$493.50
|
| Rate for Payer: Group Health Inc Commercial |
$235.00
|
| Rate for Payer: Group Health Inc Medicare |
$164.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$305.50
|
|
|
CC BS QUANT MAV 2.5MM X8MM BALL
|
Facility
OP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$493.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$258.50
|
| 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 |
$235.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$493.50
|
| Rate for Payer: Group Health Inc Commercial |
$235.00
|
| Rate for Payer: Group Health Inc Medicare |
$164.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$305.50
|
|
|
CC BS QUANT MAV 2.5MM X8MM BALL
|
Facility
IP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
|
|
CC BS QUANT MAV 2.75MMX 12MM BALL
|
Facility
IP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522057
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
|
|
CC BS QUANT MAV 2.75MMX 12MM BALL
|
Facility
OP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522057
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$493.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$258.50
|
| 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 |
$235.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$493.50
|
| Rate for Payer: Group Health Inc Commercial |
$235.00
|
| Rate for Payer: Group Health Inc Medicare |
$164.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$305.50
|
|
|
CC BS QUANT MAV 2.75MM X 15MM
|
Facility
IP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522059
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
|
|
CC BS QUANT MAV 2.75MM X 15MM
|
Facility
OP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522059
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$493.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$258.50
|
| 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 |
$235.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$493.50
|
| Rate for Payer: Group Health Inc Commercial |
$235.00
|
| Rate for Payer: Group Health Inc Medicare |
$164.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$305.50
|
|
|
CC BS QUANT MAV 2.75MMX 8MM BALL3
|
Facility
IP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522061
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
|
|
CC BS QUANT MAV 2.75MMX 8MM BALL3
|
Facility
OP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522061
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$493.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$258.50
|
| 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 |
$235.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$493.50
|
| Rate for Payer: Group Health Inc Commercial |
$235.00
|
| Rate for Payer: Group Health Inc Medicare |
$164.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$305.50
|
|
|
CC BS QUANT MAV 3.0MMX15MM BALL
|
Facility
IP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522063
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
|
|
CC BS QUANT MAV 3.0MMX15MM BALL
|
Facility
OP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522063
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$493.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$258.50
|
| 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 |
$235.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$493.50
|
| Rate for Payer: Group Health Inc Commercial |
$235.00
|
| Rate for Payer: Group Health Inc Medicare |
$164.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$305.50
|
|
|
CC BS QUANT MAV 3.0MM X 8MM BALL
|
Facility
IP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522065
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
|
|
CC BS QUANT MAV 3.0MM X 8MM BALL
|
Facility
OP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522065
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$493.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$258.50
|
| 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 |
$235.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$493.50
|
| Rate for Payer: Group Health Inc Commercial |
$235.00
|
| Rate for Payer: Group Health Inc Medicare |
$164.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$305.50
|
|
|
CC BS QUANT MAV 3.25MMX12MM BALL
|
Facility
OP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522067
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$493.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$258.50
|
| 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 |
$235.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$493.50
|
| Rate for Payer: Group Health Inc Commercial |
$235.00
|
| Rate for Payer: Group Health Inc Medicare |
$164.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$305.50
|
|
|
CC BS QUANT MAV 3.25MMX12MM BALL
|
Facility
IP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522067
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
|
|
CC BS QUANT MAV 3.25MMX15MM BALL
|
Facility
OP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522069
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$493.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$258.50
|
| 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 |
$235.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$493.50
|
| Rate for Payer: Group Health Inc Commercial |
$235.00
|
| Rate for Payer: Group Health Inc Medicare |
$164.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$305.50
|
|
|
CC BS QUANT MAV 3.25MMX15MM BALL
|
Facility
IP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522069
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
|
|
CC BS QUANT MAV 3.25MMX8MM
|
Facility
IP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522071
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
|
|
CC BS QUANT MAV 3.25MMX8MM
|
Facility
OP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522071
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$493.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$258.50
|
| 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 |
$235.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$270.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$493.50
|
| Rate for Payer: Group Health Inc Commercial |
$235.00
|
| Rate for Payer: Group Health Inc Medicare |
$164.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$305.50
|
|
|
CC BS QUANT MAV 3.5MM X 15MM BALL
|
Facility
IP
|
$470.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
66522073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.00 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$235.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$235.00
|
|
