|
CATH, PTA BAL 2.5/10CM/130 4F
|
Facility
IP
|
$1,280.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906139
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$640.00 |
| Max. Negotiated Rate |
$640.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$640.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$640.00
|
|
|
CATH, PTA BAL 2.5/22CM/130 4F
|
Facility
OP
|
$1,345.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906140
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,412.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$739.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.43
|
| Rate for Payer: Aetna Government |
$17.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$672.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$773.38
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,412.25
|
| Rate for Payer: Group Health Inc Commercial |
$672.50
|
| Rate for Payer: Group Health Inc Medicare |
$470.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$672.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$672.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$874.25
|
|
|
CATH, PTA BAL 2.5/22CM/130 4F
|
Facility
IP
|
$1,345.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906140
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.50 |
| Max. Negotiated Rate |
$672.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$672.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$672.50
|
|
|
CATH, PTA BAL 2MM/10CM/130 4FR
|
Facility
IP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906087
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
|
|
CATH, PTA BAL 2MM/10CM/130 4FR
|
Facility
OP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906087
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,512.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$792.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.43
|
| Rate for Payer: Aetna Government |
$17.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$720.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$828.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,512.00
|
| Rate for Payer: Group Health Inc Commercial |
$720.00
|
| Rate for Payer: Group Health Inc Medicare |
$504.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$936.00
|
|
|
CATH, PTA BAL 2MM/22CM/130 4FR
|
Facility
OP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906088
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,512.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$792.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.43
|
| Rate for Payer: Aetna Government |
$17.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$720.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$828.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,512.00
|
| Rate for Payer: Group Health Inc Commercial |
$720.00
|
| Rate for Payer: Group Health Inc Medicare |
$504.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$936.00
|
|
|
CATH, PTA BAL 2MM/22CM/130 4FR
|
Facility
IP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906088
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
|
|
CATH, PTA BAL 2MM/22CM/150 4FR
|
Facility
OP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,512.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$792.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.43
|
| Rate for Payer: Aetna Government |
$17.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$720.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$828.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,512.00
|
| Rate for Payer: Group Health Inc Commercial |
$720.00
|
| Rate for Payer: Group Health Inc Medicare |
$504.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$936.00
|
|
|
CATH, PTA BAL 2MM/22CM/150 4FR
|
Facility
IP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
|
|
CATH, PTA BAL 2MM/4CM/130 4FR
|
Facility
OP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906086
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,512.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$792.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.43
|
| Rate for Payer: Aetna Government |
$17.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$720.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$828.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,512.00
|
| Rate for Payer: Group Health Inc Commercial |
$720.00
|
| Rate for Payer: Group Health Inc Medicare |
$504.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$936.00
|
|
|
CATH, PTA BAL 2MM/4CM/130 4FR
|
Facility
IP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906086
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
|
|
CATH, PTA BAL 3MM/15CM/150 4FR
|
Facility
OP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,512.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$792.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.43
|
| Rate for Payer: Aetna Government |
$17.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$720.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$828.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,512.00
|
| Rate for Payer: Group Health Inc Commercial |
$720.00
|
| Rate for Payer: Group Health Inc Medicare |
$504.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$936.00
|
|
|
CATH, PTA BAL 3MM/15CM/150 4FR
|
Facility
IP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
|
|
CATH, PTA BAL 3MM/22CM/130 4FR
|
Facility
IP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906079
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
|
|
CATH, PTA BAL 3MM/22CM/130 4FR
|
Facility
OP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906079
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,512.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$792.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.43
|
| Rate for Payer: Aetna Government |
$17.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$720.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$828.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,512.00
|
| Rate for Payer: Group Health Inc Commercial |
$720.00
|
| Rate for Payer: Group Health Inc Medicare |
$504.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$936.00
|
|
|
CATH, PTA BAL 3MM/4CM/130 4FR
|
Facility
OP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906077
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,512.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$792.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.43
|
| Rate for Payer: Aetna Government |
$17.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$720.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$828.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,512.00
|
| Rate for Payer: Group Health Inc Commercial |
$720.00
|
| Rate for Payer: Group Health Inc Medicare |
$504.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$936.00
|
|
|
CATH, PTA BAL 3MM/4CM/130 4FR
|
Facility
IP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906077
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
|
|
CATH, PTA BAL 3MM/8CM/130 4FR
|
Facility
OP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906078
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,512.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$792.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.43
|
| Rate for Payer: Aetna Government |
$17.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$720.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$828.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,512.00
|
| Rate for Payer: Group Health Inc Commercial |
$720.00
|
| Rate for Payer: Group Health Inc Medicare |
$504.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$936.00
|
|
|
CATH, PTA BAL 3MM/8CM/130 4FR
|
Facility
IP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906078
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
|
|
CATH, PTA BAL 4MM/10CM/130 4FR
|
Facility
OP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,512.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$792.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.43
|
| Rate for Payer: Aetna Government |
$17.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$720.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$828.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,512.00
|
| Rate for Payer: Group Health Inc Commercial |
$720.00
|
| Rate for Payer: Group Health Inc Medicare |
$504.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$936.00
|
|
|
CATH, PTA BAL 4MM/10CM/130 4FR
|
Facility
IP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
|
|
CATH, PTA BAL 4MM/22CM/130 5FR
|
Facility
OP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,512.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$792.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.43
|
| Rate for Payer: Aetna Government |
$17.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$720.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$828.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,512.00
|
| Rate for Payer: Group Health Inc Commercial |
$720.00
|
| Rate for Payer: Group Health Inc Medicare |
$504.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$936.00
|
|
|
CATH, PTA BAL 4MM/22CM/130 5FR
|
Facility
IP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
|
|
CATH, PTA BAL 4MM/2CM/130 4FR
|
Facility
OP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906080
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,512.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$792.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$17.43
|
| Rate for Payer: Aetna Government |
$17.43
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$720.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$828.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,512.00
|
| Rate for Payer: Group Health Inc Commercial |
$720.00
|
| Rate for Payer: Group Health Inc Medicare |
$504.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$936.00
|
|
|
CATH, PTA BAL 4MM/2CM/130 4FR
|
Facility
IP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906080
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$720.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$720.00
|
|
