|
CATH, PTA BAL 5MM/10CM/130 5FR
|
Facility
OP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906084
|
|
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 5MM/10CM/130 5FR
|
Facility
IP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906084
|
|
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 5MM/22CM/130 5FR
|
Facility
IP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906085
|
|
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 5MM/22CM/130 5FR
|
Facility
OP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906085
|
|
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 5MM/4CM/130 5FR
|
Facility
IP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906083
|
|
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 5MM/4CM/130 5FR
|
Facility
OP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
64906083
|
|
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 BALL ULT 2MM/10CM/130 4F
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004764
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$576.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
|
|
CATH PTA BALL ULT 2MM/10CM/130 4F
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004764
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,209.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$633.60
|
| 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 |
$576.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$662.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,209.60
|
| Rate for Payer: Group Health Inc Commercial |
$576.00
|
| Rate for Payer: Group Health Inc Medicare |
$403.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$748.80
|
|
|
CATH PTA BALL ULT 2MM/4CM/130 4FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004763
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$576.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
|
|
CATH PTA BALL ULT 2MM/4CM/130 4FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004763
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,209.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$633.60
|
| 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 |
$576.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$662.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,209.60
|
| Rate for Payer: Group Health Inc Commercial |
$576.00
|
| Rate for Payer: Group Health Inc Medicare |
$403.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$748.80
|
|
|
CATH PTA BALL ULT 3MM/4CM/130 4FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004754
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$576.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
|
|
CATH PTA BALL ULT 3MM/4CM/130 4FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004754
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,209.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$633.60
|
| 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 |
$576.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$662.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,209.60
|
| Rate for Payer: Group Health Inc Commercial |
$576.00
|
| Rate for Payer: Group Health Inc Medicare |
$403.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$748.80
|
|
|
CATH PTA BALL ULT 3MM/8CM/130 4FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004755
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$576.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
|
|
CATH PTA BALL ULT 3MM/8CM/130 4FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004755
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,209.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$633.60
|
| 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 |
$576.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$662.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,209.60
|
| Rate for Payer: Group Health Inc Commercial |
$576.00
|
| Rate for Payer: Group Health Inc Medicare |
$403.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$748.80
|
|
|
CATH PTA BALL ULT 4MM/2CM/130 4FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$576.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
|
|
CATH PTA BALL ULT 4MM/2CM/130 4FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,209.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$633.60
|
| 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 |
$576.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$662.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,209.60
|
| Rate for Payer: Group Health Inc Commercial |
$576.00
|
| Rate for Payer: Group Health Inc Medicare |
$403.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$748.80
|
|
|
CATH PTA BALL ULT 5MM/4CM/130 5FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,209.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$633.60
|
| 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 |
$576.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$662.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,209.60
|
| Rate for Payer: Group Health Inc Commercial |
$576.00
|
| Rate for Payer: Group Health Inc Medicare |
$403.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$748.80
|
|
|
CATH PTA BALL ULT 5MM/4CM/130 5FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$576.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
|
|
CATH,PTA BAL UV 2MM/10CM/130 4FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005111
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,209.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$633.60
|
| 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 |
$576.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$662.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,209.60
|
| Rate for Payer: Group Health Inc Commercial |
$576.00
|
| Rate for Payer: Group Health Inc Medicare |
$403.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$748.80
|
|
|
CATH,PTA BAL UV 2MM/10CM/130 4FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005111
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$576.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
|
|
CATH,PTA BAL UV 2MM/22CM/130 4FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005112
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,209.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$633.60
|
| 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 |
$576.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$662.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,209.60
|
| Rate for Payer: Group Health Inc Commercial |
$576.00
|
| Rate for Payer: Group Health Inc Medicare |
$403.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$748.80
|
|
|
CATH,PTA BAL UV 2MM/22CM/130 4FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005112
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$576.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
|
|
CATH,PTA BAL,UV2MM/22CM/150MM 4FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005102
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$1,209.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$633.60
|
| 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 |
$576.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$662.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,209.60
|
| Rate for Payer: Group Health Inc Commercial |
$576.00
|
| Rate for Payer: Group Health Inc Medicare |
$403.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$748.80
|
|
|
CATH,PTA BAL,UV2MM/22CM/150MM 4FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005102
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$576.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
|
|
CATH,PTA BAL UV 2MM/4CM/130 4FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$576.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$576.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$576.00
|
|
