|
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
|
|
|
CATH,PTA BAL UV3MM/15CM/150MM 4FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005101
|
|
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 UV3MM/15CM/150MM 4FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005101
|
|
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 3MM/22CM/130 4FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005103
|
|
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 3MM/22CM/130 4FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005103
|
|
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 3MM/4CM/130 4FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005100
|
|
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 3MM/4CM/130 4FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005100
|
|
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 4MM/10CM/130 4FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005105
|
|
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 4MM/10CM/130 4FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005105
|
|
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 4MM/22CM/130 5FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005106
|
|
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 4MM/22CM/130 5FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005106
|
|
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 4MM/2CM/130 4FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005104
|
|
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 4MM/2CM/130 4FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005104
|
|
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 5MM/10CM/130 5FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005108
|
|
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 5MM/10CM/130 5FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005108
|
|
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 5MM/22CM/130 5FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005109
|
|
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 5MM/22CM/130 5FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005109
|
|
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 5MM/4CM/130 5FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005107
|
|
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 5MM/4CM/130 5FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40005107
|
|
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 BLL ULT 2MM/22CM/130 4FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004765
|
|
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 BLL ULT 2MM/22CM/130 4FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004765
|
|
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 BLL ULT 3MM/22CM/130 4FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004756
|
|
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 BLL ULT 3MM/22CM/130 4FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004756
|
|
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 BLL ULT 4MM/10CM/130 4FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004758
|
|
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 BLL ULT 4MM/10CM/130 4FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004758
|
|
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
|
|
