|
CATH PTA BLL ULT 4MM/22CM/130 5FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004759
|
|
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/22CM/130 5FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004759
|
|
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 5MM/10CM/130 5FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004761
|
|
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 5MM/10CM/130 5FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004761
|
|
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 5MM/22CM/130 5FR
|
Facility
OP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004762
|
|
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 5MM/22CM/130 5FR
|
Facility
IP
|
$1,152.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
40004762
|
|
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 EVERCRS .035 5X40MMX80CM
|
Facility
IP
|
$110.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
64906284
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$55.00 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$55.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$55.00
|
|
|
CATH PTA EVERCRS .035 5X40MMX80CM
|
Facility
OP
|
$110.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
64906284
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$38.50 |
| Max. Negotiated Rate |
$115.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$60.50
|
| 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 |
$55.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$63.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$115.50
|
| Rate for Payer: Group Health Inc Commercial |
$55.00
|
| Rate for Payer: Group Health Inc Medicare |
$38.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$55.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$55.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$71.50
|
|
|
CATH, QUICK CROS .014/135CM
|
Facility
OP
|
$1,720.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
40005137
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$1,806.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$946.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.21
|
| Rate for Payer: Aetna Government |
$3.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$860.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$989.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,806.00
|
| Rate for Payer: Group Health Inc Commercial |
$860.00
|
| Rate for Payer: Group Health Inc Medicare |
$602.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$860.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,118.00
|
|
|
CATH, QUICK CROS .014/135CM
|
Facility
IP
|
$1,720.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
40005137
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$860.00 |
| Max. Negotiated Rate |
$860.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$860.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.00
|
|
|
CATH, QUICK CROS .014/150CM
|
Facility
IP
|
$1,720.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
40005138
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$860.00 |
| Max. Negotiated Rate |
$860.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$860.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.00
|
|
|
CATH, QUICK CROS .014/150CM
|
Facility
OP
|
$1,720.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
40005138
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$1,806.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$946.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.21
|
| Rate for Payer: Aetna Government |
$3.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$860.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$989.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,806.00
|
| Rate for Payer: Group Health Inc Commercial |
$860.00
|
| Rate for Payer: Group Health Inc Medicare |
$602.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$860.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,118.00
|
|
|
CATH, QUICK CROS .018/135CM
|
Facility
IP
|
$1,720.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
40005140
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$860.00 |
| Max. Negotiated Rate |
$860.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$860.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.00
|
|
|
CATH, QUICK CROS .018/135CM
|
Facility
OP
|
$1,720.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
40005140
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$1,806.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$946.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.21
|
| Rate for Payer: Aetna Government |
$3.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$860.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$989.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,806.00
|
| Rate for Payer: Group Health Inc Commercial |
$860.00
|
| Rate for Payer: Group Health Inc Medicare |
$602.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$860.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,118.00
|
|
|
CATH, QUICK CROS .018/150CM
|
Facility
OP
|
$1,720.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
40005141
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$1,806.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$946.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.21
|
| Rate for Payer: Aetna Government |
$3.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$860.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$989.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,806.00
|
| Rate for Payer: Group Health Inc Commercial |
$860.00
|
| Rate for Payer: Group Health Inc Medicare |
$602.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$860.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,118.00
|
|
|
CATH, QUICK CROS .018/150CM
|
Facility
IP
|
$1,720.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
40005141
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$860.00 |
| Max. Negotiated Rate |
$860.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$860.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.00
|
|
|
CATH, QUICK CROS .018/90CM
|
Facility
IP
|
$430.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
40005139
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$215.00 |
| Max. Negotiated Rate |
$215.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$215.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$215.00
|
|
|
CATH, QUICK CROS .018/90CM
|
Facility
OP
|
$430.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
40005139
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$451.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$236.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.21
|
| Rate for Payer: Aetna Government |
$3.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$215.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$247.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$451.50
|
| Rate for Payer: Group Health Inc Commercial |
$215.00
|
| Rate for Payer: Group Health Inc Medicare |
$150.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$215.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$215.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$279.50
|
|
|
CATH, QUICK CROS .035/135CM
|
Facility
IP
|
$1,720.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
40005143
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$860.00 |
| Max. Negotiated Rate |
$860.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$860.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.00
|
|
|
CATH, QUICK CROS .035/135CM
|
Facility
OP
|
$1,720.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
40005143
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$1,806.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$946.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.21
|
| Rate for Payer: Aetna Government |
$3.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$860.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$989.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,806.00
|
| Rate for Payer: Group Health Inc Commercial |
$860.00
|
| Rate for Payer: Group Health Inc Medicare |
$602.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$860.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,118.00
|
|
|
CATH, QUICK CROS .035/90CM
|
Facility
OP
|
$1,720.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
40005142
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$1,806.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$946.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.21
|
| Rate for Payer: Aetna Government |
$3.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$860.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$989.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,806.00
|
| Rate for Payer: Group Health Inc Commercial |
$860.00
|
| Rate for Payer: Group Health Inc Medicare |
$602.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$860.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,118.00
|
|
|
CATH, QUICK CROS .035/90CM
|
Facility
IP
|
$1,720.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
40005142
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$860.00 |
| Max. Negotiated Rate |
$860.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$860.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.00
|
|
|
CATH,QUICK CROSS SUPP .035/150CM
|
Facility
IP
|
$1,720.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
40005144
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$860.00 |
| Max. Negotiated Rate |
$860.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$860.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.00
|
|
|
CATH,QUICK CROSS SUPP .035/150CM
|
Facility
OP
|
$1,720.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
40005144
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$1,806.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$946.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$3.21
|
| Rate for Payer: Aetna Government |
$3.21
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$860.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$989.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,806.00
|
| Rate for Payer: Group Health Inc Commercial |
$860.00
|
| Rate for Payer: Group Health Inc Medicare |
$602.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$860.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$860.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,118.00
|
|
|
CATH, QUICKXSUPPRT .014/135CM
|
Facility
OP
|
$2,150.00
|
|
| Hospital Charge Code |
64906089
|
|
Hospital Revenue Code
|
279
|
| Min. Negotiated Rate |
$752.50 |
| Max. Negotiated Rate |
$1,720.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,182.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$1,075.00
|
| Rate for Payer: Aetna Government |
$1,075.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,720.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,462.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,075.00
|
| Rate for Payer: Group Health Inc Medicare |
$752.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,075.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,075.00
|
|
