|
STEM EVOLVE
|
Facility
IP
|
$9,715.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
64907473
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,857.50 |
| Max. Negotiated Rate |
$4,857.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,857.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,857.50
|
|
|
STEM EVOLVE
|
Facility
OP
|
$9,715.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
64907473
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,400.25 |
| Max. Negotiated Rate |
$10,200.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,343.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,857.50
|
| Rate for Payer: Aetna Government |
$4,857.50
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,857.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5,586.12
|
| Rate for Payer: Fidelis Medicare Advantage |
$10,200.75
|
| Rate for Payer: Group Health Inc Commercial |
$4,857.50
|
| Rate for Payer: Group Health Inc Medicare |
$3,400.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,857.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,857.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,314.75
|
|
|
STEM EXTENDER TRI
|
Facility
IP
|
$3,920.63
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64907229
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,960.32 |
| Max. Negotiated Rate |
$1,960.32 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,960.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,960.32
|
|
|
STEM EXTENDER TRI
|
Facility
OP
|
$3,920.63
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64907229
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$4,116.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,156.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1,960.32
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,254.36
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,116.66
|
| Rate for Payer: Group Health Inc Commercial |
$1,960.32
|
| Rate for Payer: Group Health Inc Medicare |
$1,372.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,960.32
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,960.32
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,548.41
|
|
|
STEM EXTENSION
|
Facility
OP
|
$8,450.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
64907523
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,957.50 |
| Max. Negotiated Rate |
$8,872.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,647.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$4,225.00
|
| Rate for Payer: Aetna Government |
$4,225.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,225.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4,858.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$8,872.50
|
| Rate for Payer: Group Health Inc Commercial |
$4,225.00
|
| Rate for Payer: Group Health Inc Medicare |
$2,957.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,225.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,225.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5,492.50
|
|
|
STEM EXTENSION
|
Facility
IP
|
$8,450.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
64907523
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,225.00 |
| Max. Negotiated Rate |
$4,225.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,225.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,225.00
|
|
|
STEM EXTENSION REPLACEMENT SCREW
|
Facility
IP
|
$194.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202128
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$97.00 |
| Max. Negotiated Rate |
$97.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$97.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$97.00
|
|
|
STEM EXTENSION REPLACEMENT SCREW
|
Facility
OP
|
$194.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202128
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$67.90 |
| Max. Negotiated Rate |
$203.70 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$97.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$111.55
|
| Rate for Payer: Fidelis Medicare Advantage |
$203.70
|
| Rate for Payer: Group Health Inc Commercial |
$97.00
|
| Rate for Payer: Group Health Inc Medicare |
$67.90
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$97.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$97.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$126.10
|
|
|
STEM FEM 18MM 185MM L
|
Facility
IP
|
$6,223.16
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64906937
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,111.58 |
| Max. Negotiated Rate |
$3,111.58 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,111.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,111.58
|
|
|
STEM FEM 18MM 185MM L
|
Facility
OP
|
$6,223.16
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64906937
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$6,534.32 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3,422.74
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3,111.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,578.32
|
| Rate for Payer: Fidelis Medicare Advantage |
$6,534.32
|
| Rate for Payer: Group Health Inc Commercial |
$3,111.58
|
| Rate for Payer: Group Health Inc Medicare |
$2,178.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,111.58
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,111.58
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4,045.05
|
|
|
STEM FEM 23MM XL, 103MM
|
Facility
IP
|
$17,880.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905848
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,940.00 |
| Max. Negotiated Rate |
$8,940.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8,940.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,940.00
|
|
|
STEM FEM 23MM XL, 103MM
|
Facility
OP
|
$17,880.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905848
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$18,774.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9,834.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8,940.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10,281.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$18,774.00
|
| Rate for Payer: Group Health Inc Commercial |
$8,940.00
|
| Rate for Payer: Group Health Inc Medicare |
$6,258.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8,940.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,940.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11,622.00
|
|
|
STEM FEM C-LESS TAPER W SZ 2
|
Facility
OP
|
$17,115.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903651
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$17,971.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9,413.66
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$8,557.88
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$9,841.56
|
| Rate for Payer: Fidelis Medicare Advantage |
$17,971.54
|
| Rate for Payer: Group Health Inc Commercial |
$8,557.88
|
| Rate for Payer: Group Health Inc Medicare |
$5,990.51
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8,557.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,557.88
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11,125.24
|
|
|
STEM FEM C-LESS TAPER W SZ 2
|
Facility
IP
|
$17,115.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903651
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,557.88 |
| Max. Negotiated Rate |
$8,557.88 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$8,557.88
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$8,557.88
|
|
|
STEM FEM CMNTD 17MM X 190MM
|
Facility
OP
|
$22,500.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905842
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$23,625.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$12,375.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$11,250.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$12,937.50
|
| Rate for Payer: Fidelis Medicare Advantage |
$23,625.00
|
| Rate for Payer: Group Health Inc Commercial |
$11,250.00
|
| Rate for Payer: Group Health Inc Medicare |
$7,875.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11,250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11,250.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$14,625.00
|
|
|
STEM FEM CMNTD 17MM X 190MM
|
Facility
IP
|
$22,500.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905842
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,250.00 |
| Max. Negotiated Rate |
$11,250.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$11,250.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$11,250.00
|
|
|
STEM, FEM COLL CEM 12/14 NK
|
Facility
OP
|
$5,600.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64905599
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$5,880.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3,080.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,800.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,220.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$5,880.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,800.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,960.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,800.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,800.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,640.00
|
|
|
STEM, FEM COLL CEM 12/14 NK
|
Facility
IP
|
$5,600.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64905599
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,800.00 |
| Max. Negotiated Rate |
$2,800.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,800.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,800.00
|
|
|
STEM FEM COLLRD CMNTD 12/14 NECK
|
Facility
OP
|
$4,480.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40204618
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$4,704.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,464.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,240.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,576.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$4,704.00
|
| Rate for Payer: Group Health Inc Commercial |
$2,240.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,568.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,240.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,240.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,912.00
|
|
|
STEM FEM COLLRD CMNTD 12/14 NECK
|
Facility
IP
|
$4,480.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40204618
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,240.00 |
| Max. Negotiated Rate |
$2,240.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,240.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2,240.00
|
|
|
STEM FEMOR 12/14 13 250
|
Facility
OP
|
$13,038.52
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64907456
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$13,690.45 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$7,171.19
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$6,519.26
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$7,497.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$13,690.45
|
| Rate for Payer: Group Health Inc Commercial |
$6,519.26
|
| Rate for Payer: Group Health Inc Medicare |
$4,563.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6,519.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,519.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$8,475.04
|
|
|
STEM FEMOR 12/14 13 250
|
Facility
IP
|
$13,038.52
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64907456
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,519.26 |
| Max. Negotiated Rate |
$6,519.26 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$6,519.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$6,519.26
|
|
|
STEM FEMORAL CEMENTED SIZE 4 4
|
Facility
OP
|
$10,721.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64904355
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$11,257.31 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,896.69
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$339.17
|
| Rate for Payer: Aetna Government |
$339.17
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$5,360.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6,164.72
|
| Rate for Payer: Fidelis Medicare Advantage |
$11,257.31
|
| Rate for Payer: Group Health Inc Commercial |
$5,360.62
|
| Rate for Payer: Group Health Inc Medicare |
$3,752.44
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5,360.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5,360.62
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,968.81
|
|
|
STEM FEMORAL CEMENTED SIZE 4 4
|
Facility
IP
|
$10,721.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64904355
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,360.62 |
| Max. Negotiated Rate |
$5,360.62 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5,360.62
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5,360.62
|
|
|
STEM FEMORAL CEMENTLESS SIZE 1
|
Facility
OP
|
$9,329.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64902790
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$9,795.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,131.22
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$134.20
|
| Rate for Payer: Aetna Government |
$134.20
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$4,664.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5,364.46
|
| Rate for Payer: Fidelis Medicare Advantage |
$9,795.98
|
| Rate for Payer: Group Health Inc Commercial |
$4,664.75
|
| Rate for Payer: Group Health Inc Medicare |
$3,265.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,664.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,664.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,064.18
|
|
