|
STEM FEMORAL CEMENTLESS SIZE 1
|
Facility
IP
|
$9,329.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64902790
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,664.75 |
| Max. Negotiated Rate |
$4,664.75 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,664.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,664.75
|
|
|
STEM FEMORAL CEMENTLESS SZ12
|
Facility
OP
|
$9,327.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903150
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$9,793.88 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,130.12
|
| 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 |
$4,663.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5,363.31
|
| Rate for Payer: Fidelis Medicare Advantage |
$9,793.88
|
| Rate for Payer: Group Health Inc Commercial |
$4,663.75
|
| Rate for Payer: Group Health Inc Medicare |
$3,264.62
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,663.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,663.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,062.88
|
|
|
STEM FEMORAL CEMENTLESS SZ12
|
Facility
IP
|
$9,327.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903150
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,663.75 |
| Max. Negotiated Rate |
$4,663.75 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,663.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,663.75
|
|
|
STEM FEMORAL CEMENT SZ2 35MM
|
Facility
IP
|
$10,721.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904610
|
|
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 CEMENT SZ2 35MM
|
Facility
OP
|
$10,721.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64904610
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$11,257.31 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,896.69
|
| 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 |
$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 CEMLESS SZ4 38MM
|
Facility
OP
|
$17,115.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64904349
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$17,971.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9,413.66
|
| 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 |
$8,557.88
|
| 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 FEMORAL CEMLESS SZ4 38MM
|
Facility
IP
|
$17,115.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64904349
|
|
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,FEMORAL CLLRD CMTD 12/14 NCK
|
Facility
OP
|
$4,480.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40007537
|
|
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,FEMORAL CLLRD CMTD 12/14 NCK
|
Facility
IP
|
$4,480.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40007537
|
|
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 FEMORAL REV CEMEN 250MML
|
Facility
OP
|
$18,520.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64903329
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$19,446.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$10,186.00
|
| 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 |
$9,260.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10,649.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$19,446.00
|
| Rate for Payer: Group Health Inc Commercial |
$9,260.00
|
| Rate for Payer: Group Health Inc Medicare |
$6,482.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9,260.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9,260.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$12,038.00
|
|
|
STEM FEMORAL REV CEMEN 250MML
|
Facility
IP
|
$18,520.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64903329
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,260.00 |
| Max. Negotiated Rate |
$9,260.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9,260.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9,260.00
|
|
|
STEM FEMOR SZ 4 40.22MM OF-S
|
Facility
OP
|
$11,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$12,253.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$6,418.50
|
| 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 |
$5,835.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$6,710.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$12,253.50
|
| Rate for Payer: Group Health Inc Commercial |
$5,835.00
|
| Rate for Payer: Group Health Inc Medicare |
$4,084.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5,835.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5,835.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$7,585.50
|
|
|
STEM FEMOR SZ 4 40.22MM OF-S
|
Facility
IP
|
$11,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64905760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,835.00 |
| Max. Negotiated Rate |
$5,835.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$5,835.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$5,835.00
|
|
|
STEM FEM SZ 6 127MML
|
Facility
OP
|
$18,112.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903602
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$19,018.12 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9,961.88
|
| 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 |
$9,056.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$10,414.69
|
| Rate for Payer: Fidelis Medicare Advantage |
$19,018.12
|
| Rate for Payer: Group Health Inc Commercial |
$9,056.25
|
| Rate for Payer: Group Health Inc Medicare |
$6,339.38
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9,056.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9,056.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$11,773.12
|
|
|
STEM FEM SZ 6 127MML
|
Facility
IP
|
$18,112.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64903602
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,056.25 |
| Max. Negotiated Rate |
$9,056.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$9,056.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$9,056.25
|
|
|
STEM HEI
|
Facility
OP
|
$6,715.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64907184
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$7,050.75 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$3,693.25
|
| 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 |
$3,357.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,861.12
|
| Rate for Payer: Fidelis Medicare Advantage |
$7,050.75
|
| Rate for Payer: Group Health Inc Commercial |
$3,357.50
|
| Rate for Payer: Group Health Inc Medicare |
$2,350.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,357.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,357.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$4,364.75
|
|
|
STEM HEI
|
Facility
IP
|
$6,715.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64907184
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,357.50 |
| Max. Negotiated Rate |
$3,357.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,357.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,357.50
|
|
|
STEM HIP 127 DEG NECK
|
Facility
IP
|
$17,115.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64902777
|
|
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 HIP 127 DEG NECK
|
Facility
OP
|
$17,115.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64902777
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$17,971.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9,413.66
|
| 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 |
$8,557.88
|
| 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 HIP 127 DEG NECK ANGLE
|
Facility
IP
|
$17,115.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64902666
|
|
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 HIP 127 DEG NECK ANGLE
|
Facility
OP
|
$17,115.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64902666
|
|
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 HIP 127DEG NECK ANGLE
|
Facility
OP
|
$17,115.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64902771
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$17,971.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9,413.66
|
| 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 |
$8,557.88
|
| 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 HIP 127DEG NECK ANGLE
|
Facility
IP
|
$17,115.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64902771
|
|
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 HIP 127 NECK ANGLE
|
Facility
IP
|
$17,115.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64902689
|
|
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 HIP 127 NECK ANGLE
|
Facility
OP
|
$17,115.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64902689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$17,971.54 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$9,413.66
|
| 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 |
$8,557.88
|
| 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
|
|
