|
STENT URETERAL 5 FRX20CM 190-120
|
Facility
IP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209619
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
|
|
STENT URETERAL 5 FRX20CM 190-120
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209619
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.14
|
| Rate for Payer: Aetna Government |
$10.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$175.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$201.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
STENT URETERAL 5FRX 22CM
|
Facility
IP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209610
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
|
|
STENT URETERAL 5FRX 22CM
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209610
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.14
|
| Rate for Payer: Aetna Government |
$10.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$175.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$201.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
STENT URETERAL 5FRX22CM
|
Facility
IP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209683
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
|
|
STENT URETERAL 5FRX22CM
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209683
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.14
|
| Rate for Payer: Aetna Government |
$10.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$175.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$201.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
STENT URETERAL 5FRX24CM
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209391
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.14
|
| Rate for Payer: Aetna Government |
$10.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$175.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$201.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
STENT URETERAL 5FRX24CM
|
Facility
IP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209391
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
|
|
STENT URETERAL 5FRX24CM
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209684
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.14
|
| Rate for Payer: Aetna Government |
$10.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$175.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$201.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
STENT URETERAL 5FRX24CM
|
Facility
IP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209684
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
|
|
STENT URETERAL 5 FRX26CM
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209609
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.14
|
| Rate for Payer: Aetna Government |
$10.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$175.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$201.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
STENT URETERAL 5 FRX26CM
|
Facility
IP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209609
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
|
|
STENT URETERAL 5FRX26CM
|
Facility
IP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209685
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
|
|
STENT URETERAL 5FRX26CM
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209685
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.14
|
| Rate for Payer: Aetna Government |
$10.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$175.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$201.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
STENT URETERAL 5FRX28CM
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.14
|
| Rate for Payer: Aetna Government |
$10.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$175.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$201.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
STENT URETERAL 5FRX28CM
|
Facility
IP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
|
|
STENT URETERAL 5FRX30CM
|
Facility
IP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
|
|
STENT URETERAL 5FRX30CM
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209687
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.14
|
| Rate for Payer: Aetna Government |
$10.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$175.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$201.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
STENT URETERAL 6FRX20CM
|
Facility
IP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209688
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
|
|
STENT URETERAL 6FRX20CM
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209688
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.14
|
| Rate for Payer: Aetna Government |
$10.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$175.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$201.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
STENT URETERAL 6FRX22CM
|
Facility
OP
|
$585.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$614.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$321.75
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.14
|
| Rate for Payer: Aetna Government |
$10.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$292.50
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$336.38
|
| Rate for Payer: Fidelis Medicare Advantage |
$614.25
|
| Rate for Payer: Group Health Inc Commercial |
$292.50
|
| Rate for Payer: Group Health Inc Medicare |
$204.75
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$292.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$292.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$380.25
|
|
|
STENT URETERAL 6FRX22CM
|
Facility
IP
|
$585.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$292.50 |
| Max. Negotiated Rate |
$292.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$292.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$292.50
|
|
|
STENT URETERAL 6FRX24CM
|
Facility
IP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
|
|
STENT URETERAL 6FRX24CM
|
Facility
OP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$367.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$192.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.14
|
| Rate for Payer: Aetna Government |
$10.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$175.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$201.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$367.50
|
| Rate for Payer: Group Health Inc Commercial |
$175.00
|
| Rate for Payer: Group Health Inc Medicare |
$122.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$227.50
|
|
|
STENT URETERAL 6FRX28CM
|
Facility
IP
|
$350.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
40209690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$175.00 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$175.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$175.00
|
|
