STRY SCR LCK 2.7 X 24MM
|
Facility
IP
|
$450.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40204249
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$225.00 |
Max. Negotiated Rate |
$225.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$225.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$225.00
|
|
STRY SCR LCK 2.7 X 44MM
|
Facility
OP
|
$450.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40204246
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$472.50 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$247.50
|
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 |
$225.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$258.75
|
Rate for Payer: Fidelis Medicare Advantage |
$472.50
|
Rate for Payer: Group Health Inc Commercial |
$225.00
|
Rate for Payer: Group Health Inc Medicare |
$157.50
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$225.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$225.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$292.50
|
|
STRY SCR LCK 2.7 X 44MM
|
Facility
IP
|
$450.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40204246
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$225.00 |
Max. Negotiated Rate |
$225.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$225.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$225.00
|
|
STRY SCR LG 6.5X70MM
|
Facility
IP
|
$4,665.58
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40008317
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$2,332.79 |
Max. Negotiated Rate |
$2,332.79 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,332.79
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$2,332.79
|
|
STRY SCR LG 6.5X70MM
|
Facility
OP
|
$4,665.58
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40008317
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$4,898.86 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,566.07
|
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 |
$2,332.79
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,682.71
|
Rate for Payer: Fidelis Medicare Advantage |
$4,898.86
|
Rate for Payer: Group Health Inc Commercial |
$2,332.79
|
Rate for Payer: Group Health Inc Medicare |
$1,632.95
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,332.79
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$2,332.79
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,032.63
|
|
STRY SCR UN III AXS SCREW 1.5X5MM
|
Facility
IP
|
$164.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40203408
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$82.00 |
Max. Negotiated Rate |
$82.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$82.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$82.00
|
|
STRY SCR UN III AXS SCREW 1.5X5MM
|
Facility
OP
|
$164.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40203408
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$57.40 |
Max. Negotiated Rate |
$172.20 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$90.20
|
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 |
$82.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$94.30
|
Rate for Payer: Fidelis Medicare Advantage |
$172.20
|
Rate for Payer: Group Health Inc Commercial |
$82.00
|
Rate for Payer: Group Health Inc Medicare |
$57.40
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$82.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$82.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$106.60
|
|
STRY SCRW ASNIS MICR 3.0X16MM CAN
|
Facility
IP
|
$399.84
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40204263
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$199.92 |
Max. Negotiated Rate |
$199.92 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$199.92
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$199.92
|
|
STRY SCRW ASNIS MICR 3.0X16MM CAN
|
Facility
OP
|
$399.84
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40204263
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$419.83 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$219.91
|
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 |
$199.92
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$229.91
|
Rate for Payer: Fidelis Medicare Advantage |
$419.83
|
Rate for Payer: Group Health Inc Commercial |
$199.92
|
Rate for Payer: Group Health Inc Medicare |
$139.94
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$199.92
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$199.92
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$259.90
|
|
STRY SCRW BONE 3.5 X 14MM
|
Facility
IP
|
$104.00
|
|
Service Code
|
HCPCS C1776
|
Hospital Charge Code |
40208007
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$52.00 |
Max. Negotiated Rate |
$52.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$52.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$52.00
|
|
STRY SCRW BONE 3.5 X 14MM
|
Facility
OP
|
$104.00
|
|
Service Code
|
HCPCS C1776
|
Hospital Charge Code |
40208007
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$36.40 |
Max. Negotiated Rate |
$339.17 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$57.20
|
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 |
$52.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$59.80
|
Rate for Payer: Fidelis Medicare Advantage |
$109.20
|
Rate for Payer: Group Health Inc Commercial |
$52.00
|
Rate for Payer: Group Health Inc Medicare |
$36.40
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$52.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$52.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$67.60
|
|
STRY SCRW BONE 3.5 X16MM
|
Facility
OP
|
$104.00
|
|
Service Code
|
HCPCS C1776
|
Hospital Charge Code |
40208008
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$36.40 |
Max. Negotiated Rate |
$339.17 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$57.20
|
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 |
$52.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$59.80
|
Rate for Payer: Fidelis Medicare Advantage |
$109.20
|
Rate for Payer: Group Health Inc Commercial |
$52.00
|
Rate for Payer: Group Health Inc Medicare |
$36.40
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$52.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$52.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$67.60
|
|
STRY SCRW BONE 3.5 X16MM
|
Facility
IP
|
$104.00
|
|
Service Code
|
HCPCS C1776
|
Hospital Charge Code |
40208008
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$52.00 |
Max. Negotiated Rate |
$52.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$52.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$52.00
|
|
STRY SELF-DRILL HALF PIN 5X50 MM
|
Facility
OP
|
$370.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40204221
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$129.50 |
Max. Negotiated Rate |
$388.50 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$203.50
|
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 |
$185.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$212.75
|
Rate for Payer: Fidelis Medicare Advantage |
$388.50
|
Rate for Payer: Group Health Inc Commercial |
$185.00
|
Rate for Payer: Group Health Inc Medicare |
$129.50
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$185.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$185.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$240.50
|
|
STRY SELF-DRILL HALF PIN 5X50 MM
|
Facility
IP
|
$370.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40204221
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$185.00 |
Max. Negotiated Rate |
$185.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$185.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$185.00
|
|
STRY SER POLYAX 6.5X30MM
|
Facility
OP
|
$4,665.58
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40008316
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$4,898.86 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,566.07
|
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 |
$2,332.79
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,682.71
|
Rate for Payer: Fidelis Medicare Advantage |
$4,898.86
|
Rate for Payer: Group Health Inc Commercial |
$2,332.79
|
Rate for Payer: Group Health Inc Medicare |
$1,632.95
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,332.79
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$2,332.79
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,032.63
|
|
STRY SER POLYAX 6.5X30MM
|
Facility
IP
|
$4,665.58
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40008316
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$2,332.79 |
Max. Negotiated Rate |
$2,332.79 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,332.79
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$2,332.79
|
|
STRY SER POLYAX 6.5X35MM
|
Facility
OP
|
$4,665.58
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40008315
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$4,898.86 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,566.07
|
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 |
$2,332.79
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,682.71
|
Rate for Payer: Fidelis Medicare Advantage |
$4,898.86
|
Rate for Payer: Group Health Inc Commercial |
$2,332.79
|
Rate for Payer: Group Health Inc Medicare |
$1,632.95
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,332.79
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$2,332.79
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,032.63
|
|
STRY SER POLYAX 6.5X35MM
|
Facility
IP
|
$4,665.58
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40008315
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$2,332.79 |
Max. Negotiated Rate |
$2,332.79 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,332.79
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$2,332.79
|
|
STRY SPINE 3.5MM TAP
|
Facility
IP
|
$1,025.80
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40204254
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$512.90 |
Max. Negotiated Rate |
$512.90 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$512.90
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$512.90
|
|
STRY SPINE 3.5MM TAP
|
Facility
OP
|
$1,025.80
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40204254
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$1,077.09 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$564.19
|
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 |
$512.90
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$589.84
|
Rate for Payer: Fidelis Medicare Advantage |
$1,077.09
|
Rate for Payer: Group Health Inc Commercial |
$512.90
|
Rate for Payer: Group Health Inc Medicare |
$359.03
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$512.90
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$512.90
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$666.77
|
|
STRY SPINE 5.5 TAP
|
Facility
IP
|
$720.16
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40003441
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$360.08 |
Max. Negotiated Rate |
$360.08 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$360.08
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$360.08
|
|
STRY SPINE 5.5 TAP
|
Facility
OP
|
$720.16
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40003441
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$756.17 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$396.09
|
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 |
$360.08
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$414.09
|
Rate for Payer: Fidelis Medicare Advantage |
$756.17
|
Rate for Payer: Group Health Inc Commercial |
$360.08
|
Rate for Payer: Group Health Inc Medicare |
$252.06
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$360.08
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$360.08
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$468.10
|
|
STRY SRT INTERM VOLAR PL LT
|
Facility
IP
|
$3,204.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40204207
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,602.00 |
Max. Negotiated Rate |
$1,602.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,602.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,602.00
|
|
STRY SRT INTERM VOLAR PL LT
|
Facility
OP
|
$3,204.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40204207
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$3,364.20 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,762.20
|
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 |
$1,602.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,842.30
|
Rate for Payer: Fidelis Medicare Advantage |
$3,364.20
|
Rate for Payer: Group Health Inc Commercial |
$1,602.00
|
Rate for Payer: Group Health Inc Medicare |
$1,121.40
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,602.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,602.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,082.60
|
|