11X300MM X 125 RIGHT
|
Facility
IP
|
$2,650.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200575
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,325.00 |
Max. Negotiated Rate |
$1,325.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,325.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,325.00
|
|
11X300 T2 TIBIAL NAIL, STANDARD
|
Facility
IP
|
$2,364.60
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200574
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,182.30 |
Max. Negotiated Rate |
$1,182.30 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,182.30
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,182.30
|
|
11X300 T2 TIBIAL NAIL, STANDARD
|
Facility
OP
|
$2,364.60
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200574
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$2,482.83 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,300.53
|
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 |
$1,182.30
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,359.64
|
Rate for Payer: Fidelis Medicare Advantage |
$2,482.83
|
Rate for Payer: Group Health Inc Commercial |
$1,182.30
|
Rate for Payer: Group Health Inc Medicare |
$827.61
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,182.30
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,182.30
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,536.99
|
|
11X330MM T2 TIBIAL NAIL, STANDARD
|
Facility
IP
|
$2,264.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200576
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,132.00 |
Max. Negotiated Rate |
$1,132.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,132.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,132.00
|
|
11X330MM T2 TIBIAL NAIL, STANDARD
|
Facility
OP
|
$2,264.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200576
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$2,377.20 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,245.20
|
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 |
$1,132.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,301.80
|
Rate for Payer: Fidelis Medicare Advantage |
$2,377.20
|
Rate for Payer: Group Health Inc Commercial |
$1,132.00
|
Rate for Payer: Group Health Inc Medicare |
$792.40
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,132.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,132.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,471.60
|
|
11X340X125 DEGREE RIGHT
|
Facility
IP
|
$2,650.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40203000
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,325.00 |
Max. Negotiated Rate |
$1,325.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,325.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,325.00
|
|
11X340X125 DEGREE RIGHT
|
Facility
OP
|
$2,650.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40203000
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$2,782.50 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,457.50
|
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 |
$1,325.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,523.75
|
Rate for Payer: Fidelis Medicare Advantage |
$2,782.50
|
Rate for Payer: Group Health Inc Commercial |
$1,325.00
|
Rate for Payer: Group Health Inc Medicare |
$927.50
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,325.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,325.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,722.50
|
|
11X345MM T2 TIBIAL NAIL, STANDARD
|
Facility
IP
|
$2,264.00
|
|
Service Code
|
HCPCS C1776
|
Hospital Charge Code |
40200578
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,132.00 |
Max. Negotiated Rate |
$1,132.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,132.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,132.00
|
|
11X345MM T2 TIBIAL NAIL, STANDARD
|
Facility
OP
|
$2,264.00
|
|
Service Code
|
HCPCS C1776
|
Hospital Charge Code |
40200578
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$339.17 |
Max. Negotiated Rate |
$2,377.20 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,245.20
|
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 |
$1,132.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,301.80
|
Rate for Payer: Fidelis Medicare Advantage |
$2,377.20
|
Rate for Payer: Group Health Inc Commercial |
$1,132.00
|
Rate for Payer: Group Health Inc Medicare |
$792.40
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,132.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,132.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,471.60
|
|
11X360MMX125 DEGREE LEFT
|
Facility
OP
|
$3,150.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200580
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$3,307.50 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,732.50
|
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 |
$1,575.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,811.25
|
Rate for Payer: Fidelis Medicare Advantage |
$3,307.50
|
Rate for Payer: Group Health Inc Commercial |
$1,575.00
|
Rate for Payer: Group Health Inc Medicare |
$1,102.50
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,575.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,575.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,047.50
|
|
11X360MMX125 DEGREE LEFT
|
Facility
IP
|
$3,150.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200580
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,575.00 |
Max. Negotiated Rate |
$1,575.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,575.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,575.00
|
|
11X360X125 DEGREE RIGHT
|
Facility
OP
|
$3,150.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200579
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$3,307.50 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,732.50
|
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 |
$1,575.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,811.25
|
Rate for Payer: Fidelis Medicare Advantage |
$3,307.50
|
Rate for Payer: Group Health Inc Commercial |
$1,575.00
|
Rate for Payer: Group Health Inc Medicare |
$1,102.50
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,575.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,575.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,047.50
|
|
11X360X125 DEGREE RIGHT
|
Facility
IP
|
$3,150.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200579
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,575.00 |
Max. Negotiated Rate |
$1,575.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,575.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,575.00
|
|
11X380MMX124 DEGREE LEFT
|
Facility
OP
|
$3,150.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40209921
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$3,307.50 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,732.50
|
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 |
$1,575.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,811.25
|
Rate for Payer: Fidelis Medicare Advantage |
$3,307.50
|
Rate for Payer: Group Health Inc Commercial |
$1,575.00
|
Rate for Payer: Group Health Inc Medicare |
$1,102.50
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,575.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,575.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,047.50
|
|
11X380MMX124 DEGREE LEFT
|
Facility
IP
|
$3,150.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40209921
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,575.00 |
Max. Negotiated Rate |
$1,575.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,575.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,575.00
|
|
11X380MMX125 DEGREE LN KITR2.0LFT
|
Facility
IP
|
$3,150.00
|
|
Service Code
|
HCPCS C1776
|
Hospital Charge Code |
40208097
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,575.00 |
Max. Negotiated Rate |
$1,575.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,575.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,575.00
|
|
11X380MMX125 DEGREE LN KITR2.0LFT
|
Facility
OP
|
$3,150.00
|
|
Service Code
|
HCPCS C1776
|
Hospital Charge Code |
40208097
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$339.17 |
Max. Negotiated Rate |
$3,307.50 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,732.50
|
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 |
$1,575.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,811.25
|
Rate for Payer: Fidelis Medicare Advantage |
$3,307.50
|
Rate for Payer: Group Health Inc Commercial |
$1,575.00
|
Rate for Payer: Group Health Inc Medicare |
$1,102.50
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,575.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,575.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,047.50
|
|
11X420MMX125 DEGREE RIGHT
|
Facility
IP
|
$2,940.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200581
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,470.00 |
Max. Negotiated Rate |
$1,470.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,470.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,470.00
|
|
11X420MMX125 DEGREE RIGHT
|
Facility
OP
|
$2,940.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200581
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$3,087.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,617.00
|
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 |
$1,470.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,690.50
|
Rate for Payer: Fidelis Medicare Advantage |
$3,087.00
|
Rate for Payer: Group Health Inc Commercial |
$1,470.00
|
Rate for Payer: Group Health Inc Medicare |
$1,029.00
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,470.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,470.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,911.00
|
|
12/14 COCR FEMORAL HEAD 36MM -3.5
|
Facility
IP
|
$2,544.00
|
|
Service Code
|
HCPCS C1776
|
Hospital Charge Code |
40204610
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,272.00 |
Max. Negotiated Rate |
$1,272.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,272.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,272.00
|
|
12/14 COCR FEMORAL HEAD 36MM -3.5
|
Facility
OP
|
$2,544.00
|
|
Service Code
|
HCPCS C1776
|
Hospital Charge Code |
40007529
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$339.17 |
Max. Negotiated Rate |
$2,671.20 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,399.20
|
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 |
$1,272.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,462.80
|
Rate for Payer: Fidelis Medicare Advantage |
$2,671.20
|
Rate for Payer: Group Health Inc Commercial |
$1,272.00
|
Rate for Payer: Group Health Inc Medicare |
$890.40
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,272.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,272.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,653.60
|
|
12/14 COCR FEMORAL HEAD 36MM -3.5
|
Facility
IP
|
$2,544.00
|
|
Service Code
|
HCPCS C1776
|
Hospital Charge Code |
40007529
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,272.00 |
Max. Negotiated Rate |
$1,272.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,272.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,272.00
|
|
12/14 COCR FEMORAL HEAD 36MM -3.5
|
Facility
OP
|
$2,544.00
|
|
Service Code
|
HCPCS C1776
|
Hospital Charge Code |
40204610
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$339.17 |
Max. Negotiated Rate |
$2,671.20 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,399.20
|
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 |
$1,272.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,462.80
|
Rate for Payer: Fidelis Medicare Advantage |
$2,671.20
|
Rate for Payer: Group Health Inc Commercial |
$1,272.00
|
Rate for Payer: Group Health Inc Medicare |
$890.40
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,272.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,272.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,653.60
|
|
1,25-DIHYDROXY,VITAMIN D BY MS
|
Facility
OP
|
$96.25
|
|
Service Code
|
HCPCS 82652
|
Hospital Charge Code |
40609065
|
Hospital Revenue Code
|
300
|
Min. Negotiated Rate |
$30.80 |
Max. Negotiated Rate |
$61.20 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$52.94
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$38.50
|
Rate for Payer: Aetna Government |
$38.50
|
Rate for Payer: Cash Price |
$38.50
|
Rate for Payer: Cash Price |
$38.50
|
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$38.50
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$61.20
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$51.79
|
Rate for Payer: Elderplan Medicare Advantage |
$38.50
|
Rate for Payer: EmblemHealth Commercial |
$38.50
|
Rate for Payer: Fidelis CHP/HARP/Medicaid |
$34.65
|
Rate for Payer: Fidelis Essential Plan Aliesa |
$32.72
|
Rate for Payer: Fidelis Essential Plan QHP |
$34.26
|
Rate for Payer: Fidelis Medicare Advantage |
$38.50
|
Rate for Payer: Fidelis Qualified Health Plan |
$34.26
|
Rate for Payer: Group Health Inc Commercial |
$38.50
|
Rate for Payer: Group Health Inc Medicare |
$38.50
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$48.12
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$38.50
|
Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$38.50
|
Rate for Payer: Healthfirst Medicare Advantage |
$38.50
|
Rate for Payer: Healthfirst QHP |
$38.50
|
Rate for Payer: Senior Whole Health Medicare Advantage |
$38.50
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$38.50
|
Rate for Payer: Wellcare CHP/FHP/Medicaid |
$30.80
|
Rate for Payer: Wellcare Medicare |
$34.65
|
|
1.2 BURR H COVER PLATE 10MM
|
Facility
OP
|
$346.00
|
|
Service Code
|
HCPCS C1781
|
Hospital Charge Code |
40209752
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$69.35 |
Max. Negotiated Rate |
$363.30 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$190.30
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$69.35
|
Rate for Payer: Aetna Government |
$69.35
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$173.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$198.95
|
Rate for Payer: Fidelis Medicare Advantage |
$363.30
|
Rate for Payer: Group Health Inc Commercial |
$173.00
|
Rate for Payer: Group Health Inc Medicare |
$121.10
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$173.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$173.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$224.90
|
|