|
6H 2.3MM COMPRESSION PLATE
|
Facility
IP
|
$728.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202259
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$364.00 |
| Max. Negotiated Rate |
$364.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$364.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$364.00
|
|
|
6H DBL Y-BONE PLT NO BAR
|
Facility
OP
|
$472.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202261
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$495.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$259.60
|
| 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 |
$236.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$271.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$495.60
|
| Rate for Payer: Group Health Inc Commercial |
$236.00
|
| Rate for Payer: Group Health Inc Medicare |
$165.20
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$236.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$236.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$306.80
|
|
|
6H DBL Y-BONE PLT NO BAR
|
Facility
IP
|
$472.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202261
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$236.00 |
| Max. Negotiated Rate |
$236.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$236.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$236.00
|
|
|
6H L PLATE, 12MM ADV MDFC LOC
|
Facility
IP
|
$406.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202274
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$203.00 |
| Max. Negotiated Rate |
$203.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$203.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$203.00
|
|
|
6H L PLATE, 12MM ADV MDFC LOC
|
Facility
OP
|
$406.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202274
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$426.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$223.30
|
| 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 |
$203.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$233.45
|
| Rate for Payer: Fidelis Medicare Advantage |
$426.30
|
| Rate for Payer: Group Health Inc Commercial |
$203.00
|
| Rate for Payer: Group Health Inc Medicare |
$142.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$203.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$203.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$263.90
|
|
|
6H L PLATE12MM ADVMT 100D LFT,STD
|
Facility
OP
|
$126.36
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202265
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.23 |
| Max. Negotiated Rate |
$134.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$69.50
|
| 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 |
$63.18
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$72.66
|
| Rate for Payer: Fidelis Medicare Advantage |
$132.68
|
| Rate for Payer: Group Health Inc Commercial |
$63.18
|
| Rate for Payer: Group Health Inc Medicare |
$44.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$63.18
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$63.18
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$82.13
|
|
|
6H L PLATE12MM ADVMT 100D LFT,STD
|
Facility
IP
|
$126.36
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202265
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$63.18 |
| Max. Negotiated Rate |
$63.18 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$63.18
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$63.18
|
|
|
6H L PLATE, 8MM ADV MDFC LOC
|
Facility
IP
|
$396.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$198.00 |
| Max. Negotiated Rate |
$198.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$198.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$198.00
|
|
|
6H L PLATE, 8MM ADV MDFC LOC
|
Facility
OP
|
$396.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$415.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$217.80
|
| 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 |
$198.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$227.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$415.80
|
| Rate for Payer: Group Health Inc Commercial |
$198.00
|
| Rate for Payer: Group Health Inc Medicare |
$138.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$198.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$198.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$257.40
|
|
|
6H L PT 12MM ADVC 100D LT STD
|
Facility
IP
|
$364.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202276
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$182.00 |
| Max. Negotiated Rate |
$182.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$182.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$182.00
|
|
|
6H L PT 12MM ADVC 100D LT STD
|
Facility
OP
|
$364.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202276
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$382.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$200.20
|
| 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 |
$182.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$209.30
|
| Rate for Payer: Fidelis Medicare Advantage |
$382.20
|
| Rate for Payer: Group Health Inc Commercial |
$182.00
|
| Rate for Payer: Group Health Inc Medicare |
$127.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$182.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$182.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$236.60
|
|
|
6H L PT 12MM ADVC 100D RT STD
|
Facility
OP
|
$364.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202277
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$382.20 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$200.20
|
| 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 |
$182.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$209.30
|
| Rate for Payer: Fidelis Medicare Advantage |
$382.20
|
| Rate for Payer: Group Health Inc Commercial |
$182.00
|
| Rate for Payer: Group Health Inc Medicare |
$127.40
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$182.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$182.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$236.60
|
|
|
6H L PT 12MM ADVC 100D RT STD
|
Facility
IP
|
$364.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202277
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$182.00 |
| Max. Negotiated Rate |
$182.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$182.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$182.00
|
|
|
6H L PT 8MM ADVC 100D LT STD
|
Facility
IP
|
$346.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202278
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$173.00 |
| Max. Negotiated Rate |
$173.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$173.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$173.00
|
|
|
6H L PT 8MM ADVC 100D LT STD
|
Facility
OP
|
$346.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202278
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$121.10 |
| Max. Negotiated Rate |
$363.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$190.30
|
| 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 |
$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
|
|
|
6H L PT 8MM ADVC 100D RT STD
|
Facility
IP
|
$346.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202279
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$173.00 |
| Max. Negotiated Rate |
$173.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$173.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$173.00
|
|
|
6H L PT 8MM ADVC 100D RT STD
|
Facility
OP
|
$346.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40202279
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$121.10 |
| Max. Negotiated Rate |
$363.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$190.30
|
| 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 |
$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
|
|
|
6 HOLE BP NO BAR
|
Facility
OP
|
$442.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40201158
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$464.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$243.10
|
| 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 |
$221.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$254.15
|
| Rate for Payer: Fidelis Medicare Advantage |
$464.10
|
| Rate for Payer: Group Health Inc Commercial |
$221.00
|
| Rate for Payer: Group Health Inc Medicare |
$154.70
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$221.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$221.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$287.30
|
|
|
6 HOLE BP NO BAR
|
Facility
IP
|
$442.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40201158
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$221.00 |
| Max. Negotiated Rate |
$221.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$221.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$221.00
|
|
|
6HOLE PLT,12MM ADVMDFC LOC
|
Facility
IP
|
$406.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40201156
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$203.00 |
| Max. Negotiated Rate |
$203.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$203.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$203.00
|
|
|
6HOLE PLT,12MM ADVMDFC LOC
|
Facility
OP
|
$406.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40201156
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$426.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$223.30
|
| 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 |
$203.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$233.45
|
| Rate for Payer: Fidelis Medicare Advantage |
$426.30
|
| Rate for Payer: Group Health Inc Commercial |
$203.00
|
| Rate for Payer: Group Health Inc Medicare |
$142.10
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$203.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$203.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$263.90
|
|
|
6HOLE PLT, 8MM ADV MDFC LOC
|
Facility
IP
|
$396.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40201157
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$198.00 |
| Max. Negotiated Rate |
$198.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$198.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$198.00
|
|
|
6HOLE PLT, 8MM ADV MDFC LOC
|
Facility
OP
|
$396.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40201157
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$415.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$217.80
|
| 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 |
$198.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$227.70
|
| Rate for Payer: Fidelis Medicare Advantage |
$415.80
|
| Rate for Payer: Group Health Inc Commercial |
$198.00
|
| Rate for Payer: Group Health Inc Medicare |
$138.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$198.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$198.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$257.40
|
|
|
6 HOLE RIGHT PROX LOCKING PLATE
|
Facility
IP
|
$1,910.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40201152
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$955.00 |
| Max. Negotiated Rate |
$955.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$955.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$955.00
|
|
|
6 HOLE RIGHT PROX LOCKING PLATE
|
Facility
OP
|
$1,910.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
40201152
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$2,005.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,050.50
|
| 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 |
$955.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,098.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,005.50
|
| Rate for Payer: Group Health Inc Commercial |
$955.00
|
| Rate for Payer: Group Health Inc Medicare |
$668.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$955.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$955.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,241.50
|
|
