|
CC BMS MED INTEGRITY 2.75MMX12MM
|
Facility
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529189
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$1,732.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$907.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$825.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$948.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,732.50
|
| Rate for Payer: Group Health Inc Commercial |
$825.00
|
| Rate for Payer: Group Health Inc Medicare |
$577.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,072.50
|
|
|
CC BMS MED INTEGRITY 2.75MMX14MM
|
Facility
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529190
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$1,732.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$907.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$825.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$948.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,732.50
|
| Rate for Payer: Group Health Inc Commercial |
$825.00
|
| Rate for Payer: Group Health Inc Medicare |
$577.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,072.50
|
|
|
CC BMS MED INTEGRITY 2.75MMX14MM
|
Facility
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529190
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.00 |
| Max. Negotiated Rate |
$825.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
|
|
CC BMS MED INTEGRITY 2.75MMX 18MM
|
Facility
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529204
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.00 |
| Max. Negotiated Rate |
$825.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
|
|
CC BMS MED INTEGRITY 2.75MMX 18MM
|
Facility
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529204
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$1,732.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$907.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$825.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$948.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,732.50
|
| Rate for Payer: Group Health Inc Commercial |
$825.00
|
| Rate for Payer: Group Health Inc Medicare |
$577.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,072.50
|
|
|
CC BMS MED INTEGRITY 2.75MMX22MM
|
Facility
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529207
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.00 |
| Max. Negotiated Rate |
$825.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
|
|
CC BMS MED INTEGRITY 2.75MMX22MM
|
Facility
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529207
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$1,732.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$907.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$825.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$948.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,732.50
|
| Rate for Payer: Group Health Inc Commercial |
$825.00
|
| Rate for Payer: Group Health Inc Medicare |
$577.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,072.50
|
|
|
CC BMS MED INTEGRITY 2.75MMX 26MM
|
Facility
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529213
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.00 |
| Max. Negotiated Rate |
$825.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
|
|
CC BMS MED INTEGRITY 2.75MMX 26MM
|
Facility
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529213
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$1,732.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$907.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$825.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$948.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,732.50
|
| Rate for Payer: Group Health Inc Commercial |
$825.00
|
| Rate for Payer: Group Health Inc Medicare |
$577.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,072.50
|
|
|
CC BMS MED INTEGRITY 2.75MM X 8MM
|
Facility
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529214
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$1,732.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$907.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$825.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$948.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,732.50
|
| Rate for Payer: Group Health Inc Commercial |
$825.00
|
| Rate for Payer: Group Health Inc Medicare |
$577.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,072.50
|
|
|
CC BMS MED INTEGRITY 2.75MM X 8MM
|
Facility
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529214
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.00 |
| Max. Negotiated Rate |
$825.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
|
|
CC BMS MED INTEGRITY 3.0MMX 12MM
|
Facility
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529286
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$1,732.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$907.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$825.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$948.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,732.50
|
| Rate for Payer: Group Health Inc Commercial |
$825.00
|
| Rate for Payer: Group Health Inc Medicare |
$577.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,072.50
|
|
|
CC BMS MED INTEGRITY 3.0MMX 12MM
|
Facility
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529286
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.00 |
| Max. Negotiated Rate |
$825.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
|
|
CC BMS MED INTEGRITY 3.0MM X 15MM
|
Facility
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529287
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.00 |
| Max. Negotiated Rate |
$825.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
|
|
CC BMS MED INTEGRITY 3.0MM X 15MM
|
Facility
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529287
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$1,732.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$907.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$825.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$948.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,732.50
|
| Rate for Payer: Group Health Inc Commercial |
$825.00
|
| Rate for Payer: Group Health Inc Medicare |
$577.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,072.50
|
|
|
CC BMS MED INTEGRITY 3.0MMX 18MM
|
Facility
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529288
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$1,732.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$907.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$825.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$948.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,732.50
|
| Rate for Payer: Group Health Inc Commercial |
$825.00
|
| Rate for Payer: Group Health Inc Medicare |
$577.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,072.50
|
|
|
CC BMS MED INTEGRITY 3.0MMX 18MM
|
Facility
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529288
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.00 |
| Max. Negotiated Rate |
$825.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
|
|
CC BMS MED INTEGRITY 3.0MM X22MM
|
Facility
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529289
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.00 |
| Max. Negotiated Rate |
$825.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
|
|
CC BMS MED INTEGRITY 3.0MM X22MM
|
Facility
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529289
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$1,732.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$907.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$825.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$948.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,732.50
|
| Rate for Payer: Group Health Inc Commercial |
$825.00
|
| Rate for Payer: Group Health Inc Medicare |
$577.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,072.50
|
|
|
CC BMS MED INTEGRITY 3.0MM X 26MM
|
Facility
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529290
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$1,732.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$907.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$825.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$948.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,732.50
|
| Rate for Payer: Group Health Inc Commercial |
$825.00
|
| Rate for Payer: Group Health Inc Medicare |
$577.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,072.50
|
|
|
CC BMS MED INTEGRITY 3.0MM X 26MM
|
Facility
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529290
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.00 |
| Max. Negotiated Rate |
$825.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
|
|
CC BMS MED INTEGRITY 3.0MMX9MM
|
Facility
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529291
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$1,732.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$907.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$825.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$948.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,732.50
|
| Rate for Payer: Group Health Inc Commercial |
$825.00
|
| Rate for Payer: Group Health Inc Medicare |
$577.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,072.50
|
|
|
CC BMS MED INTEGRITY 3.0MMX9MM
|
Facility
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529291
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.00 |
| Max. Negotiated Rate |
$825.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
|
|
CC BMS MED INTEGRITY 3.5MM X 12MM
|
Facility
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529296
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$398.18 |
| Max. Negotiated Rate |
$1,732.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$907.50
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$398.18
|
| Rate for Payer: Aetna Government |
$398.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$825.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$948.75
|
| Rate for Payer: Fidelis Medicare Advantage |
$1,732.50
|
| Rate for Payer: Group Health Inc Commercial |
$825.00
|
| Rate for Payer: Group Health Inc Medicare |
$577.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,072.50
|
|
|
CC BMS MED INTEGRITY 3.5MM X 12MM
|
Facility
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
66529296
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$825.00 |
| Max. Negotiated Rate |
$825.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$825.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$825.00
|
|
