|
COMPLX RPR-S/A/L 2.6-7.5 CM
|
Facility
OP
|
$1,505.35
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
30305946
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$726.29
|
| Rate for Payer: Aetna Government |
$726.29
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$726.29
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$726.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$726.29
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$277.33
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$617.35
|
| Rate for Payer: Fidelis Essential Plan QHP |
$646.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$726.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$646.40
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$752.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$726.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$726.29
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$726.29
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$726.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$726.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$581.03
|
| Rate for Payer: Wellcare Medicare |
$689.98
|
|
|
COMPLX RPR-S/A/L 2.6-7.5 CM
|
Facility
OP
|
$1,505.35
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
30105946
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,134.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$726.29
|
| Rate for Payer: Aetna Government |
$726.29
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Carelon Behavioral Health CHP/Medicaid |
$726.29
|
| Rate for Payer: Carelon Behavioral Health Medicare Advantage |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Cash Price |
$726.29
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$726.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: Elderplan Medicare Advantage |
$726.29
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$277.33
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$617.35
|
| Rate for Payer: Fidelis Essential Plan QHP |
$646.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$726.29
|
| Rate for Payer: Fidelis Qualified Health Plan |
$646.40
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$752.68
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$726.29
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
| Rate for Payer: Healthfirst QHP |
$726.29
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$726.29
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$726.29
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$726.29
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$581.03
|
| Rate for Payer: Wellcare Medicare |
$689.98
|
|
|
COMPLX RPR S/A/L ADDL 5CM/>
|
Facility
OP
|
$752.68
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
30305947
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$91.06 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$114.77
|
| Rate for Payer: Aetna Government |
$114.77
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$91.06
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$376.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$376.34
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
|
|
COMPLX RPR S/A/L ADDL 5CM/>
|
Facility
OP
|
$752.68
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
30105947
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$91.06 |
| Max. Negotiated Rate |
$2,915.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,412.00
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$114.77
|
| Rate for Payer: Aetna Government |
$114.77
|
| Rate for Payer: Brighton Health Commercial |
$874.00
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$2,915.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,477.75
|
| Rate for Payer: EmblemHealth Commercial |
$525.00
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$91.06
|
| Rate for Payer: Group Health Inc Commercial |
$525.00
|
| Rate for Payer: Group Health Inc Medicare |
$525.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$376.34
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$376.34
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$165.00
|
| Rate for Payer: Healthfirst Medicare Advantage |
$225.00
|
|
|
COMP. METABOLIC PANEL (14)
|
Facility
OP
|
$26.40
|
|
|
Service Code
|
HCPCS 80053
|
| Hospital Charge Code |
40609816
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$16.80 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$14.52
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.56
|
| Rate for Payer: Aetna Government |
$10.56
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus |
$10.56
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.80
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$14.21
|
| Rate for Payer: Elderplan Medicare Advantage |
$10.56
|
| Rate for Payer: EmblemHealth Commercial |
$10.56
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$9.50
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$8.98
|
| Rate for Payer: Fidelis Essential Plan QHP |
$9.40
|
| Rate for Payer: Fidelis Medicare Advantage |
$10.56
|
| Rate for Payer: Fidelis Qualified Health Plan |
$9.40
|
| Rate for Payer: Group Health Inc Commercial |
$10.56
|
| Rate for Payer: Group Health Inc Medicare |
$10.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$13.20
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.56
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$10.56
|
| Rate for Payer: Healthfirst Medicare Advantage |
$10.56
|
| Rate for Payer: Healthfirst QHP |
$10.56
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$10.56
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$10.56
|
| Rate for Payer: Wellcare CHP/FHP/Medicaid |
$8.45
|
| Rate for Payer: Wellcare Medicare |
$9.50
|
|
|
COMP MONO TIB SZ 7 FEM SZ C-H
|
Facility
IP
|
$9,710.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64901992
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,855.00 |
| Max. Negotiated Rate |
$4,855.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,855.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,855.00
|
|
|
COMP MONO TIB SZ 7 FEM SZ C-H
|
Facility
OP
|
$7,768.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40205072
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$8,156.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$4,272.40
|
| 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 |
$3,884.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$4,466.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$8,156.40
|
| Rate for Payer: Group Health Inc Commercial |
$3,884.00
|
| Rate for Payer: Group Health Inc Medicare |
$2,718.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,884.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,884.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$5,049.20
|
|
|
COMP MONO TIB SZ 7 FEM SZ C-H
|
Facility
IP
|
$7,768.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40205072
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,884.00 |
| Max. Negotiated Rate |
$3,884.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$3,884.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$3,884.00
|
|
|
COMP MONO TIB SZ 7 FEM SZ C-H
|
Facility
OP
|
$9,710.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64901992
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$10,195.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$5,340.50
|
| 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 |
$4,855.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$5,583.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$10,195.50
|
| Rate for Payer: Group Health Inc Commercial |
$4,855.00
|
| Rate for Payer: Group Health Inc Medicare |
$3,398.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$4,855.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$4,855.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$6,311.50
|
|
|
COMP NEXGEN PATELLA 29MM
|
Facility
IP
|
$2,940.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40205053
|
|
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
|
|
|
COMP NEXGEN PATELLA 29MM
|
Facility
OP
|
$2,940.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40205053
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$3,087.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,617.00
|
| 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 |
$1,470.00
|
| 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
|
|
|
COMP NEXGEN PATELLA 32MM
|
Facility
IP
|
$2,269.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40204057
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,134.75 |
| Max. Negotiated Rate |
$1,134.75 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,134.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,134.75
|
|
|
COMP NEXGEN PATELLA 32MM
|
Facility
IP
|
$2,836.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64901884
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,418.44 |
| Max. Negotiated Rate |
$1,418.44 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,418.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,418.44
|
|
|
COMP NEXGEN PATELLA 32MM
|
Facility
OP
|
$2,836.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64901884
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$2,978.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,560.28
|
| 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 |
$1,418.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,631.21
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,978.72
|
| Rate for Payer: Group Health Inc Commercial |
$1,418.44
|
| Rate for Payer: Group Health Inc Medicare |
$992.91
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,418.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,418.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,843.97
|
|
|
COMP NEXGEN PATELLA 32MM
|
Facility
OP
|
$2,269.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
40204057
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$2,382.98 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,248.22
|
| 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 |
$1,134.75
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,304.96
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,382.98
|
| Rate for Payer: Group Health Inc Commercial |
$1,134.75
|
| Rate for Payer: Group Health Inc Medicare |
$794.32
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,134.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,134.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,475.18
|
|
|
COMP NEXGEN PATTELLA 35MM
|
Facility
OP
|
$2,836.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64902135
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$2,978.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,560.28
|
| 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 |
$1,418.44
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,631.21
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,978.72
|
| Rate for Payer: Group Health Inc Commercial |
$1,418.44
|
| Rate for Payer: Group Health Inc Medicare |
$992.91
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,418.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,418.44
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,843.97
|
|
|
COMP NEXGEN PATTELLA 35MM
|
Facility
IP
|
$2,836.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64902135
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,418.44 |
| Max. Negotiated Rate |
$1,418.44 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,418.44
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,418.44
|
|
|
COMPONENT 29MM 8.0 MM CEMNT
|
Facility
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64905820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$2,100.00 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,100.00
|
| 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 |
$1,000.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,150.00
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,100.00
|
| Rate for Payer: Group Health Inc Commercial |
$1,000.00
|
| Rate for Payer: Group Health Inc Medicare |
$700.00
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,000.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,000.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,300.00
|
|
|
COMPONENT 29MM 8.0 MM CEMNT
|
Facility
IP
|
$2,000.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
64905820
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,000.00 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,000.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,000.00
|
|
|
COMPONENT ARTC 15MM,2.5X4.5
|
Facility
IP
|
$3,470.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64906477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,735.00 |
| Max. Negotiated Rate |
$1,735.00 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,735.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,735.00
|
|
|
COMPONENT ARTC 15MM,2.5X4.5
|
Facility
OP
|
$3,470.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64906477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$3,643.50 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,908.50
|
| 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 |
$1,735.00
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,995.25
|
| Rate for Payer: Fidelis Medicare Advantage |
$3,643.50
|
| Rate for Payer: Group Health Inc Commercial |
$1,735.00
|
| Rate for Payer: Group Health Inc Medicare |
$1,214.50
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,735.00
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,735.00
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,255.50
|
|
|
COMPONENT BIPOLAR 28MM ID 44MM
|
Facility
OP
|
$2,085.63
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64903538
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$2,189.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,147.10
|
| 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 |
$1,042.82
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,199.24
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,189.91
|
| Rate for Payer: Group Health Inc Commercial |
$1,042.82
|
| Rate for Payer: Group Health Inc Medicare |
$729.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,042.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,042.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,355.66
|
|
|
COMPONENT BIPOLAR 28MM ID 44MM
|
Facility
IP
|
$2,085.63
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64903538
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,042.82 |
| Max. Negotiated Rate |
$1,042.82 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,042.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,042.82
|
|
|
COMPONENT BIPOLAR 28MM ID 45MM
|
Facility
OP
|
$2,085.63
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64903544
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$339.17 |
| Max. Negotiated Rate |
$2,189.91 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,147.10
|
| 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 |
$1,042.82
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,199.24
|
| Rate for Payer: Fidelis Medicare Advantage |
$2,189.91
|
| Rate for Payer: Group Health Inc Commercial |
$1,042.82
|
| Rate for Payer: Group Health Inc Medicare |
$729.97
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,042.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,042.82
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1,355.66
|
|
|
COMPONENT BIPOLAR 28MM ID 45MM
|
Facility
IP
|
$2,085.63
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
64903544
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,042.82 |
| Max. Negotiated Rate |
$1,042.82 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,042.82
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$1,042.82
|
|
