13X380MMX125 GAMMA 3 LONG
|
Facility
OP
|
$3,453.80
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40203003
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$3,626.49 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1,899.59
|
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 |
$1,726.90
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$1,985.94
|
Rate for Payer: Fidelis Medicare Advantage |
$3,626.49
|
Rate for Payer: Group Health Inc Commercial |
$1,726.90
|
Rate for Payer: Group Health Inc Medicare |
$1,208.83
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,726.90
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,726.90
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2,244.97
|
|
13X380MMX125 GAMMA 3 LONG
|
Facility
IP
|
$3,453.80
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40203003
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,726.90 |
Max. Negotiated Rate |
$1,726.90 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$1,726.90
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$1,726.90
|
|
14 SHAFT ANTLAT TIBIA PLATE
|
Facility
IP
|
$5,278.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40005311
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$2,639.00 |
Max. Negotiated Rate |
$2,639.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,639.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$2,639.00
|
|
14 SHAFT ANTLAT TIBIA PLATE
|
Facility
OP
|
$5,278.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40005311
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$5,541.90 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,902.90
|
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 |
$2,639.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$3,034.85
|
Rate for Payer: Fidelis Medicare Advantage |
$5,541.90
|
Rate for Payer: Group Health Inc Commercial |
$2,639.00
|
Rate for Payer: Group Health Inc Medicare |
$1,847.30
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,639.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$2,639.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,430.70
|
|
1.4 X 3 MM EMERGENCY SCREW
|
Facility
OP
|
$132.38
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40005309
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$46.33 |
Max. Negotiated Rate |
$139.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$72.81
|
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 |
$66.19
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$76.12
|
Rate for Payer: Fidelis Medicare Advantage |
$139.00
|
Rate for Payer: Group Health Inc Commercial |
$66.19
|
Rate for Payer: Group Health Inc Medicare |
$46.33
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$66.19
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$66.19
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$86.05
|
|
1.4 X 3 MM EMERGENCY SCREW
|
Facility
IP
|
$132.38
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40005309
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$66.19 |
Max. Negotiated Rate |
$66.19 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$66.19
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$66.19
|
|
150MM FOOT RING
|
Facility
OP
|
$1,140.00
|
|
Hospital Charge Code |
40200585
|
Hospital Revenue Code
|
270
|
Min. Negotiated Rate |
$399.00 |
Max. Negotiated Rate |
$912.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$627.00
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$570.00
|
Rate for Payer: Aetna Government |
$570.00
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$912.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$775.20
|
Rate for Payer: Group Health Inc Commercial |
$570.00
|
Rate for Payer: Group Health Inc Medicare |
$399.00
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$570.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$570.00
|
|
150MM OPEN RING
|
Facility
OP
|
$804.00
|
|
Hospital Charge Code |
40200586
|
Hospital Revenue Code
|
270
|
Min. Negotiated Rate |
$281.40 |
Max. Negotiated Rate |
$643.20 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$442.20
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$402.00
|
Rate for Payer: Aetna Government |
$402.00
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$643.20
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$546.72
|
Rate for Payer: Group Health Inc Commercial |
$402.00
|
Rate for Payer: Group Health Inc Medicare |
$281.40
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$402.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$402.00
|
|
15CC HYDROSET BONE SUBSTITUTE
|
Facility
OP
|
$5,040.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40009116
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$5,292.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2,772.00
|
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 |
$2,520.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$2,898.00
|
Rate for Payer: Fidelis Medicare Advantage |
$5,292.00
|
Rate for Payer: Group Health Inc Commercial |
$2,520.00
|
Rate for Payer: Group Health Inc Medicare |
$1,764.00
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,520.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$2,520.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$3,276.00
|
|
15CC HYDROSET BONE SUBSTITUTE
|
Facility
IP
|
$5,040.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40009116
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$2,520.00 |
Max. Negotiated Rate |
$2,520.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$2,520.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$2,520.00
|
|
1.5X4MM SELF DRILLING SCREW
|
Facility
OP
|
$116.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40202316
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$40.60 |
Max. Negotiated Rate |
$134.20 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$63.80
|
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 |
$58.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$66.70
|
Rate for Payer: Fidelis Medicare Advantage |
$121.80
|
Rate for Payer: Group Health Inc Commercial |
$58.00
|
Rate for Payer: Group Health Inc Medicare |
$40.60
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$58.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$58.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$75.40
|
|
1.5X4MM SELF DRILLING SCREW
|
Facility
IP
|
$116.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40202316
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$58.00 |
Max. Negotiated Rate |
$58.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$58.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$58.00
|
|
1.5X5MM NEURO SCREW C-P SELF DRL
|
Facility
OP
|
$718.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40202317
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$753.90 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$394.90
|
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 |
$359.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$412.85
|
Rate for Payer: Fidelis Medicare Advantage |
$753.90
|
Rate for Payer: Group Health Inc Commercial |
$359.00
|
Rate for Payer: Group Health Inc Medicare |
$251.30
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$359.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$359.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$466.70
|
|
1.5X5MM NEURO SCREW C-P SELF DRL
|
Facility
IP
|
$718.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40202317
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$359.00 |
Max. Negotiated Rate |
$359.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$359.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$359.00
|
|
16H BP NO BAR
|
Facility
OP
|
$794.00
|
|
Service Code
|
HCPCS C1781
|
Hospital Charge Code |
40209810
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$69.35 |
Max. Negotiated Rate |
$833.70 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$436.70
|
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 |
$397.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$456.55
|
Rate for Payer: Fidelis Medicare Advantage |
$833.70
|
Rate for Payer: Group Health Inc Commercial |
$397.00
|
Rate for Payer: Group Health Inc Medicare |
$277.90
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$397.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$397.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$516.10
|
|
16H BP NO BAR
|
Facility
IP
|
$794.00
|
|
Service Code
|
HCPCS C1781
|
Hospital Charge Code |
40209810
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$397.00 |
Max. Negotiated Rate |
$397.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$397.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$397.00
|
|
16H START PLT MAN LOCK CONDSD
|
Facility
IP
|
$656.00
|
|
Service Code
|
HCPCS C1781
|
Hospital Charge Code |
40209811
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$328.00 |
Max. Negotiated Rate |
$328.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$328.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$328.00
|
|
16H START PLT MAN LOCK CONDSD
|
Facility
OP
|
$656.00
|
|
Service Code
|
HCPCS C1781
|
Hospital Charge Code |
40209811
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$69.35 |
Max. Negotiated Rate |
$688.80 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$360.80
|
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 |
$328.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$377.20
|
Rate for Payer: Fidelis Medicare Advantage |
$688.80
|
Rate for Payer: Group Health Inc Commercial |
$328.00
|
Rate for Payer: Group Health Inc Medicare |
$229.60
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$328.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$328.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$426.40
|
|
16H STRIP PLATE
|
Facility
OP
|
$550.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200063
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$577.50 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$302.50
|
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 |
$275.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$316.25
|
Rate for Payer: Fidelis Medicare Advantage |
$577.50
|
Rate for Payer: Group Health Inc Commercial |
$275.00
|
Rate for Payer: Group Health Inc Medicare |
$192.50
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$275.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$275.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$357.50
|
|
16H STRIP PLATE
|
Facility
IP
|
$550.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40200063
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$275.00 |
Max. Negotiated Rate |
$275.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$275.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$275.00
|
|
16H STRT PLT, MDFACE LOCK
|
Facility
IP
|
$624.00
|
|
Service Code
|
HCPCS C1781
|
Hospital Charge Code |
40209812
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$312.00 |
Max. Negotiated Rate |
$312.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$312.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$312.00
|
|
16H STRT PLT, MDFACE LOCK
|
Facility
OP
|
$624.00
|
|
Service Code
|
HCPCS C1781
|
Hospital Charge Code |
40209812
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$69.35 |
Max. Negotiated Rate |
$655.20 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$343.20
|
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 |
$312.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$358.80
|
Rate for Payer: Fidelis Medicare Advantage |
$655.20
|
Rate for Payer: Group Health Inc Commercial |
$312.00
|
Rate for Payer: Group Health Inc Medicare |
$218.40
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$312.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$312.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$405.60
|
|
1/6 MLAR SODUM LACTATE 1000CC
|
Facility
OP
|
$16.31
|
|
Hospital Charge Code |
40504100
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$5.71 |
Max. Negotiated Rate |
$13.05 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$8.97
|
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$8.16
|
Rate for Payer: Aetna Government |
$8.16
|
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$13.05
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$11.09
|
Rate for Payer: Group Health Inc Commercial |
$8.16
|
Rate for Payer: Group Health Inc Medicare |
$5.71
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$8.16
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$8.16
|
|
1.7 EMERGENCY SCREW
|
Facility
OP
|
$700.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40202318
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$134.20 |
Max. Negotiated Rate |
$735.00 |
Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$385.00
|
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 |
$350.00
|
Rate for Payer: Cigna LocalPlus Benefit Plan |
$402.50
|
Rate for Payer: Fidelis Medicare Advantage |
$735.00
|
Rate for Payer: Group Health Inc Commercial |
$350.00
|
Rate for Payer: Group Health Inc Medicare |
$245.00
|
Rate for Payer: Hamaspik Choice Inc Medicaid |
$350.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$350.00
|
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$455.00
|
|
1.7 EMERGENCY SCREW
|
Facility
IP
|
$700.00
|
|
Service Code
|
HCPCS C1713
|
Hospital Charge Code |
40202318
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$350.00 |
Max. Negotiated Rate |
$350.00 |
Rate for Payer: Hamaspik Choice Inc Medicaid |
$350.00
|
Rate for Payer: Hamaspik Choice Inc Medicare |
$350.00
|
|