|
PLATE CONDYLAR 4.5 VA-LCP CURVED 12 HL LT 02.124.413
|
Facility
|
IP
|
$9,037.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4778610
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,605.26 |
| Max. Negotiated Rate |
$8,646.60 |
| Rate for Payer: Aetna Commercial |
$8,458.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,082.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,981.19
|
| Rate for Payer: Cash Price |
$2,711.10
|
| Rate for Payer: Cigna Commercial |
$8,646.60
|
| Rate for Payer: Health EOS Commercial |
$8,364.65
|
| Rate for Payer: HFN Commercial |
$8,646.60
|
| Rate for Payer: Multiplan Commercial |
$7,518.78
|
| Rate for Payer: Preferred Network Access Commercial |
$8,646.60
|
| Rate for Payer: Quartz Beloit One Network |
$4,605.26
|
| Rate for Payer: Quartz Commercial |
$5,639.09
|
| Rate for Payer: WEA Trust Commercial |
$5,169.16
|
| Rate for Payer: WPS Commercial |
$6,961.20
|
|
|
PLATE CONDYLAR 4.5 VA-LCP CURVED 14 HL LT 02.124.415
|
Facility
|
OP
|
$9,644.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3393528
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,808.33 |
| Max. Negotiated Rate |
$9,227.38 |
| Rate for Payer: Aetna Commercial |
$9,026.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,625.59
|
| Rate for Payer: Aetna Managed Medicare |
$2,808.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,519.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,014.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,814.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,315.77
|
| Rate for Payer: Cash Price |
$2,893.20
|
| Rate for Payer: Cigna Commercial |
$9,227.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,612.81
|
| Rate for Payer: Health EOS Commercial |
$8,926.49
|
| Rate for Payer: HFN Commercial |
$9,227.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,522.32
|
| Rate for Payer: Multiplan Commercial |
$8,023.81
|
| Rate for Payer: NAPHCARE Commercial |
$6,017.86
|
| Rate for Payer: Preferred Network Access Commercial |
$9,227.38
|
| Rate for Payer: Quartz Beloit One Network |
$4,914.58
|
| Rate for Payer: Quartz Commercial |
$6,519.34
|
| Rate for Payer: Quartz Medicare Advantage |
$6,017.86
|
| Rate for Payer: The Alliance Commercial |
$5,014.88
|
| Rate for Payer: WEA Trust Commercial |
$5,516.37
|
| Rate for Payer: WPS Commercial |
$7,428.77
|
|
|
PLATE CONDYLAR 4.5 VA-LCP CURVED 14 HL LT 02.124.415
|
Facility
|
IP
|
$9,644.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3393528
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,914.58 |
| Max. Negotiated Rate |
$9,227.38 |
| Rate for Payer: Aetna Commercial |
$9,026.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,625.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,315.77
|
| Rate for Payer: Cash Price |
$2,893.20
|
| Rate for Payer: Cigna Commercial |
$9,227.38
|
| Rate for Payer: Health EOS Commercial |
$8,926.49
|
| Rate for Payer: HFN Commercial |
$9,227.38
|
| Rate for Payer: Multiplan Commercial |
$8,023.81
|
| Rate for Payer: Preferred Network Access Commercial |
$9,227.38
|
| Rate for Payer: Quartz Beloit One Network |
$4,914.58
|
| Rate for Payer: Quartz Commercial |
$6,017.86
|
| Rate for Payer: WEA Trust Commercial |
$5,516.37
|
| Rate for Payer: WPS Commercial |
$7,428.77
|
|
|
PLATE CONDYLAR 4.5 VA-LCP CURVED 8 HL 230MM LT 02.124.409S
|
Facility
|
IP
|
$7,814.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5286725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,982.01 |
| Max. Negotiated Rate |
$7,476.44 |
| Rate for Payer: Aetna Commercial |
$7,313.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,988.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,307.08
|
| Rate for Payer: Cash Price |
$2,344.20
|
| Rate for Payer: Cigna Commercial |
$7,476.44
|
| Rate for Payer: Health EOS Commercial |
$7,232.64
|
| Rate for Payer: HFN Commercial |
$7,476.44
|
| Rate for Payer: Multiplan Commercial |
$6,501.25
|
| Rate for Payer: Preferred Network Access Commercial |
$7,476.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,982.01
|
| Rate for Payer: Quartz Commercial |
$4,875.94
|
| Rate for Payer: WEA Trust Commercial |
$4,469.61
|
| Rate for Payer: WPS Commercial |
$6,019.12
|
|
|
PLATE CONDYLAR 4.5 VA-LCP CURVED 8 HL 230MM LT 02.124.409S
|
Facility
|
OP
|
$7,814.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5286725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,275.44 |
| Max. Negotiated Rate |
$7,476.44 |
| Rate for Payer: Aetna Commercial |
$7,313.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,988.84
|
| Rate for Payer: Aetna Managed Medicare |
$2,275.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,282.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,063.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,900.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,307.08
|
| Rate for Payer: Cash Price |
$2,344.20
|
| Rate for Payer: Cigna Commercial |
$7,476.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,547.75
|
| Rate for Payer: Health EOS Commercial |
$7,232.64
|
| Rate for Payer: HFN Commercial |
$7,476.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,094.92
|
| Rate for Payer: Multiplan Commercial |
$6,501.25
|
| Rate for Payer: NAPHCARE Commercial |
$4,875.94
|
| Rate for Payer: Preferred Network Access Commercial |
$7,476.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,982.01
|
| Rate for Payer: Quartz Commercial |
$5,282.26
|
| Rate for Payer: Quartz Medicare Advantage |
$4,875.94
|
| Rate for Payer: The Alliance Commercial |
$4,063.28
|
| Rate for Payer: WEA Trust Commercial |
$4,469.61
|
| Rate for Payer: WPS Commercial |
$6,019.12
|
|
|
PLATE CONDYLAR CRV 10 HL LT 02.001.300
|
Facility
|
IP
|
$10,068.00
|
|
| Hospital Charge Code |
2966364
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,130.65 |
| Max. Negotiated Rate |
$9,633.06 |
| Rate for Payer: Aetna Commercial |
$9,423.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,004.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,549.48
|
| Rate for Payer: Cash Price |
$3,020.40
|
| Rate for Payer: Cigna Commercial |
$9,633.06
|
| Rate for Payer: Health EOS Commercial |
$9,318.94
|
| Rate for Payer: HFN Commercial |
$9,633.06
|
| Rate for Payer: Multiplan Commercial |
$8,376.58
|
| Rate for Payer: Preferred Network Access Commercial |
$9,633.06
|
| Rate for Payer: Quartz Beloit One Network |
$5,130.65
|
| Rate for Payer: Quartz Commercial |
$6,282.43
|
| Rate for Payer: WEA Trust Commercial |
$5,758.90
|
| Rate for Payer: WPS Commercial |
$7,755.38
|
|
|
PLATE CONDYLAR CRV 10 HL LT 02.001.300
|
Facility
|
OP
|
$10,068.00
|
|
| Hospital Charge Code |
2966364
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,931.80 |
| Max. Negotiated Rate |
$9,633.06 |
| Rate for Payer: Aetna Commercial |
$9,423.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,004.82
|
| Rate for Payer: Aetna Managed Medicare |
$2,931.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,805.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,235.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,025.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,549.48
|
| Rate for Payer: Cash Price |
$3,020.40
|
| Rate for Payer: Cigna Commercial |
$9,633.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,859.58
|
| Rate for Payer: Health EOS Commercial |
$9,318.94
|
| Rate for Payer: HFN Commercial |
$9,633.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,853.04
|
| Rate for Payer: Multiplan Commercial |
$8,376.58
|
| Rate for Payer: NAPHCARE Commercial |
$6,282.43
|
| Rate for Payer: Preferred Network Access Commercial |
$9,633.06
|
| Rate for Payer: Quartz Beloit One Network |
$5,130.65
|
| Rate for Payer: Quartz Commercial |
$6,805.97
|
| Rate for Payer: Quartz Medicare Advantage |
$6,282.43
|
| Rate for Payer: The Alliance Commercial |
$5,235.36
|
| Rate for Payer: WEA Trust Commercial |
$5,758.90
|
| Rate for Payer: WPS Commercial |
$7,755.38
|
|
|
PLATE CONDYLAR CRVD 4.5 VA-LCP 8HL LT 02.124.409
|
Facility
|
OP
|
$7,814.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5458854
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,275.44 |
| Max. Negotiated Rate |
$7,476.44 |
| Rate for Payer: Aetna Commercial |
$7,313.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,988.84
|
| Rate for Payer: Aetna Managed Medicare |
$2,275.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,282.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,063.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,900.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,307.08
|
| Rate for Payer: Cash Price |
$2,344.20
|
| Rate for Payer: Cigna Commercial |
$7,476.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,547.75
|
| Rate for Payer: Health EOS Commercial |
$7,232.64
|
| Rate for Payer: HFN Commercial |
$7,476.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,094.92
|
| Rate for Payer: Multiplan Commercial |
$6,501.25
|
| Rate for Payer: NAPHCARE Commercial |
$4,875.94
|
| Rate for Payer: Preferred Network Access Commercial |
$7,476.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,982.01
|
| Rate for Payer: Quartz Commercial |
$5,282.26
|
| Rate for Payer: Quartz Medicare Advantage |
$4,875.94
|
| Rate for Payer: The Alliance Commercial |
$4,063.28
|
| Rate for Payer: WEA Trust Commercial |
$4,469.61
|
| Rate for Payer: WPS Commercial |
$6,019.12
|
|
|
PLATE CONDYLAR CRVD 4.5 VA-LCP 8HL LT 02.124.409
|
Facility
|
IP
|
$7,814.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5458854
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,982.01 |
| Max. Negotiated Rate |
$7,476.44 |
| Rate for Payer: Aetna Commercial |
$7,313.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,988.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,307.08
|
| Rate for Payer: Cash Price |
$2,344.20
|
| Rate for Payer: Cigna Commercial |
$7,476.44
|
| Rate for Payer: Health EOS Commercial |
$7,232.64
|
| Rate for Payer: HFN Commercial |
$7,476.44
|
| Rate for Payer: Multiplan Commercial |
$6,501.25
|
| Rate for Payer: Preferred Network Access Commercial |
$7,476.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,982.01
|
| Rate for Payer: Quartz Commercial |
$4,875.94
|
| Rate for Payer: WEA Trust Commercial |
$4,469.61
|
| Rate for Payer: WPS Commercial |
$6,019.12
|
|
|
PLATE CONDYLAR CRVD 4.5 VA-LCP 8HL RT 02.124.408S
|
Facility
|
OP
|
$10,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3072538
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,965.58 |
| Max. Negotiated Rate |
$9,744.05 |
| Rate for Payer: Aetna Commercial |
$9,532.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,108.57
|
| Rate for Payer: Aetna Managed Medicare |
$2,965.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,884.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,295.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,083.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,613.42
|
| Rate for Payer: Cash Price |
$3,055.20
|
| Rate for Payer: Cigna Commercial |
$9,744.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.09
|
| Rate for Payer: Health EOS Commercial |
$9,426.31
|
| Rate for Payer: HFN Commercial |
$9,744.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,943.52
|
| Rate for Payer: Multiplan Commercial |
$8,473.09
|
| Rate for Payer: NAPHCARE Commercial |
$6,354.82
|
| Rate for Payer: Preferred Network Access Commercial |
$9,744.05
|
| Rate for Payer: Quartz Beloit One Network |
$5,189.77
|
| Rate for Payer: Quartz Commercial |
$6,884.38
|
| Rate for Payer: Quartz Medicare Advantage |
$6,354.82
|
| Rate for Payer: The Alliance Commercial |
$5,295.68
|
| Rate for Payer: WEA Trust Commercial |
$5,825.25
|
| Rate for Payer: WPS Commercial |
$7,844.74
|
|
|
PLATE CONDYLAR CRVD 4.5 VA-LCP 8HL RT 02.124.408S
|
Facility
|
IP
|
$10,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3072538
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,189.77 |
| Max. Negotiated Rate |
$9,744.05 |
| Rate for Payer: Aetna Commercial |
$9,532.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,108.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,613.42
|
| Rate for Payer: Cash Price |
$3,055.20
|
| Rate for Payer: Cigna Commercial |
$9,744.05
|
| Rate for Payer: Health EOS Commercial |
$9,426.31
|
| Rate for Payer: HFN Commercial |
$9,744.05
|
| Rate for Payer: Multiplan Commercial |
$8,473.09
|
| Rate for Payer: Preferred Network Access Commercial |
$9,744.05
|
| Rate for Payer: Quartz Beloit One Network |
$5,189.77
|
| Rate for Payer: Quartz Commercial |
$6,354.82
|
| Rate for Payer: WEA Trust Commercial |
$5,825.25
|
| Rate for Payer: WPS Commercial |
$7,844.74
|
|
|
PLATE CONDYLAR CUR VA-LCP 6 HL RT 02.124.406S
|
Facility
|
OP
|
$7,667.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3937333
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,232.63 |
| Max. Negotiated Rate |
$7,335.79 |
| Rate for Payer: Aetna Commercial |
$7,176.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,857.36
|
| Rate for Payer: Aetna Managed Medicare |
$2,232.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,182.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,986.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,827.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,226.05
|
| Rate for Payer: Cash Price |
$2,300.10
|
| Rate for Payer: Cigna Commercial |
$7,335.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,462.19
|
| Rate for Payer: Health EOS Commercial |
$7,096.58
|
| Rate for Payer: HFN Commercial |
$7,335.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,980.26
|
| Rate for Payer: Multiplan Commercial |
$6,378.94
|
| Rate for Payer: NAPHCARE Commercial |
$4,784.21
|
| Rate for Payer: Preferred Network Access Commercial |
$7,335.79
|
| Rate for Payer: Quartz Beloit One Network |
$3,907.10
|
| Rate for Payer: Quartz Commercial |
$5,182.89
|
| Rate for Payer: Quartz Medicare Advantage |
$4,784.21
|
| Rate for Payer: The Alliance Commercial |
$3,986.84
|
| Rate for Payer: WEA Trust Commercial |
$4,385.52
|
| Rate for Payer: WPS Commercial |
$5,905.89
|
|
|
PLATE CONDYLAR CUR VA-LCP 6 HL RT 02.124.406S
|
Facility
|
IP
|
$7,667.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3937333
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,907.10 |
| Max. Negotiated Rate |
$7,335.79 |
| Rate for Payer: Aetna Commercial |
$7,176.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,857.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,226.05
|
| Rate for Payer: Cash Price |
$2,300.10
|
| Rate for Payer: Cigna Commercial |
$7,335.79
|
| Rate for Payer: Health EOS Commercial |
$7,096.58
|
| Rate for Payer: HFN Commercial |
$7,335.79
|
| Rate for Payer: Multiplan Commercial |
$6,378.94
|
| Rate for Payer: Preferred Network Access Commercial |
$7,335.79
|
| Rate for Payer: Quartz Beloit One Network |
$3,907.10
|
| Rate for Payer: Quartz Commercial |
$4,784.21
|
| Rate for Payer: WEA Trust Commercial |
$4,385.52
|
| Rate for Payer: WPS Commercial |
$5,905.89
|
|
|
PLATE DCP MATRIX MANDIBLE 1.25MM 2HL X 2HL 04.503.710
|
Facility
|
OP
|
$4,442.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831673
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,293.51 |
| Max. Negotiated Rate |
$4,250.11 |
| Rate for Payer: Aetna Commercial |
$4,157.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,972.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,293.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,002.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,309.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,217.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,448.43
|
| Rate for Payer: Cash Price |
$1,332.60
|
| Rate for Payer: Cigna Commercial |
$4,250.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,585.24
|
| Rate for Payer: Health EOS Commercial |
$4,111.52
|
| Rate for Payer: HFN Commercial |
$4,250.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,464.76
|
| Rate for Payer: Multiplan Commercial |
$3,695.74
|
| Rate for Payer: NAPHCARE Commercial |
$2,771.81
|
| Rate for Payer: Preferred Network Access Commercial |
$4,250.11
|
| Rate for Payer: Quartz Beloit One Network |
$2,263.64
|
| Rate for Payer: Quartz Commercial |
$3,002.79
|
| Rate for Payer: Quartz Medicare Advantage |
$2,771.81
|
| Rate for Payer: The Alliance Commercial |
$2,309.84
|
| Rate for Payer: WEA Trust Commercial |
$2,540.82
|
| Rate for Payer: WPS Commercial |
$3,421.67
|
|
|
PLATE DCP MATRIX MANDIBLE 1.25MM 2HL X 2HL 04.503.710
|
Facility
|
IP
|
$4,442.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831673
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,263.64 |
| Max. Negotiated Rate |
$4,250.11 |
| Rate for Payer: Aetna Commercial |
$4,157.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,972.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,448.43
|
| Rate for Payer: Cash Price |
$1,332.60
|
| Rate for Payer: Cigna Commercial |
$4,250.11
|
| Rate for Payer: Health EOS Commercial |
$4,111.52
|
| Rate for Payer: HFN Commercial |
$4,250.11
|
| Rate for Payer: Multiplan Commercial |
$3,695.74
|
| Rate for Payer: Preferred Network Access Commercial |
$4,250.11
|
| Rate for Payer: Quartz Beloit One Network |
$2,263.64
|
| Rate for Payer: Quartz Commercial |
$2,771.81
|
| Rate for Payer: WEA Trust Commercial |
$2,540.82
|
| Rate for Payer: WPS Commercial |
$3,421.67
|
|
|
PLATE DCP MATRIX MANDIBLE 1.5MM 2HL X 2HL 04.503.723
|
Facility
|
OP
|
$5,257.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,530.84 |
| Max. Negotiated Rate |
$5,029.90 |
| Rate for Payer: Aetna Commercial |
$4,920.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,701.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,530.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,553.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,733.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,624.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,897.66
|
| Rate for Payer: Cash Price |
$1,577.10
|
| Rate for Payer: Cigna Commercial |
$5,029.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,059.57
|
| Rate for Payer: Health EOS Commercial |
$4,865.88
|
| Rate for Payer: HFN Commercial |
$5,029.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,100.46
|
| Rate for Payer: Multiplan Commercial |
$4,373.82
|
| Rate for Payer: NAPHCARE Commercial |
$3,280.37
|
| Rate for Payer: Preferred Network Access Commercial |
$5,029.90
|
| Rate for Payer: Quartz Beloit One Network |
$2,678.97
|
| Rate for Payer: Quartz Commercial |
$3,553.73
|
| Rate for Payer: Quartz Medicare Advantage |
$3,280.37
|
| Rate for Payer: The Alliance Commercial |
$2,733.64
|
| Rate for Payer: WEA Trust Commercial |
$3,007.00
|
| Rate for Payer: WPS Commercial |
$4,049.47
|
|
|
PLATE DCP MATRIX MANDIBLE 1.5MM 2HL X 2HL 04.503.723
|
Facility
|
IP
|
$5,257.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831674
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,678.97 |
| Max. Negotiated Rate |
$5,029.90 |
| Rate for Payer: Aetna Commercial |
$4,920.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,701.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,897.66
|
| Rate for Payer: Cash Price |
$1,577.10
|
| Rate for Payer: Cigna Commercial |
$5,029.90
|
| Rate for Payer: Health EOS Commercial |
$4,865.88
|
| Rate for Payer: HFN Commercial |
$5,029.90
|
| Rate for Payer: Multiplan Commercial |
$4,373.82
|
| Rate for Payer: Preferred Network Access Commercial |
$5,029.90
|
| Rate for Payer: Quartz Beloit One Network |
$2,678.97
|
| Rate for Payer: Quartz Commercial |
$3,280.37
|
| Rate for Payer: WEA Trust Commercial |
$3,007.00
|
| Rate for Payer: WPS Commercial |
$4,049.47
|
|
|
PLATE DHS 130 DEG 3 HOLE/38MM 281.131
|
Facility
|
IP
|
$4,613.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
5611672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,350.78 |
| Max. Negotiated Rate |
$4,413.72 |
| Rate for Payer: Aetna Commercial |
$4,317.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,125.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,542.69
|
| Rate for Payer: Cash Price |
$1,383.90
|
| Rate for Payer: Cigna Commercial |
$4,413.72
|
| Rate for Payer: Health EOS Commercial |
$4,269.79
|
| Rate for Payer: HFN Commercial |
$4,413.72
|
| Rate for Payer: Multiplan Commercial |
$3,838.02
|
| Rate for Payer: Preferred Network Access Commercial |
$4,413.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,350.78
|
| Rate for Payer: Quartz Commercial |
$2,878.51
|
| Rate for Payer: WEA Trust Commercial |
$2,638.64
|
| Rate for Payer: WPS Commercial |
$3,553.39
|
|
|
PLATE DHS 130 DEG 3 HOLE/38MM 281.131
|
Facility
|
OP
|
$4,613.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
5611672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,343.31 |
| Max. Negotiated Rate |
$4,413.72 |
| Rate for Payer: Aetna Commercial |
$4,317.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,125.87
|
| Rate for Payer: Aetna Managed Medicare |
$1,343.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,118.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,398.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,302.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,542.69
|
| Rate for Payer: Cash Price |
$1,383.90
|
| Rate for Payer: Cigna Commercial |
$4,413.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,684.77
|
| Rate for Payer: Health EOS Commercial |
$4,269.79
|
| Rate for Payer: HFN Commercial |
$4,413.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,598.14
|
| Rate for Payer: Multiplan Commercial |
$3,838.02
|
| Rate for Payer: NAPHCARE Commercial |
$2,878.51
|
| Rate for Payer: Preferred Network Access Commercial |
$4,413.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,350.78
|
| Rate for Payer: Quartz Commercial |
$3,118.39
|
| Rate for Payer: Quartz Medicare Advantage |
$2,878.51
|
| Rate for Payer: The Alliance Commercial |
$2,398.76
|
| Rate for Payer: WEA Trust Commercial |
$2,638.64
|
| Rate for Payer: WPS Commercial |
$3,553.39
|
|
|
PLATE DHS 135 DEG 2 HOLE/46MM 281.102S
|
Facility
|
IP
|
$4,900.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
5178634
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,497.04 |
| Max. Negotiated Rate |
$4,688.32 |
| Rate for Payer: Aetna Commercial |
$4,586.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,382.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,700.88
|
| Rate for Payer: Cash Price |
$1,470.00
|
| Rate for Payer: Cigna Commercial |
$4,688.32
|
| Rate for Payer: Health EOS Commercial |
$4,535.44
|
| Rate for Payer: HFN Commercial |
$4,688.32
|
| Rate for Payer: Multiplan Commercial |
$4,076.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,688.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,497.04
|
| Rate for Payer: Quartz Commercial |
$3,057.60
|
| Rate for Payer: WEA Trust Commercial |
$2,802.80
|
| Rate for Payer: WPS Commercial |
$3,774.47
|
|
|
PLATE DHS 135 DEG 2 HOLE/46MM 281.102S
|
Facility
|
OP
|
$4,900.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
5178634
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,426.88 |
| Max. Negotiated Rate |
$4,688.32 |
| Rate for Payer: Aetna Commercial |
$4,586.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,382.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,426.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,312.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,548.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,446.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,700.88
|
| Rate for Payer: Cash Price |
$1,470.00
|
| Rate for Payer: Cigna Commercial |
$4,688.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,851.80
|
| Rate for Payer: Health EOS Commercial |
$4,535.44
|
| Rate for Payer: HFN Commercial |
$4,688.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,822.00
|
| Rate for Payer: Multiplan Commercial |
$4,076.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,057.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,688.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,497.04
|
| Rate for Payer: Quartz Commercial |
$3,312.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,057.60
|
| Rate for Payer: The Alliance Commercial |
$2,548.00
|
| Rate for Payer: WEA Trust Commercial |
$2,802.80
|
| Rate for Payer: WPS Commercial |
$3,774.47
|
|
|
PLATE DHS 135 DEG 4 HOLE/78MM 281.140
|
Facility
|
OP
|
$5,292.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2966319
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,541.03 |
| Max. Negotiated Rate |
$5,063.39 |
| Rate for Payer: Aetna Commercial |
$4,953.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,733.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,541.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,577.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,751.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,641.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,916.95
|
| Rate for Payer: Cash Price |
$1,587.60
|
| Rate for Payer: Cigna Commercial |
$5,063.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,079.94
|
| Rate for Payer: Health EOS Commercial |
$4,898.28
|
| Rate for Payer: HFN Commercial |
$5,063.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,127.76
|
| Rate for Payer: Multiplan Commercial |
$4,402.94
|
| Rate for Payer: NAPHCARE Commercial |
$3,302.21
|
| Rate for Payer: Preferred Network Access Commercial |
$5,063.39
|
| Rate for Payer: Quartz Beloit One Network |
$2,696.80
|
| Rate for Payer: Quartz Commercial |
$3,577.39
|
| Rate for Payer: Quartz Medicare Advantage |
$3,302.21
|
| Rate for Payer: The Alliance Commercial |
$2,751.84
|
| Rate for Payer: WEA Trust Commercial |
$3,027.02
|
| Rate for Payer: WPS Commercial |
$4,076.43
|
|
|
PLATE DHS 135 DEG 4 HOLE/78MM 281.140
|
Facility
|
IP
|
$5,292.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2966319
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,696.80 |
| Max. Negotiated Rate |
$5,063.39 |
| Rate for Payer: Aetna Commercial |
$4,953.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,733.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,916.95
|
| Rate for Payer: Cash Price |
$1,587.60
|
| Rate for Payer: Cigna Commercial |
$5,063.39
|
| Rate for Payer: Health EOS Commercial |
$4,898.28
|
| Rate for Payer: HFN Commercial |
$5,063.39
|
| Rate for Payer: Multiplan Commercial |
$4,402.94
|
| Rate for Payer: Preferred Network Access Commercial |
$5,063.39
|
| Rate for Payer: Quartz Beloit One Network |
$2,696.80
|
| Rate for Payer: Quartz Commercial |
$3,302.21
|
| Rate for Payer: WEA Trust Commercial |
$3,027.02
|
| Rate for Payer: WPS Commercial |
$4,076.43
|
|
|
PLATE DHS 135 DEG 5 HOLE/94MM 281.150S
|
Facility
|
IP
|
$4,613.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
4640730
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,350.78 |
| Max. Negotiated Rate |
$4,413.72 |
| Rate for Payer: Aetna Commercial |
$4,317.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,125.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,542.69
|
| Rate for Payer: Cash Price |
$1,383.90
|
| Rate for Payer: Cigna Commercial |
$4,413.72
|
| Rate for Payer: Health EOS Commercial |
$4,269.79
|
| Rate for Payer: HFN Commercial |
$4,413.72
|
| Rate for Payer: Multiplan Commercial |
$3,838.02
|
| Rate for Payer: Preferred Network Access Commercial |
$4,413.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,350.78
|
| Rate for Payer: Quartz Commercial |
$2,878.51
|
| Rate for Payer: WEA Trust Commercial |
$2,638.64
|
| Rate for Payer: WPS Commercial |
$3,553.39
|
|
|
PLATE DHS 135 DEG 5 HOLE/94MM 281.150S
|
Facility
|
OP
|
$4,613.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
4640730
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,343.31 |
| Max. Negotiated Rate |
$4,413.72 |
| Rate for Payer: Aetna Commercial |
$4,317.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,125.87
|
| Rate for Payer: Aetna Managed Medicare |
$1,343.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,118.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,398.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,302.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,542.69
|
| Rate for Payer: Cash Price |
$1,383.90
|
| Rate for Payer: Cigna Commercial |
$4,413.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,684.77
|
| Rate for Payer: Health EOS Commercial |
$4,269.79
|
| Rate for Payer: HFN Commercial |
$4,413.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,598.14
|
| Rate for Payer: Multiplan Commercial |
$3,838.02
|
| Rate for Payer: NAPHCARE Commercial |
$2,878.51
|
| Rate for Payer: Preferred Network Access Commercial |
$4,413.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,350.78
|
| Rate for Payer: Quartz Commercial |
$3,118.39
|
| Rate for Payer: Quartz Medicare Advantage |
$2,878.51
|
| Rate for Payer: The Alliance Commercial |
$2,398.76
|
| Rate for Payer: WEA Trust Commercial |
$2,638.64
|
| Rate for Payer: WPS Commercial |
$3,553.39
|
|
