|
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 |
$4,428.13 |
| Max. Negotiated Rate |
$8,314.04 |
| Rate for Payer: Aetna Commercial |
$8,133.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,771.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,789.61
|
| Rate for Payer: Cash Price |
$2,711.10
|
| Rate for Payer: Cigna Commercial |
$8,314.04
|
| Rate for Payer: Health EOS Commercial |
$8,042.93
|
| Rate for Payer: HFN Commercial |
$8,314.04
|
| Rate for Payer: Multiplan Commercial |
$7,229.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,422.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,314.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,428.13
|
| Rate for Payer: Quartz Commercial |
$5,422.20
|
| Rate for Payer: WEA Trust Commercial |
$4,970.35
|
| Rate for Payer: WPS Commercial |
$6,693.71
|
|
|
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 |
$4,725.56 |
| Max. Negotiated Rate |
$8,872.48 |
| Rate for Payer: Aetna Commercial |
$8,679.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,293.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,111.32
|
| Rate for Payer: Cash Price |
$2,893.20
|
| Rate for Payer: Cigna Commercial |
$8,872.48
|
| Rate for Payer: Health EOS Commercial |
$8,583.16
|
| Rate for Payer: HFN Commercial |
$8,872.48
|
| Rate for Payer: Multiplan Commercial |
$7,715.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,786.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,872.48
|
| Rate for Payer: Quartz Beloit One Network |
$4,725.56
|
| Rate for Payer: Quartz Commercial |
$5,786.40
|
| Rate for Payer: WEA Trust Commercial |
$5,304.20
|
| Rate for Payer: WPS Commercial |
$7,143.31
|
|
|
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 |
$2,700.32 |
| Max. Negotiated Rate |
$38,576.00 |
| Rate for Payer: Aetna Commercial |
$8,679.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,293.84
|
| Rate for Payer: Aetna Managed Medicare |
$2,700.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,268.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,822.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,629.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,111.32
|
| Rate for Payer: Cash Price |
$2,893.20
|
| Rate for Payer: Cigna Commercial |
$8,872.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,396.78
|
| Rate for Payer: Health EOS Commercial |
$8,583.16
|
| Rate for Payer: HFN Commercial |
$8,872.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,233.00
|
| Rate for Payer: Multiplan Commercial |
$7,715.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,786.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8,872.48
|
| Rate for Payer: Quartz Beloit One Network |
$4,725.56
|
| Rate for Payer: Quartz Commercial |
$6,268.60
|
| Rate for Payer: Quartz Medicare Advantage |
$5,786.40
|
| Rate for Payer: The Alliance Commercial |
$38,576.00
|
| Rate for Payer: WEA Trust Commercial |
$5,304.20
|
| Rate for Payer: WPS Commercial |
$7,143.31
|
|
|
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 |
$2,187.92 |
| Max. Negotiated Rate |
$31,256.00 |
| Rate for Payer: Aetna Commercial |
$7,032.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,720.04
|
| Rate for Payer: Aetna Managed Medicare |
$2,187.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,079.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,907.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,750.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,141.42
|
| Rate for Payer: Cash Price |
$2,344.20
|
| Rate for Payer: Cigna Commercial |
$7,188.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,372.71
|
| Rate for Payer: Health EOS Commercial |
$6,954.46
|
| Rate for Payer: HFN Commercial |
$7,188.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,860.50
|
| Rate for Payer: Multiplan Commercial |
$6,251.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,688.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,188.88
|
| Rate for Payer: Quartz Beloit One Network |
$3,828.86
|
| Rate for Payer: Quartz Commercial |
$5,079.10
|
| Rate for Payer: Quartz Medicare Advantage |
$4,688.40
|
| Rate for Payer: The Alliance Commercial |
$31,256.00
|
| Rate for Payer: WEA Trust Commercial |
$4,297.70
|
| Rate for Payer: WPS Commercial |
$5,787.83
|
|
|
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 |
$3,828.86 |
| Max. Negotiated Rate |
$7,188.88 |
| Rate for Payer: Aetna Commercial |
$7,032.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,720.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,141.42
|
| Rate for Payer: Cash Price |
$2,344.20
|
| Rate for Payer: Cigna Commercial |
$7,188.88
|
| Rate for Payer: Health EOS Commercial |
$6,954.46
|
| Rate for Payer: HFN Commercial |
$7,188.88
|
| Rate for Payer: Multiplan Commercial |
$6,251.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,688.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,188.88
|
| Rate for Payer: Quartz Beloit One Network |
$3,828.86
|
| Rate for Payer: Quartz Commercial |
$4,688.40
|
| Rate for Payer: WEA Trust Commercial |
$4,297.70
|
| Rate for Payer: WPS Commercial |
$5,787.83
|
|
|
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 |
$2,819.04 |
| Max. Negotiated Rate |
$40,272.00 |
| Rate for Payer: Aetna Commercial |
$9,061.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,658.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,819.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,544.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,034.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,832.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,336.04
|
| Rate for Payer: Cash Price |
$3,020.40
|
| Rate for Payer: Cigna Commercial |
$9,262.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,634.05
|
| Rate for Payer: Health EOS Commercial |
$8,960.52
|
| Rate for Payer: HFN Commercial |
$9,262.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,551.00
|
| Rate for Payer: Multiplan Commercial |
$8,054.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,040.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,262.56
|
| Rate for Payer: Quartz Beloit One Network |
$4,933.32
|
| Rate for Payer: Quartz Commercial |
$6,544.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,040.80
|
| Rate for Payer: The Alliance Commercial |
$40,272.00
|
| Rate for Payer: WEA Trust Commercial |
$5,537.40
|
| Rate for Payer: WPS Commercial |
$7,457.37
|
|
|
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 |
$4,933.32 |
| Max. Negotiated Rate |
$9,262.56 |
| Rate for Payer: Aetna Commercial |
$9,061.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,658.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,336.04
|
| Rate for Payer: Cash Price |
$3,020.40
|
| Rate for Payer: Cigna Commercial |
$9,262.56
|
| Rate for Payer: Health EOS Commercial |
$8,960.52
|
| Rate for Payer: HFN Commercial |
$9,262.56
|
| Rate for Payer: Multiplan Commercial |
$8,054.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,040.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,262.56
|
| Rate for Payer: Quartz Beloit One Network |
$4,933.32
|
| Rate for Payer: Quartz Commercial |
$6,040.80
|
| Rate for Payer: WEA Trust Commercial |
$5,537.40
|
| Rate for Payer: WPS Commercial |
$7,457.37
|
|
|
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 |
$2,187.92 |
| Max. Negotiated Rate |
$31,256.00 |
| Rate for Payer: Aetna Commercial |
$7,032.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,720.04
|
| Rate for Payer: Aetna Managed Medicare |
$2,187.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,079.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,907.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,750.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,141.42
|
| Rate for Payer: Cash Price |
$2,344.20
|
| Rate for Payer: Cigna Commercial |
$7,188.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,372.71
|
| Rate for Payer: Health EOS Commercial |
$6,954.46
|
| Rate for Payer: HFN Commercial |
$7,188.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,860.50
|
| Rate for Payer: Multiplan Commercial |
$6,251.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,688.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,188.88
|
| Rate for Payer: Quartz Beloit One Network |
$3,828.86
|
| Rate for Payer: Quartz Commercial |
$5,079.10
|
| Rate for Payer: Quartz Medicare Advantage |
$4,688.40
|
| Rate for Payer: The Alliance Commercial |
$31,256.00
|
| Rate for Payer: WEA Trust Commercial |
$4,297.70
|
| Rate for Payer: WPS Commercial |
$5,787.83
|
|
|
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 |
$3,828.86 |
| Max. Negotiated Rate |
$7,188.88 |
| Rate for Payer: Aetna Commercial |
$7,032.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,720.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,141.42
|
| Rate for Payer: Cash Price |
$2,344.20
|
| Rate for Payer: Cigna Commercial |
$7,188.88
|
| Rate for Payer: Health EOS Commercial |
$6,954.46
|
| Rate for Payer: HFN Commercial |
$7,188.88
|
| Rate for Payer: Multiplan Commercial |
$6,251.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,688.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,188.88
|
| Rate for Payer: Quartz Beloit One Network |
$3,828.86
|
| Rate for Payer: Quartz Commercial |
$4,688.40
|
| Rate for Payer: WEA Trust Commercial |
$4,297.70
|
| Rate for Payer: WPS Commercial |
$5,787.83
|
|
|
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 |
$4,990.16 |
| Max. Negotiated Rate |
$9,369.28 |
| Rate for Payer: Aetna Commercial |
$9,165.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,758.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,397.52
|
| Rate for Payer: Cash Price |
$3,055.20
|
| Rate for Payer: Cigna Commercial |
$9,369.28
|
| Rate for Payer: Health EOS Commercial |
$9,063.76
|
| Rate for Payer: HFN Commercial |
$9,369.28
|
| Rate for Payer: Multiplan Commercial |
$8,147.20
|
| Rate for Payer: NAPHCARE Commercial |
$6,110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,369.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,990.16
|
| Rate for Payer: Quartz Commercial |
$6,110.40
|
| Rate for Payer: WEA Trust Commercial |
$5,601.20
|
| Rate for Payer: WPS Commercial |
$7,543.29
|
|
|
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 |
$2,851.52 |
| Max. Negotiated Rate |
$40,736.00 |
| Rate for Payer: Aetna Commercial |
$9,165.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,758.24
|
| Rate for Payer: Aetna Managed Medicare |
$2,851.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,619.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,092.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,888.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,397.52
|
| Rate for Payer: Cash Price |
$3,055.20
|
| Rate for Payer: Cigna Commercial |
$9,369.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,698.97
|
| Rate for Payer: Health EOS Commercial |
$9,063.76
|
| Rate for Payer: HFN Commercial |
$9,369.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,638.00
|
| Rate for Payer: Multiplan Commercial |
$8,147.20
|
| Rate for Payer: NAPHCARE Commercial |
$6,110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,369.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,990.16
|
| Rate for Payer: Quartz Commercial |
$6,619.60
|
| Rate for Payer: Quartz Medicare Advantage |
$6,110.40
|
| Rate for Payer: The Alliance Commercial |
$40,736.00
|
| Rate for Payer: WEA Trust Commercial |
$5,601.20
|
| Rate for Payer: WPS Commercial |
$7,543.29
|
|
|
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 |
$2,146.76 |
| Max. Negotiated Rate |
$30,668.00 |
| Rate for Payer: Aetna Commercial |
$6,900.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,593.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,146.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,983.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,833.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,680.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,063.51
|
| Rate for Payer: Cash Price |
$2,300.10
|
| Rate for Payer: Cigna Commercial |
$7,053.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,290.45
|
| Rate for Payer: Health EOS Commercial |
$6,823.63
|
| Rate for Payer: HFN Commercial |
$7,053.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,750.25
|
| Rate for Payer: Multiplan Commercial |
$6,133.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,600.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,053.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,756.83
|
| Rate for Payer: Quartz Commercial |
$4,983.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4,600.20
|
| Rate for Payer: The Alliance Commercial |
$30,668.00
|
| Rate for Payer: WEA Trust Commercial |
$4,216.85
|
| Rate for Payer: WPS Commercial |
$5,678.95
|
|
|
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 |
$3,756.83 |
| Max. Negotiated Rate |
$7,053.64 |
| Rate for Payer: Aetna Commercial |
$6,900.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,593.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,063.51
|
| Rate for Payer: Cash Price |
$2,300.10
|
| Rate for Payer: Cigna Commercial |
$7,053.64
|
| Rate for Payer: Health EOS Commercial |
$6,823.63
|
| Rate for Payer: HFN Commercial |
$7,053.64
|
| Rate for Payer: Multiplan Commercial |
$6,133.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,600.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,053.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,756.83
|
| Rate for Payer: Quartz Commercial |
$4,600.20
|
| Rate for Payer: WEA Trust Commercial |
$4,216.85
|
| Rate for Payer: WPS Commercial |
$5,678.95
|
|
|
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 |
$1,243.76 |
| Max. Negotiated Rate |
$17,768.00 |
| Rate for Payer: Aetna Commercial |
$3,997.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,820.12
|
| Rate for Payer: Aetna Managed Medicare |
$1,243.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,887.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,221.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,132.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,354.26
|
| Rate for Payer: Cash Price |
$1,332.60
|
| Rate for Payer: Cigna Commercial |
$4,086.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,485.74
|
| Rate for Payer: Health EOS Commercial |
$3,953.38
|
| Rate for Payer: HFN Commercial |
$4,086.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,331.50
|
| Rate for Payer: Multiplan Commercial |
$3,553.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,665.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,086.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,176.58
|
| Rate for Payer: Quartz Commercial |
$2,887.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,665.20
|
| Rate for Payer: The Alliance Commercial |
$17,768.00
|
| Rate for Payer: WEA Trust Commercial |
$2,443.10
|
| Rate for Payer: WPS Commercial |
$3,290.19
|
|
|
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 |
$2,176.58 |
| Max. Negotiated Rate |
$4,086.64 |
| Rate for Payer: Aetna Commercial |
$3,997.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,820.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,354.26
|
| Rate for Payer: Cash Price |
$1,332.60
|
| Rate for Payer: Cigna Commercial |
$4,086.64
|
| Rate for Payer: Health EOS Commercial |
$3,953.38
|
| Rate for Payer: HFN Commercial |
$4,086.64
|
| Rate for Payer: Multiplan Commercial |
$3,553.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,665.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,086.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,176.58
|
| Rate for Payer: Quartz Commercial |
$2,665.20
|
| Rate for Payer: WEA Trust Commercial |
$2,443.10
|
| Rate for Payer: WPS Commercial |
$3,290.19
|
|
|
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 |
$1,471.96 |
| Max. Negotiated Rate |
$21,028.00 |
| Rate for Payer: Aetna Commercial |
$4,731.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,521.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,471.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,417.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,628.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,523.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,786.21
|
| Rate for Payer: Cash Price |
$1,577.10
|
| Rate for Payer: Cigna Commercial |
$4,836.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,941.82
|
| Rate for Payer: Health EOS Commercial |
$4,678.73
|
| Rate for Payer: HFN Commercial |
$4,836.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,942.75
|
| Rate for Payer: Multiplan Commercial |
$4,205.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,154.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,836.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,575.93
|
| Rate for Payer: Quartz Commercial |
$3,417.05
|
| Rate for Payer: Quartz Medicare Advantage |
$3,154.20
|
| Rate for Payer: The Alliance Commercial |
$21,028.00
|
| Rate for Payer: WEA Trust Commercial |
$2,891.35
|
| Rate for Payer: WPS Commercial |
$3,893.86
|
|
|
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 |
$2,575.93 |
| Max. Negotiated Rate |
$4,836.44 |
| Rate for Payer: Aetna Commercial |
$4,731.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,521.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,786.21
|
| Rate for Payer: Cash Price |
$1,577.10
|
| Rate for Payer: Cigna Commercial |
$4,836.44
|
| Rate for Payer: Health EOS Commercial |
$4,678.73
|
| Rate for Payer: HFN Commercial |
$4,836.44
|
| Rate for Payer: Multiplan Commercial |
$4,205.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,154.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,836.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,575.93
|
| Rate for Payer: Quartz Commercial |
$3,154.20
|
| Rate for Payer: WEA Trust Commercial |
$2,891.35
|
| Rate for Payer: WPS Commercial |
$3,893.86
|
|
|
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 |
$2,260.37 |
| Max. Negotiated Rate |
$4,243.96 |
| Rate for Payer: Aetna Commercial |
$4,151.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,967.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,444.89
|
| Rate for Payer: Cash Price |
$1,383.90
|
| Rate for Payer: Cigna Commercial |
$4,243.96
|
| Rate for Payer: Health EOS Commercial |
$4,105.57
|
| Rate for Payer: HFN Commercial |
$4,243.96
|
| Rate for Payer: Multiplan Commercial |
$3,690.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,767.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,243.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,260.37
|
| Rate for Payer: Quartz Commercial |
$2,767.80
|
| Rate for Payer: WEA Trust Commercial |
$2,537.15
|
| Rate for Payer: WPS Commercial |
$3,416.85
|
|
|
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 |
$1,291.64 |
| Max. Negotiated Rate |
$18,452.00 |
| Rate for Payer: Aetna Commercial |
$4,151.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,967.18
|
| Rate for Payer: Aetna Managed Medicare |
$1,291.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,998.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,306.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,214.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,444.89
|
| Rate for Payer: Cash Price |
$1,383.90
|
| Rate for Payer: Cigna Commercial |
$4,243.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,581.43
|
| Rate for Payer: Health EOS Commercial |
$4,105.57
|
| Rate for Payer: HFN Commercial |
$4,243.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,459.75
|
| Rate for Payer: Multiplan Commercial |
$3,690.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,767.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,243.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,260.37
|
| Rate for Payer: Quartz Commercial |
$2,998.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,767.80
|
| Rate for Payer: The Alliance Commercial |
$18,452.00
|
| Rate for Payer: WEA Trust Commercial |
$2,537.15
|
| Rate for Payer: WPS Commercial |
$3,416.85
|
|
|
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 |
$1,372.00 |
| Max. Negotiated Rate |
$19,600.00 |
| Rate for Payer: Aetna Commercial |
$4,410.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,214.00
|
| Rate for Payer: Aetna Managed Medicare |
$1,372.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,185.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,450.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,352.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,597.00
|
| Rate for Payer: Cash Price |
$1,470.00
|
| Rate for Payer: Cigna Commercial |
$4,508.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,742.04
|
| Rate for Payer: Health EOS Commercial |
$4,361.00
|
| Rate for Payer: HFN Commercial |
$4,508.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,675.00
|
| Rate for Payer: Multiplan Commercial |
$3,920.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,940.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,508.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,401.00
|
| Rate for Payer: Quartz Commercial |
$3,185.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,940.00
|
| Rate for Payer: The Alliance Commercial |
$19,600.00
|
| Rate for Payer: WEA Trust Commercial |
$2,695.00
|
| Rate for Payer: WPS Commercial |
$3,629.43
|
|
|
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 |
$2,401.00 |
| Max. Negotiated Rate |
$4,508.00 |
| Rate for Payer: Aetna Commercial |
$4,410.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,214.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,597.00
|
| Rate for Payer: Cash Price |
$1,470.00
|
| Rate for Payer: Cigna Commercial |
$4,508.00
|
| Rate for Payer: Health EOS Commercial |
$4,361.00
|
| Rate for Payer: HFN Commercial |
$4,508.00
|
| Rate for Payer: Multiplan Commercial |
$3,920.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,940.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,508.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,401.00
|
| Rate for Payer: Quartz Commercial |
$2,940.00
|
| Rate for Payer: WEA Trust Commercial |
$2,695.00
|
| Rate for Payer: WPS Commercial |
$3,629.43
|
|
|
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 |
$1,481.76 |
| Max. Negotiated Rate |
$21,168.00 |
| Rate for Payer: Aetna Commercial |
$4,762.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,551.12
|
| Rate for Payer: Aetna Managed Medicare |
$1,481.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,439.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,646.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,540.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,804.76
|
| Rate for Payer: Cash Price |
$1,587.60
|
| Rate for Payer: Cigna Commercial |
$4,868.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,961.40
|
| Rate for Payer: Health EOS Commercial |
$4,709.88
|
| Rate for Payer: HFN Commercial |
$4,868.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,969.00
|
| Rate for Payer: Multiplan Commercial |
$4,233.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,175.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,868.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,593.08
|
| Rate for Payer: Quartz Commercial |
$3,439.80
|
| Rate for Payer: Quartz Medicare Advantage |
$3,175.20
|
| Rate for Payer: The Alliance Commercial |
$21,168.00
|
| Rate for Payer: WEA Trust Commercial |
$2,910.60
|
| Rate for Payer: WPS Commercial |
$3,919.78
|
|
|
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 |
$2,593.08 |
| Max. Negotiated Rate |
$4,868.64 |
| Rate for Payer: Aetna Commercial |
$4,762.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,551.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,804.76
|
| Rate for Payer: Cash Price |
$1,587.60
|
| Rate for Payer: Cigna Commercial |
$4,868.64
|
| Rate for Payer: Health EOS Commercial |
$4,709.88
|
| Rate for Payer: HFN Commercial |
$4,868.64
|
| Rate for Payer: Multiplan Commercial |
$4,233.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,175.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,868.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,593.08
|
| Rate for Payer: Quartz Commercial |
$3,175.20
|
| Rate for Payer: WEA Trust Commercial |
$2,910.60
|
| Rate for Payer: WPS Commercial |
$3,919.78
|
|
|
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 |
$2,260.37 |
| Max. Negotiated Rate |
$4,243.96 |
| Rate for Payer: Aetna Commercial |
$4,151.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,967.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,444.89
|
| Rate for Payer: Cash Price |
$1,383.90
|
| Rate for Payer: Cigna Commercial |
$4,243.96
|
| Rate for Payer: Health EOS Commercial |
$4,105.57
|
| Rate for Payer: HFN Commercial |
$4,243.96
|
| Rate for Payer: Multiplan Commercial |
$3,690.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,767.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,243.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,260.37
|
| Rate for Payer: Quartz Commercial |
$2,767.80
|
| Rate for Payer: WEA Trust Commercial |
$2,537.15
|
| Rate for Payer: WPS Commercial |
$3,416.85
|
|
|
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 |
$1,291.64 |
| Max. Negotiated Rate |
$18,452.00 |
| Rate for Payer: Aetna Commercial |
$4,151.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,967.18
|
| Rate for Payer: Aetna Managed Medicare |
$1,291.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,998.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,306.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,214.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,444.89
|
| Rate for Payer: Cash Price |
$1,383.90
|
| Rate for Payer: Cigna Commercial |
$4,243.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,581.43
|
| Rate for Payer: Health EOS Commercial |
$4,105.57
|
| Rate for Payer: HFN Commercial |
$4,243.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,459.75
|
| Rate for Payer: Multiplan Commercial |
$3,690.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,767.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,243.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,260.37
|
| Rate for Payer: Quartz Commercial |
$2,998.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,767.80
|
| Rate for Payer: The Alliance Commercial |
$18,452.00
|
| Rate for Payer: WEA Trust Commercial |
$2,537.15
|
| Rate for Payer: WPS Commercial |
$3,416.85
|
|
