|
SCREW LOCK LP 3.5 X 16MM BRONZE ORTHOLOC 58813516
|
Facility
|
OP
|
$1,792.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5459799
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$501.76 |
| Max. Negotiated Rate |
$7,168.00 |
| Rate for Payer: Aetna Commercial |
$1,612.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,541.12
|
| Rate for Payer: Aetna Managed Medicare |
$501.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,164.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$896.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$860.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$949.76
|
| Rate for Payer: Cash Price |
$537.60
|
| Rate for Payer: Cigna Commercial |
$1,648.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,002.80
|
| Rate for Payer: Health EOS Commercial |
$1,594.88
|
| Rate for Payer: HFN Commercial |
$1,648.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,344.00
|
| Rate for Payer: Multiplan Commercial |
$1,433.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,075.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,648.64
|
| Rate for Payer: Quartz Beloit One Network |
$878.08
|
| Rate for Payer: Quartz Commercial |
$1,164.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,075.20
|
| Rate for Payer: The Alliance Commercial |
$7,168.00
|
| Rate for Payer: WEA Trust Commercial |
$985.60
|
| Rate for Payer: WPS Commercial |
$1,327.33
|
|
|
SCREW LOCK LP 3.5 X 18MM BRONZE ORTHOLOC 58813518
|
Facility
|
IP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6228132
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$857.99 |
| Max. Negotiated Rate |
$1,610.92 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,050.60
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
SCREW LOCK LP 3.5 X 18MM BRONZE ORTHOLOC 58813518
|
Facility
|
OP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6228132
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.28 |
| Max. Negotiated Rate |
$7,004.00 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Aetna Managed Medicare |
$490.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,138.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$875.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$840.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$979.86
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,313.25
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,138.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,050.60
|
| Rate for Payer: The Alliance Commercial |
$7,004.00
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
SCREW LOCK LP 3.5 X 20MM ORTHOLOC 58813520
|
Facility
|
OP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6185021
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.28 |
| Max. Negotiated Rate |
$7,004.00 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Aetna Managed Medicare |
$490.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,138.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$875.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$840.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$979.86
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,313.25
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,138.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,050.60
|
| Rate for Payer: The Alliance Commercial |
$7,004.00
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
SCREW LOCK LP 3.5 X 20MM ORTHOLOC 58813520
|
Facility
|
IP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6185021
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$857.99 |
| Max. Negotiated Rate |
$1,610.92 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,050.60
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
SCREW LOCK LP 3.5 X 26MM ORTHOLOC 58813526
|
Facility
|
OP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6206973
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.28 |
| Max. Negotiated Rate |
$7,004.00 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Aetna Managed Medicare |
$490.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,138.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$875.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$840.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$979.86
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,313.25
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,138.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,050.60
|
| Rate for Payer: The Alliance Commercial |
$7,004.00
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
SCREW LOCK LP 3.5 X 26MM ORTHOLOC 58813526
|
Facility
|
IP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6206973
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$857.99 |
| Max. Negotiated Rate |
$1,610.92 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,050.60
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
SCREW LOCK LP 3.5 X 28MM BRONZE ORTHOLOC 58813528
|
Facility
|
IP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6228133
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$857.99 |
| Max. Negotiated Rate |
$1,610.92 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,050.60
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
SCREW LOCK LP 3.5 X 28MM BRONZE ORTHOLOC 58813528
|
Facility
|
OP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6228133
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.28 |
| Max. Negotiated Rate |
$7,004.00 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Aetna Managed Medicare |
$490.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,138.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$875.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$840.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$979.86
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,313.25
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,138.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,050.60
|
| Rate for Payer: The Alliance Commercial |
$7,004.00
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
SCREW LOCK LP 3.5 X 30MM BRONZE ORTHOLOC 58813530
|
Facility
|
IP
|
$2,234.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6171780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,094.66 |
| Max. Negotiated Rate |
$2,055.28 |
| Rate for Payer: Aetna Commercial |
$2,010.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,921.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,184.02
|
| Rate for Payer: Cash Price |
$670.20
|
| Rate for Payer: Cigna Commercial |
$2,055.28
|
| Rate for Payer: Health EOS Commercial |
$1,988.26
|
| Rate for Payer: HFN Commercial |
$2,055.28
|
| Rate for Payer: Multiplan Commercial |
$1,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,340.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,055.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,094.66
|
| Rate for Payer: Quartz Commercial |
$1,340.40
|
| Rate for Payer: WEA Trust Commercial |
$1,228.70
|
| Rate for Payer: WPS Commercial |
$1,654.72
|
|
|
SCREW LOCK LP 3.5 X 30MM BRONZE ORTHOLOC 58813530
|
Facility
|
OP
|
$2,234.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6171780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$625.52 |
| Max. Negotiated Rate |
$8,936.00 |
| Rate for Payer: Aetna Commercial |
$2,010.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,921.24
|
| Rate for Payer: Aetna Managed Medicare |
$625.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,452.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,117.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,072.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,184.02
|
| Rate for Payer: Cash Price |
$670.20
|
| Rate for Payer: Cigna Commercial |
$2,055.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,250.15
|
| Rate for Payer: Health EOS Commercial |
$1,988.26
|
| Rate for Payer: HFN Commercial |
$2,055.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,675.50
|
| Rate for Payer: Multiplan Commercial |
$1,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,340.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,055.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,094.66
|
| Rate for Payer: Quartz Commercial |
$1,452.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,340.40
|
| Rate for Payer: The Alliance Commercial |
$8,936.00
|
| Rate for Payer: WEA Trust Commercial |
$1,228.70
|
| Rate for Payer: WPS Commercial |
$1,654.72
|
|
|
SCREW LOCK LP 3.5 X 48MM BRONZE ORTHOLOC 58813548
|
Facility
|
OP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6228142
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.28 |
| Max. Negotiated Rate |
$7,004.00 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Aetna Managed Medicare |
$490.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,138.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$875.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$840.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$979.86
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,313.25
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,138.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,050.60
|
| Rate for Payer: The Alliance Commercial |
$7,004.00
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
SCREW LOCK LP 3.5 X 48MM BRONZE ORTHOLOC 58813548
|
Facility
|
IP
|
$1,751.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6228142
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$857.99 |
| Max. Negotiated Rate |
$1,610.92 |
| Rate for Payer: Aetna Commercial |
$1,575.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$928.03
|
| Rate for Payer: Cash Price |
$525.30
|
| Rate for Payer: Cigna Commercial |
$1,610.92
|
| Rate for Payer: Health EOS Commercial |
$1,558.39
|
| Rate for Payer: HFN Commercial |
$1,610.92
|
| Rate for Payer: Multiplan Commercial |
$1,400.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.92
|
| Rate for Payer: Quartz Beloit One Network |
$857.99
|
| Rate for Payer: Quartz Commercial |
$1,050.60
|
| Rate for Payer: WEA Trust Commercial |
$963.05
|
| Rate for Payer: WPS Commercial |
$1,296.97
|
|
|
SCREW LOCK MATRIX MANDIBLE 2.0 X 12MM 04.503.612.01
|
Facility
|
IP
|
$2,308.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6192960
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,130.92 |
| Max. Negotiated Rate |
$2,123.36 |
| Rate for Payer: Aetna Commercial |
$2,077.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,984.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,223.24
|
| Rate for Payer: Cash Price |
$692.40
|
| Rate for Payer: Cigna Commercial |
$2,123.36
|
| Rate for Payer: Health EOS Commercial |
$2,054.12
|
| Rate for Payer: HFN Commercial |
$2,123.36
|
| Rate for Payer: Multiplan Commercial |
$1,846.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,384.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,123.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,130.92
|
| Rate for Payer: Quartz Commercial |
$1,384.80
|
| Rate for Payer: WEA Trust Commercial |
$1,269.40
|
| Rate for Payer: WPS Commercial |
$1,709.54
|
|
|
SCREW LOCK MATRIX MANDIBLE 2.0 X 12MM 04.503.612.01
|
Facility
|
OP
|
$2,308.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6192960
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$646.24 |
| Max. Negotiated Rate |
$9,232.00 |
| Rate for Payer: Aetna Commercial |
$2,077.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,984.88
|
| Rate for Payer: Aetna Managed Medicare |
$646.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,500.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,154.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,107.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,223.24
|
| Rate for Payer: Cash Price |
$692.40
|
| Rate for Payer: Cigna Commercial |
$2,123.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,291.56
|
| Rate for Payer: Health EOS Commercial |
$2,054.12
|
| Rate for Payer: HFN Commercial |
$2,123.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,731.00
|
| Rate for Payer: Multiplan Commercial |
$1,846.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,384.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,123.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,130.92
|
| Rate for Payer: Quartz Commercial |
$1,500.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,384.80
|
| Rate for Payer: The Alliance Commercial |
$9,232.00
|
| Rate for Payer: WEA Trust Commercial |
$1,269.40
|
| Rate for Payer: WPS Commercial |
$1,709.54
|
|
|
SCREW LOCK MATRIX MANDIBLE 2.0 X 14MM 04.503.614.01
|
Facility
|
IP
|
$2,308.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6192961
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,130.92 |
| Max. Negotiated Rate |
$2,123.36 |
| Rate for Payer: Aetna Commercial |
$2,077.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,984.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,223.24
|
| Rate for Payer: Cash Price |
$692.40
|
| Rate for Payer: Cigna Commercial |
$2,123.36
|
| Rate for Payer: Health EOS Commercial |
$2,054.12
|
| Rate for Payer: HFN Commercial |
$2,123.36
|
| Rate for Payer: Multiplan Commercial |
$1,846.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,384.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,123.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,130.92
|
| Rate for Payer: Quartz Commercial |
$1,384.80
|
| Rate for Payer: WEA Trust Commercial |
$1,269.40
|
| Rate for Payer: WPS Commercial |
$1,709.54
|
|
|
SCREW LOCK MATRIX MANDIBLE 2.0 X 14MM 04.503.614.01
|
Facility
|
OP
|
$2,308.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6192961
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$646.24 |
| Max. Negotiated Rate |
$9,232.00 |
| Rate for Payer: Aetna Commercial |
$2,077.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,984.88
|
| Rate for Payer: Aetna Managed Medicare |
$646.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,500.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,154.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,107.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,223.24
|
| Rate for Payer: Cash Price |
$692.40
|
| Rate for Payer: Cigna Commercial |
$2,123.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,291.56
|
| Rate for Payer: Health EOS Commercial |
$2,054.12
|
| Rate for Payer: HFN Commercial |
$2,123.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,731.00
|
| Rate for Payer: Multiplan Commercial |
$1,846.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,384.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,123.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,130.92
|
| Rate for Payer: Quartz Commercial |
$1,500.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,384.80
|
| Rate for Payer: The Alliance Commercial |
$9,232.00
|
| Rate for Payer: WEA Trust Commercial |
$1,269.40
|
| Rate for Payer: WPS Commercial |
$1,709.54
|
|
|
SCREW LOCK MATRIX MANDIBLE 2.0 X 6MM 04.503.606.01
|
Facility
|
IP
|
$2,222.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6172584
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,088.78 |
| Max. Negotiated Rate |
$2,044.24 |
| Rate for Payer: Aetna Commercial |
$1,999.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,910.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,177.66
|
| Rate for Payer: Cash Price |
$666.60
|
| Rate for Payer: Cigna Commercial |
$2,044.24
|
| Rate for Payer: Health EOS Commercial |
$1,977.58
|
| Rate for Payer: HFN Commercial |
$2,044.24
|
| Rate for Payer: Multiplan Commercial |
$1,777.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,333.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,044.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,088.78
|
| Rate for Payer: Quartz Commercial |
$1,333.20
|
| Rate for Payer: WEA Trust Commercial |
$1,222.10
|
| Rate for Payer: WPS Commercial |
$1,645.84
|
|
|
SCREW LOCK MATRIX MANDIBLE 2.0 X 6MM 04.503.606.01
|
Facility
|
OP
|
$2,222.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6172584
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$622.16 |
| Max. Negotiated Rate |
$8,888.00 |
| Rate for Payer: Aetna Commercial |
$1,999.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,910.92
|
| Rate for Payer: Aetna Managed Medicare |
$622.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,444.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,111.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,066.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,177.66
|
| Rate for Payer: Cash Price |
$666.60
|
| Rate for Payer: Cigna Commercial |
$2,044.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,243.43
|
| Rate for Payer: Health EOS Commercial |
$1,977.58
|
| Rate for Payer: HFN Commercial |
$2,044.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,666.50
|
| Rate for Payer: Multiplan Commercial |
$1,777.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,333.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,044.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,088.78
|
| Rate for Payer: Quartz Commercial |
$1,444.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,333.20
|
| Rate for Payer: The Alliance Commercial |
$8,888.00
|
| Rate for Payer: WEA Trust Commercial |
$1,222.10
|
| Rate for Payer: WPS Commercial |
$1,645.84
|
|
|
SCREW LOCK MATRIX MANDIBLE 2.4 X 10MM 04.503.640.01
|
Facility
|
IP
|
$2,598.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831666
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,273.02 |
| Max. Negotiated Rate |
$2,390.16 |
| Rate for Payer: Aetna Commercial |
$2,338.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,234.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,376.94
|
| Rate for Payer: Cash Price |
$779.40
|
| Rate for Payer: Cigna Commercial |
$2,390.16
|
| Rate for Payer: Health EOS Commercial |
$2,312.22
|
| Rate for Payer: HFN Commercial |
$2,390.16
|
| Rate for Payer: Multiplan Commercial |
$2,078.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,558.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,390.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,273.02
|
| Rate for Payer: Quartz Commercial |
$1,558.80
|
| Rate for Payer: WEA Trust Commercial |
$1,428.90
|
| Rate for Payer: WPS Commercial |
$1,924.34
|
|
|
SCREW LOCK MATRIX MANDIBLE 2.4 X 10MM 04.503.640.01
|
Facility
|
OP
|
$2,598.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831666
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$727.44 |
| Max. Negotiated Rate |
$10,392.00 |
| Rate for Payer: Aetna Commercial |
$2,338.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,234.28
|
| Rate for Payer: Aetna Managed Medicare |
$727.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,688.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,299.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,247.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,376.94
|
| Rate for Payer: Cash Price |
$779.40
|
| Rate for Payer: Cigna Commercial |
$2,390.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,453.84
|
| Rate for Payer: Health EOS Commercial |
$2,312.22
|
| Rate for Payer: HFN Commercial |
$2,390.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,948.50
|
| Rate for Payer: Multiplan Commercial |
$2,078.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,558.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,390.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,273.02
|
| Rate for Payer: Quartz Commercial |
$1,688.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,558.80
|
| Rate for Payer: The Alliance Commercial |
$10,392.00
|
| Rate for Payer: WEA Trust Commercial |
$1,428.90
|
| Rate for Payer: WPS Commercial |
$1,924.34
|
|
|
SCREW LOCK MATRIX MANDIBLE 2.4 X 12MM 04.503.642.01
|
Facility
|
IP
|
$2,598.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831667
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,273.02 |
| Max. Negotiated Rate |
$2,390.16 |
| Rate for Payer: Aetna Commercial |
$2,338.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,234.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,376.94
|
| Rate for Payer: Cash Price |
$779.40
|
| Rate for Payer: Cigna Commercial |
$2,390.16
|
| Rate for Payer: Health EOS Commercial |
$2,312.22
|
| Rate for Payer: HFN Commercial |
$2,390.16
|
| Rate for Payer: Multiplan Commercial |
$2,078.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,558.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,390.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,273.02
|
| Rate for Payer: Quartz Commercial |
$1,558.80
|
| Rate for Payer: WEA Trust Commercial |
$1,428.90
|
| Rate for Payer: WPS Commercial |
$1,924.34
|
|
|
SCREW LOCK MATRIX MANDIBLE 2.4 X 12MM 04.503.642.01
|
Facility
|
OP
|
$2,598.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831667
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$727.44 |
| Max. Negotiated Rate |
$10,392.00 |
| Rate for Payer: Aetna Commercial |
$2,338.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,234.28
|
| Rate for Payer: Aetna Managed Medicare |
$727.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,688.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,299.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,247.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,376.94
|
| Rate for Payer: Cash Price |
$779.40
|
| Rate for Payer: Cigna Commercial |
$2,390.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,453.84
|
| Rate for Payer: Health EOS Commercial |
$2,312.22
|
| Rate for Payer: HFN Commercial |
$2,390.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,948.50
|
| Rate for Payer: Multiplan Commercial |
$2,078.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,558.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,390.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,273.02
|
| Rate for Payer: Quartz Commercial |
$1,688.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,558.80
|
| Rate for Payer: The Alliance Commercial |
$10,392.00
|
| Rate for Payer: WEA Trust Commercial |
$1,428.90
|
| Rate for Payer: WPS Commercial |
$1,924.34
|
|
|
SCREW LOCK MATRIX MANDIBLE 2.4 X 14MM 04.503.644.01
|
Facility
|
OP
|
$2,598.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$727.44 |
| Max. Negotiated Rate |
$10,392.00 |
| Rate for Payer: Aetna Commercial |
$2,338.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,234.28
|
| Rate for Payer: Aetna Managed Medicare |
$727.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,688.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,299.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,247.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,376.94
|
| Rate for Payer: Cash Price |
$779.40
|
| Rate for Payer: Cigna Commercial |
$2,390.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,453.84
|
| Rate for Payer: Health EOS Commercial |
$2,312.22
|
| Rate for Payer: HFN Commercial |
$2,390.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,948.50
|
| Rate for Payer: Multiplan Commercial |
$2,078.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,558.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,390.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,273.02
|
| Rate for Payer: Quartz Commercial |
$1,688.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,558.80
|
| Rate for Payer: The Alliance Commercial |
$10,392.00
|
| Rate for Payer: WEA Trust Commercial |
$1,428.90
|
| Rate for Payer: WPS Commercial |
$1,924.34
|
|
|
SCREW LOCK MATRIX MANDIBLE 2.4 X 14MM 04.503.644.01
|
Facility
|
IP
|
$2,598.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,273.02 |
| Max. Negotiated Rate |
$2,390.16 |
| Rate for Payer: Aetna Commercial |
$2,338.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,234.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,376.94
|
| Rate for Payer: Cash Price |
$779.40
|
| Rate for Payer: Cigna Commercial |
$2,390.16
|
| Rate for Payer: Health EOS Commercial |
$2,312.22
|
| Rate for Payer: HFN Commercial |
$2,390.16
|
| Rate for Payer: Multiplan Commercial |
$2,078.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,558.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,390.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,273.02
|
| Rate for Payer: Quartz Commercial |
$1,558.80
|
| Rate for Payer: WEA Trust Commercial |
$1,428.90
|
| Rate for Payer: WPS Commercial |
$1,924.34
|
|
