|
SCREW MALL 4.5 X 50 215.050
|
Facility
|
IP
|
$262.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2967322
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$133.52 |
| Max. Negotiated Rate |
$250.68 |
| Rate for Payer: Aetna Commercial |
$245.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$234.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.41
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$250.68
|
| Rate for Payer: Health EOS Commercial |
$242.51
|
| Rate for Payer: HFN Commercial |
$250.68
|
| Rate for Payer: Multiplan Commercial |
$217.98
|
| Rate for Payer: Preferred Network Access Commercial |
$250.68
|
| Rate for Payer: Quartz Beloit One Network |
$133.52
|
| Rate for Payer: Quartz Commercial |
$163.49
|
| Rate for Payer: WEA Trust Commercial |
$149.86
|
| Rate for Payer: WPS Commercial |
$201.82
|
|
|
SCREW MALL 4.5 X 55 215.055
|
Facility
|
IP
|
$262.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2967323
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$133.52 |
| Max. Negotiated Rate |
$250.68 |
| Rate for Payer: Aetna Commercial |
$245.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$234.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.41
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$250.68
|
| Rate for Payer: Health EOS Commercial |
$242.51
|
| Rate for Payer: HFN Commercial |
$250.68
|
| Rate for Payer: Multiplan Commercial |
$217.98
|
| Rate for Payer: Preferred Network Access Commercial |
$250.68
|
| Rate for Payer: Quartz Beloit One Network |
$133.52
|
| Rate for Payer: Quartz Commercial |
$163.49
|
| Rate for Payer: WEA Trust Commercial |
$149.86
|
| Rate for Payer: WPS Commercial |
$201.82
|
|
|
SCREW MALL 4.5 X 55 215.055
|
Facility
|
OP
|
$262.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2967323
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$76.29 |
| Max. Negotiated Rate |
$250.68 |
| Rate for Payer: Aetna Commercial |
$245.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$234.33
|
| Rate for Payer: Aetna Managed Medicare |
$76.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$177.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$136.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.41
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$250.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.48
|
| Rate for Payer: Health EOS Commercial |
$242.51
|
| Rate for Payer: HFN Commercial |
$250.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$204.36
|
| Rate for Payer: Multiplan Commercial |
$217.98
|
| Rate for Payer: NAPHCARE Commercial |
$163.49
|
| Rate for Payer: Preferred Network Access Commercial |
$250.68
|
| Rate for Payer: Quartz Beloit One Network |
$133.52
|
| Rate for Payer: Quartz Commercial |
$177.11
|
| Rate for Payer: Quartz Medicare Advantage |
$163.49
|
| Rate for Payer: The Alliance Commercial |
$136.24
|
| Rate for Payer: WEA Trust Commercial |
$149.86
|
| Rate for Payer: WPS Commercial |
$201.82
|
|
|
SCREW MALL 4.5 X 60 215.060
|
Facility
|
OP
|
$262.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2967324
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$76.29 |
| Max. Negotiated Rate |
$250.68 |
| Rate for Payer: Aetna Commercial |
$245.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$234.33
|
| Rate for Payer: Aetna Managed Medicare |
$76.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$177.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$136.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.41
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$250.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.48
|
| Rate for Payer: Health EOS Commercial |
$242.51
|
| Rate for Payer: HFN Commercial |
$250.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$204.36
|
| Rate for Payer: Multiplan Commercial |
$217.98
|
| Rate for Payer: NAPHCARE Commercial |
$163.49
|
| Rate for Payer: Preferred Network Access Commercial |
$250.68
|
| Rate for Payer: Quartz Beloit One Network |
$133.52
|
| Rate for Payer: Quartz Commercial |
$177.11
|
| Rate for Payer: Quartz Medicare Advantage |
$163.49
|
| Rate for Payer: The Alliance Commercial |
$136.24
|
| Rate for Payer: WEA Trust Commercial |
$149.86
|
| Rate for Payer: WPS Commercial |
$201.82
|
|
|
SCREW MALL 4.5 X 60 215.060
|
Facility
|
IP
|
$262.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2967324
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$133.52 |
| Max. Negotiated Rate |
$250.68 |
| Rate for Payer: Aetna Commercial |
$245.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$234.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.41
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$250.68
|
| Rate for Payer: Health EOS Commercial |
$242.51
|
| Rate for Payer: HFN Commercial |
$250.68
|
| Rate for Payer: Multiplan Commercial |
$217.98
|
| Rate for Payer: Preferred Network Access Commercial |
$250.68
|
| Rate for Payer: Quartz Beloit One Network |
$133.52
|
| Rate for Payer: Quartz Commercial |
$163.49
|
| Rate for Payer: WEA Trust Commercial |
$149.86
|
| Rate for Payer: WPS Commercial |
$201.82
|
|
|
SCREW MALL 4.5 X 65 215.065
|
Facility
|
OP
|
$262.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2967325
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$76.29 |
| Max. Negotiated Rate |
$250.68 |
| Rate for Payer: Aetna Commercial |
$245.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$234.33
|
| Rate for Payer: Aetna Managed Medicare |
$76.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$177.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$136.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.41
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$250.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.48
|
| Rate for Payer: Health EOS Commercial |
$242.51
|
| Rate for Payer: HFN Commercial |
$250.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$204.36
|
| Rate for Payer: Multiplan Commercial |
$217.98
|
| Rate for Payer: NAPHCARE Commercial |
$163.49
|
| Rate for Payer: Preferred Network Access Commercial |
$250.68
|
| Rate for Payer: Quartz Beloit One Network |
$133.52
|
| Rate for Payer: Quartz Commercial |
$177.11
|
| Rate for Payer: Quartz Medicare Advantage |
$163.49
|
| Rate for Payer: The Alliance Commercial |
$136.24
|
| Rate for Payer: WEA Trust Commercial |
$149.86
|
| Rate for Payer: WPS Commercial |
$201.82
|
|
|
SCREW MALL 4.5 X 65 215.065
|
Facility
|
IP
|
$262.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2967325
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$133.52 |
| Max. Negotiated Rate |
$250.68 |
| Rate for Payer: Aetna Commercial |
$245.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$234.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.41
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$250.68
|
| Rate for Payer: Health EOS Commercial |
$242.51
|
| Rate for Payer: HFN Commercial |
$250.68
|
| Rate for Payer: Multiplan Commercial |
$217.98
|
| Rate for Payer: Preferred Network Access Commercial |
$250.68
|
| Rate for Payer: Quartz Beloit One Network |
$133.52
|
| Rate for Payer: Quartz Commercial |
$163.49
|
| Rate for Payer: WEA Trust Commercial |
$149.86
|
| Rate for Payer: WPS Commercial |
$201.82
|
|
|
SCREW MALL 4.5 X 70 215.070
|
Facility
|
OP
|
$262.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2967326
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$76.29 |
| Max. Negotiated Rate |
$250.68 |
| Rate for Payer: Aetna Commercial |
$245.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$234.33
|
| Rate for Payer: Aetna Managed Medicare |
$76.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$177.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$136.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.41
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$250.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.48
|
| Rate for Payer: Health EOS Commercial |
$242.51
|
| Rate for Payer: HFN Commercial |
$250.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$204.36
|
| Rate for Payer: Multiplan Commercial |
$217.98
|
| Rate for Payer: NAPHCARE Commercial |
$163.49
|
| Rate for Payer: Preferred Network Access Commercial |
$250.68
|
| Rate for Payer: Quartz Beloit One Network |
$133.52
|
| Rate for Payer: Quartz Commercial |
$177.11
|
| Rate for Payer: Quartz Medicare Advantage |
$163.49
|
| Rate for Payer: The Alliance Commercial |
$136.24
|
| Rate for Payer: WEA Trust Commercial |
$149.86
|
| Rate for Payer: WPS Commercial |
$201.82
|
|
|
SCREW MALL 4.5 X 70 215.070
|
Facility
|
IP
|
$262.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2967326
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$133.52 |
| Max. Negotiated Rate |
$250.68 |
| Rate for Payer: Aetna Commercial |
$245.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$234.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.41
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$250.68
|
| Rate for Payer: Health EOS Commercial |
$242.51
|
| Rate for Payer: HFN Commercial |
$250.68
|
| Rate for Payer: Multiplan Commercial |
$217.98
|
| Rate for Payer: Preferred Network Access Commercial |
$250.68
|
| Rate for Payer: Quartz Beloit One Network |
$133.52
|
| Rate for Payer: Quartz Commercial |
$163.49
|
| Rate for Payer: WEA Trust Commercial |
$149.86
|
| Rate for Payer: WPS Commercial |
$201.82
|
|
|
SCREW MATRIX EMERGENCY MANDIBLE 2.7 X 6MM 04.503.466.01
|
Facility
|
IP
|
$2,202.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831669
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,122.14 |
| Max. Negotiated Rate |
$2,106.87 |
| Rate for Payer: Aetna Commercial |
$2,061.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,969.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,213.74
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,106.87
|
| Rate for Payer: Health EOS Commercial |
$2,038.17
|
| Rate for Payer: HFN Commercial |
$2,106.87
|
| Rate for Payer: Multiplan Commercial |
$1,832.06
|
| Rate for Payer: Preferred Network Access Commercial |
$2,106.87
|
| Rate for Payer: Quartz Beloit One Network |
$1,122.14
|
| Rate for Payer: Quartz Commercial |
$1,374.05
|
| Rate for Payer: WEA Trust Commercial |
$1,259.54
|
| Rate for Payer: WPS Commercial |
$1,696.20
|
|
|
SCREW MATRIX EMERGENCY MANDIBLE 2.7 X 6MM 04.503.466.01
|
Facility
|
OP
|
$2,202.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831669
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$641.22 |
| Max. Negotiated Rate |
$2,106.87 |
| Rate for Payer: Aetna Commercial |
$2,061.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,969.47
|
| Rate for Payer: Aetna Managed Medicare |
$641.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,488.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,145.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,099.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,213.74
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,106.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,281.56
|
| Rate for Payer: Health EOS Commercial |
$2,038.17
|
| Rate for Payer: HFN Commercial |
$2,106.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,717.56
|
| Rate for Payer: Multiplan Commercial |
$1,832.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,374.05
|
| Rate for Payer: Preferred Network Access Commercial |
$2,106.87
|
| Rate for Payer: Quartz Beloit One Network |
$1,122.14
|
| Rate for Payer: Quartz Commercial |
$1,488.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,374.05
|
| Rate for Payer: The Alliance Commercial |
$1,145.04
|
| Rate for Payer: WEA Trust Commercial |
$1,259.54
|
| Rate for Payer: WPS Commercial |
$1,696.20
|
|
|
SCREW MATRIX EMERGENCY MIDFACE 4MM 04.503.234.01
|
Facility
|
IP
|
$884.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5349486
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$450.49 |
| Max. Negotiated Rate |
$845.81 |
| Rate for Payer: Aetna Commercial |
$827.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$790.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$487.26
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cigna Commercial |
$845.81
|
| Rate for Payer: Health EOS Commercial |
$818.23
|
| Rate for Payer: HFN Commercial |
$845.81
|
| Rate for Payer: Multiplan Commercial |
$735.49
|
| Rate for Payer: Preferred Network Access Commercial |
$845.81
|
| Rate for Payer: Quartz Beloit One Network |
$450.49
|
| Rate for Payer: Quartz Commercial |
$551.62
|
| Rate for Payer: WEA Trust Commercial |
$505.65
|
| Rate for Payer: WPS Commercial |
$680.95
|
|
|
SCREW MATRIX EMERGENCY MIDFACE 4MM 04.503.234.01
|
Facility
|
OP
|
$884.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5349486
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$257.42 |
| Max. Negotiated Rate |
$845.81 |
| Rate for Payer: Aetna Commercial |
$827.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$790.65
|
| Rate for Payer: Aetna Managed Medicare |
$257.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$597.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$459.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$441.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$487.26
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cigna Commercial |
$845.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$514.49
|
| Rate for Payer: Health EOS Commercial |
$818.23
|
| Rate for Payer: HFN Commercial |
$845.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$689.52
|
| Rate for Payer: Multiplan Commercial |
$735.49
|
| Rate for Payer: NAPHCARE Commercial |
$551.62
|
| Rate for Payer: Preferred Network Access Commercial |
$845.81
|
| Rate for Payer: Quartz Beloit One Network |
$450.49
|
| Rate for Payer: Quartz Commercial |
$597.58
|
| Rate for Payer: Quartz Medicare Advantage |
$551.62
|
| Rate for Payer: The Alliance Commercial |
$459.68
|
| Rate for Payer: WEA Trust Commercial |
$505.65
|
| Rate for Payer: WPS Commercial |
$680.95
|
|
|
SCREW MATRIX MANDIBLE 2.0 X 10MM 04.503.410.01
|
Facility
|
OP
|
$1,408.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831664
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$410.01 |
| Max. Negotiated Rate |
$1,347.17 |
| Rate for Payer: Aetna Commercial |
$1,317.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,259.32
|
| Rate for Payer: Aetna Managed Medicare |
$410.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$951.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$732.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$702.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$776.09
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,347.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$819.46
|
| Rate for Payer: Health EOS Commercial |
$1,303.24
|
| Rate for Payer: HFN Commercial |
$1,347.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,098.24
|
| Rate for Payer: Multiplan Commercial |
$1,171.46
|
| Rate for Payer: NAPHCARE Commercial |
$878.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,347.17
|
| Rate for Payer: Quartz Beloit One Network |
$717.52
|
| Rate for Payer: Quartz Commercial |
$951.81
|
| Rate for Payer: Quartz Medicare Advantage |
$878.59
|
| Rate for Payer: The Alliance Commercial |
$732.16
|
| Rate for Payer: WEA Trust Commercial |
$805.38
|
| Rate for Payer: WPS Commercial |
$1,084.58
|
|
|
SCREW MATRIX MANDIBLE 2.0 X 10MM 04.503.410.01
|
Facility
|
IP
|
$1,408.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831664
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$717.52 |
| Max. Negotiated Rate |
$1,347.17 |
| Rate for Payer: Aetna Commercial |
$1,317.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,259.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$776.09
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,347.17
|
| Rate for Payer: Health EOS Commercial |
$1,303.24
|
| Rate for Payer: HFN Commercial |
$1,347.17
|
| Rate for Payer: Multiplan Commercial |
$1,171.46
|
| Rate for Payer: Preferred Network Access Commercial |
$1,347.17
|
| Rate for Payer: Quartz Beloit One Network |
$717.52
|
| Rate for Payer: Quartz Commercial |
$878.59
|
| Rate for Payer: WEA Trust Commercial |
$805.38
|
| Rate for Payer: WPS Commercial |
$1,084.58
|
|
|
SCREW MATRIX MANDIBLE 2.0 X 14MM 04.503.414.01
|
Facility
|
IP
|
$1,408.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$717.52 |
| Max. Negotiated Rate |
$1,347.17 |
| Rate for Payer: Aetna Commercial |
$1,317.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,259.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$776.09
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,347.17
|
| Rate for Payer: Health EOS Commercial |
$1,303.24
|
| Rate for Payer: HFN Commercial |
$1,347.17
|
| Rate for Payer: Multiplan Commercial |
$1,171.46
|
| Rate for Payer: Preferred Network Access Commercial |
$1,347.17
|
| Rate for Payer: Quartz Beloit One Network |
$717.52
|
| Rate for Payer: Quartz Commercial |
$878.59
|
| Rate for Payer: WEA Trust Commercial |
$805.38
|
| Rate for Payer: WPS Commercial |
$1,084.58
|
|
|
SCREW MATRIX MANDIBLE 2.0 X 14MM 04.503.414.01
|
Facility
|
OP
|
$1,408.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$410.01 |
| Max. Negotiated Rate |
$1,347.17 |
| Rate for Payer: Aetna Commercial |
$1,317.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,259.32
|
| Rate for Payer: Aetna Managed Medicare |
$410.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$951.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$732.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$702.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$776.09
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,347.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$819.46
|
| Rate for Payer: Health EOS Commercial |
$1,303.24
|
| Rate for Payer: HFN Commercial |
$1,347.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,098.24
|
| Rate for Payer: Multiplan Commercial |
$1,171.46
|
| Rate for Payer: NAPHCARE Commercial |
$878.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,347.17
|
| Rate for Payer: Quartz Beloit One Network |
$717.52
|
| Rate for Payer: Quartz Commercial |
$951.81
|
| Rate for Payer: Quartz Medicare Advantage |
$878.59
|
| Rate for Payer: The Alliance Commercial |
$732.16
|
| Rate for Payer: WEA Trust Commercial |
$805.38
|
| Rate for Payer: WPS Commercial |
$1,084.58
|
|
|
SCREW MATRIX MANDIBLE 2.0 X 5MM 04.503.405.01
|
Facility
|
OP
|
$1,408.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4038106
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$410.01 |
| Max. Negotiated Rate |
$1,347.17 |
| Rate for Payer: Aetna Commercial |
$1,317.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,259.32
|
| Rate for Payer: Aetna Managed Medicare |
$410.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$951.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$732.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$702.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$776.09
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,347.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$819.46
|
| Rate for Payer: Health EOS Commercial |
$1,303.24
|
| Rate for Payer: HFN Commercial |
$1,347.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,098.24
|
| Rate for Payer: Multiplan Commercial |
$1,171.46
|
| Rate for Payer: NAPHCARE Commercial |
$878.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,347.17
|
| Rate for Payer: Quartz Beloit One Network |
$717.52
|
| Rate for Payer: Quartz Commercial |
$951.81
|
| Rate for Payer: Quartz Medicare Advantage |
$878.59
|
| Rate for Payer: The Alliance Commercial |
$732.16
|
| Rate for Payer: WEA Trust Commercial |
$805.38
|
| Rate for Payer: WPS Commercial |
$1,084.58
|
|
|
SCREW MATRIX MANDIBLE 2.0 X 5MM 04.503.405.01
|
Facility
|
IP
|
$1,408.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4038106
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$717.52 |
| Max. Negotiated Rate |
$1,347.17 |
| Rate for Payer: Aetna Commercial |
$1,317.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,259.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$776.09
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,347.17
|
| Rate for Payer: Health EOS Commercial |
$1,303.24
|
| Rate for Payer: HFN Commercial |
$1,347.17
|
| Rate for Payer: Multiplan Commercial |
$1,171.46
|
| Rate for Payer: Preferred Network Access Commercial |
$1,347.17
|
| Rate for Payer: Quartz Beloit One Network |
$717.52
|
| Rate for Payer: Quartz Commercial |
$878.59
|
| Rate for Payer: WEA Trust Commercial |
$805.38
|
| Rate for Payer: WPS Commercial |
$1,084.58
|
|
|
SCREW MATRIX MANDIBLE 2.0 X 6MM 04.503.406.01
|
Facility
|
OP
|
$1,408.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4038107
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$410.01 |
| Max. Negotiated Rate |
$1,347.17 |
| Rate for Payer: Aetna Commercial |
$1,317.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,259.32
|
| Rate for Payer: Aetna Managed Medicare |
$410.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$951.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$732.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$702.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$776.09
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,347.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$819.46
|
| Rate for Payer: Health EOS Commercial |
$1,303.24
|
| Rate for Payer: HFN Commercial |
$1,347.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,098.24
|
| Rate for Payer: Multiplan Commercial |
$1,171.46
|
| Rate for Payer: NAPHCARE Commercial |
$878.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,347.17
|
| Rate for Payer: Quartz Beloit One Network |
$717.52
|
| Rate for Payer: Quartz Commercial |
$951.81
|
| Rate for Payer: Quartz Medicare Advantage |
$878.59
|
| Rate for Payer: The Alliance Commercial |
$732.16
|
| Rate for Payer: WEA Trust Commercial |
$805.38
|
| Rate for Payer: WPS Commercial |
$1,084.58
|
|
|
SCREW MATRIX MANDIBLE 2.0 X 6MM 04.503.406.01
|
Facility
|
IP
|
$1,408.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4038107
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$717.52 |
| Max. Negotiated Rate |
$1,347.17 |
| Rate for Payer: Aetna Commercial |
$1,317.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,259.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$776.09
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,347.17
|
| Rate for Payer: Health EOS Commercial |
$1,303.24
|
| Rate for Payer: HFN Commercial |
$1,347.17
|
| Rate for Payer: Multiplan Commercial |
$1,171.46
|
| Rate for Payer: Preferred Network Access Commercial |
$1,347.17
|
| Rate for Payer: Quartz Beloit One Network |
$717.52
|
| Rate for Payer: Quartz Commercial |
$878.59
|
| Rate for Payer: WEA Trust Commercial |
$805.38
|
| Rate for Payer: WPS Commercial |
$1,084.58
|
|
|
SCREW MATRIX MANDIBLE 2.4 X 6MM 04.503.436.01
|
Facility
|
IP
|
$2,035.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4038108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.04 |
| Max. Negotiated Rate |
$1,947.09 |
| Rate for Payer: Aetna Commercial |
$1,904.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,820.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,121.69
|
| Rate for Payer: Cash Price |
$610.50
|
| Rate for Payer: Cigna Commercial |
$1,947.09
|
| Rate for Payer: Health EOS Commercial |
$1,883.60
|
| Rate for Payer: HFN Commercial |
$1,947.09
|
| Rate for Payer: Multiplan Commercial |
$1,693.12
|
| Rate for Payer: Preferred Network Access Commercial |
$1,947.09
|
| Rate for Payer: Quartz Beloit One Network |
$1,037.04
|
| Rate for Payer: Quartz Commercial |
$1,269.84
|
| Rate for Payer: WEA Trust Commercial |
$1,164.02
|
| Rate for Payer: WPS Commercial |
$1,567.56
|
|
|
SCREW MATRIX MANDIBLE 2.4 X 6MM 04.503.436.01
|
Facility
|
OP
|
$2,035.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4038108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$592.59 |
| Max. Negotiated Rate |
$1,947.09 |
| Rate for Payer: Aetna Commercial |
$1,904.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,820.10
|
| Rate for Payer: Aetna Managed Medicare |
$592.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,375.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,058.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,015.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,121.69
|
| Rate for Payer: Cash Price |
$610.50
|
| Rate for Payer: Cigna Commercial |
$1,947.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,184.37
|
| Rate for Payer: Health EOS Commercial |
$1,883.60
|
| Rate for Payer: HFN Commercial |
$1,947.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,587.30
|
| Rate for Payer: Multiplan Commercial |
$1,693.12
|
| Rate for Payer: NAPHCARE Commercial |
$1,269.84
|
| Rate for Payer: Preferred Network Access Commercial |
$1,947.09
|
| Rate for Payer: Quartz Beloit One Network |
$1,037.04
|
| Rate for Payer: Quartz Commercial |
$1,375.66
|
| Rate for Payer: Quartz Medicare Advantage |
$1,269.84
|
| Rate for Payer: The Alliance Commercial |
$1,058.20
|
| Rate for Payer: WEA Trust Commercial |
$1,164.02
|
| Rate for Payer: WPS Commercial |
$1,567.56
|
|
|
SCREW MATRIX MIDFACE 4MM SELF-DRILLING TI 04.503.224.01
|
Facility
|
OP
|
$884.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5264663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$257.42 |
| Max. Negotiated Rate |
$845.81 |
| Rate for Payer: Aetna Commercial |
$827.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$790.65
|
| Rate for Payer: Aetna Managed Medicare |
$257.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$597.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$459.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$441.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$487.26
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cigna Commercial |
$845.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$514.49
|
| Rate for Payer: Health EOS Commercial |
$818.23
|
| Rate for Payer: HFN Commercial |
$845.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$689.52
|
| Rate for Payer: Multiplan Commercial |
$735.49
|
| Rate for Payer: NAPHCARE Commercial |
$551.62
|
| Rate for Payer: Preferred Network Access Commercial |
$845.81
|
| Rate for Payer: Quartz Beloit One Network |
$450.49
|
| Rate for Payer: Quartz Commercial |
$597.58
|
| Rate for Payer: Quartz Medicare Advantage |
$551.62
|
| Rate for Payer: The Alliance Commercial |
$459.68
|
| Rate for Payer: WEA Trust Commercial |
$505.65
|
| Rate for Payer: WPS Commercial |
$680.95
|
|
|
SCREW MATRIX MIDFACE 4MM SELF-DRILLING TI 04.503.224.01
|
Facility
|
IP
|
$884.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5264663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$450.49 |
| Max. Negotiated Rate |
$845.81 |
| Rate for Payer: Aetna Commercial |
$827.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$790.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$487.26
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cigna Commercial |
$845.81
|
| Rate for Payer: Health EOS Commercial |
$818.23
|
| Rate for Payer: HFN Commercial |
$845.81
|
| Rate for Payer: Multiplan Commercial |
$735.49
|
| Rate for Payer: Preferred Network Access Commercial |
$845.81
|
| Rate for Payer: Quartz Beloit One Network |
$450.49
|
| Rate for Payer: Quartz Commercial |
$551.62
|
| Rate for Payer: WEA Trust Commercial |
$505.65
|
| Rate for Payer: WPS Commercial |
$680.95
|
|
