|
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 |
$73.36 |
| Max. Negotiated Rate |
$1,048.00 |
| Rate for Payer: Aetna Commercial |
$235.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$225.32
|
| Rate for Payer: Aetna Managed Medicare |
$73.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$170.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$131.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$125.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.86
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$241.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.62
|
| Rate for Payer: Health EOS Commercial |
$233.18
|
| Rate for Payer: HFN Commercial |
$241.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$196.50
|
| Rate for Payer: Multiplan Commercial |
$209.60
|
| Rate for Payer: NAPHCARE Commercial |
$157.20
|
| Rate for Payer: Preferred Network Access Commercial |
$241.04
|
| Rate for Payer: Quartz Beloit One Network |
$128.38
|
| Rate for Payer: Quartz Commercial |
$170.30
|
| Rate for Payer: Quartz Medicare Advantage |
$157.20
|
| Rate for Payer: The Alliance Commercial |
$1,048.00
|
| Rate for Payer: WEA Trust Commercial |
$144.10
|
| Rate for Payer: WPS Commercial |
$194.06
|
|
|
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 |
$128.38 |
| Max. Negotiated Rate |
$241.04 |
| Rate for Payer: Aetna Commercial |
$235.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$225.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.86
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$241.04
|
| Rate for Payer: Health EOS Commercial |
$233.18
|
| Rate for Payer: HFN Commercial |
$241.04
|
| Rate for Payer: Multiplan Commercial |
$209.60
|
| Rate for Payer: NAPHCARE Commercial |
$157.20
|
| Rate for Payer: Preferred Network Access Commercial |
$241.04
|
| Rate for Payer: Quartz Beloit One Network |
$128.38
|
| Rate for Payer: Quartz Commercial |
$157.20
|
| Rate for Payer: WEA Trust Commercial |
$144.10
|
| Rate for Payer: WPS Commercial |
$194.06
|
|
|
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 |
$73.36 |
| Max. Negotiated Rate |
$1,048.00 |
| Rate for Payer: Aetna Commercial |
$235.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$225.32
|
| Rate for Payer: Aetna Managed Medicare |
$73.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$170.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$131.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$125.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.86
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cigna Commercial |
$241.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.62
|
| Rate for Payer: Health EOS Commercial |
$233.18
|
| Rate for Payer: HFN Commercial |
$241.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$196.50
|
| Rate for Payer: Multiplan Commercial |
$209.60
|
| Rate for Payer: NAPHCARE Commercial |
$157.20
|
| Rate for Payer: Preferred Network Access Commercial |
$241.04
|
| Rate for Payer: Quartz Beloit One Network |
$128.38
|
| Rate for Payer: Quartz Commercial |
$170.30
|
| Rate for Payer: Quartz Medicare Advantage |
$157.20
|
| Rate for Payer: The Alliance Commercial |
$1,048.00
|
| Rate for Payer: WEA Trust Commercial |
$144.10
|
| Rate for Payer: WPS Commercial |
$194.06
|
|
|
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 |
$616.56 |
| Max. Negotiated Rate |
$8,808.00 |
| Rate for Payer: Aetna Commercial |
$1,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,893.72
|
| Rate for Payer: Aetna Managed Medicare |
$616.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,431.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,056.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,167.06
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,025.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,232.24
|
| Rate for Payer: Health EOS Commercial |
$1,959.78
|
| Rate for Payer: HFN Commercial |
$2,025.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,651.50
|
| Rate for Payer: Multiplan Commercial |
$1,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,025.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,078.98
|
| Rate for Payer: Quartz Commercial |
$1,431.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,321.20
|
| Rate for Payer: The Alliance Commercial |
$8,808.00
|
| Rate for Payer: WEA Trust Commercial |
$1,211.10
|
| Rate for Payer: WPS Commercial |
$1,631.02
|
|
|
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 |
$1,078.98 |
| Max. Negotiated Rate |
$2,025.84 |
| Rate for Payer: Aetna Commercial |
$1,981.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,893.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,167.06
|
| Rate for Payer: Cash Price |
$660.60
|
| Rate for Payer: Cigna Commercial |
$2,025.84
|
| Rate for Payer: Health EOS Commercial |
$1,959.78
|
| Rate for Payer: HFN Commercial |
$2,025.84
|
| Rate for Payer: Multiplan Commercial |
$1,761.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,321.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,025.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,078.98
|
| Rate for Payer: Quartz Commercial |
$1,321.20
|
| Rate for Payer: WEA Trust Commercial |
$1,211.10
|
| Rate for Payer: WPS Commercial |
$1,631.02
|
|
|
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 |
$247.52 |
| Max. Negotiated Rate |
$3,536.00 |
| Rate for Payer: Aetna Commercial |
$795.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$760.24
|
| Rate for Payer: Aetna Managed Medicare |
$247.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$574.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$442.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$424.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$468.52
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cigna Commercial |
$813.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$494.69
|
| Rate for Payer: Health EOS Commercial |
$786.76
|
| Rate for Payer: HFN Commercial |
$813.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$663.00
|
| Rate for Payer: Multiplan Commercial |
$707.20
|
| Rate for Payer: NAPHCARE Commercial |
$530.40
|
| Rate for Payer: Preferred Network Access Commercial |
$813.28
|
| Rate for Payer: Quartz Beloit One Network |
$433.16
|
| Rate for Payer: Quartz Commercial |
$574.60
|
| Rate for Payer: Quartz Medicare Advantage |
$530.40
|
| Rate for Payer: The Alliance Commercial |
$3,536.00
|
| Rate for Payer: WEA Trust Commercial |
$486.20
|
| Rate for Payer: WPS Commercial |
$654.78
|
|
|
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 |
$433.16 |
| Max. Negotiated Rate |
$813.28 |
| Rate for Payer: Aetna Commercial |
$795.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$760.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$468.52
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cigna Commercial |
$813.28
|
| Rate for Payer: Health EOS Commercial |
$786.76
|
| Rate for Payer: HFN Commercial |
$813.28
|
| Rate for Payer: Multiplan Commercial |
$707.20
|
| Rate for Payer: NAPHCARE Commercial |
$530.40
|
| Rate for Payer: Preferred Network Access Commercial |
$813.28
|
| Rate for Payer: Quartz Beloit One Network |
$433.16
|
| Rate for Payer: Quartz Commercial |
$530.40
|
| Rate for Payer: WEA Trust Commercial |
$486.20
|
| Rate for Payer: WPS Commercial |
$654.78
|
|
|
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 |
$689.92 |
| Max. Negotiated Rate |
$1,295.36 |
| Rate for Payer: Aetna Commercial |
$1,267.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,210.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$746.24
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,295.36
|
| Rate for Payer: Health EOS Commercial |
$1,253.12
|
| Rate for Payer: HFN Commercial |
$1,295.36
|
| Rate for Payer: Multiplan Commercial |
$1,126.40
|
| Rate for Payer: NAPHCARE Commercial |
$844.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,295.36
|
| Rate for Payer: Quartz Beloit One Network |
$689.92
|
| Rate for Payer: Quartz Commercial |
$844.80
|
| Rate for Payer: WEA Trust Commercial |
$774.40
|
| Rate for Payer: WPS Commercial |
$1,042.91
|
|
|
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 |
$394.24 |
| Max. Negotiated Rate |
$5,632.00 |
| Rate for Payer: Aetna Commercial |
$1,267.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,210.88
|
| Rate for Payer: Aetna Managed Medicare |
$394.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$915.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$675.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$746.24
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,295.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$787.92
|
| Rate for Payer: Health EOS Commercial |
$1,253.12
|
| Rate for Payer: HFN Commercial |
$1,295.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,056.00
|
| Rate for Payer: Multiplan Commercial |
$1,126.40
|
| Rate for Payer: NAPHCARE Commercial |
$844.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,295.36
|
| Rate for Payer: Quartz Beloit One Network |
$689.92
|
| Rate for Payer: Quartz Commercial |
$915.20
|
| Rate for Payer: Quartz Medicare Advantage |
$844.80
|
| Rate for Payer: The Alliance Commercial |
$5,632.00
|
| Rate for Payer: WEA Trust Commercial |
$774.40
|
| Rate for Payer: WPS Commercial |
$1,042.91
|
|
|
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 |
$394.24 |
| Max. Negotiated Rate |
$5,632.00 |
| Rate for Payer: Aetna Commercial |
$1,267.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,210.88
|
| Rate for Payer: Aetna Managed Medicare |
$394.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$915.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$675.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$746.24
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,295.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$787.92
|
| Rate for Payer: Health EOS Commercial |
$1,253.12
|
| Rate for Payer: HFN Commercial |
$1,295.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,056.00
|
| Rate for Payer: Multiplan Commercial |
$1,126.40
|
| Rate for Payer: NAPHCARE Commercial |
$844.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,295.36
|
| Rate for Payer: Quartz Beloit One Network |
$689.92
|
| Rate for Payer: Quartz Commercial |
$915.20
|
| Rate for Payer: Quartz Medicare Advantage |
$844.80
|
| Rate for Payer: The Alliance Commercial |
$5,632.00
|
| Rate for Payer: WEA Trust Commercial |
$774.40
|
| Rate for Payer: WPS Commercial |
$1,042.91
|
|
|
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 |
$689.92 |
| Max. Negotiated Rate |
$1,295.36 |
| Rate for Payer: Aetna Commercial |
$1,267.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,210.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$746.24
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,295.36
|
| Rate for Payer: Health EOS Commercial |
$1,253.12
|
| Rate for Payer: HFN Commercial |
$1,295.36
|
| Rate for Payer: Multiplan Commercial |
$1,126.40
|
| Rate for Payer: NAPHCARE Commercial |
$844.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,295.36
|
| Rate for Payer: Quartz Beloit One Network |
$689.92
|
| Rate for Payer: Quartz Commercial |
$844.80
|
| Rate for Payer: WEA Trust Commercial |
$774.40
|
| Rate for Payer: WPS Commercial |
$1,042.91
|
|
|
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 |
$689.92 |
| Max. Negotiated Rate |
$1,295.36 |
| Rate for Payer: Aetna Commercial |
$1,267.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,210.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$746.24
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,295.36
|
| Rate for Payer: Health EOS Commercial |
$1,253.12
|
| Rate for Payer: HFN Commercial |
$1,295.36
|
| Rate for Payer: Multiplan Commercial |
$1,126.40
|
| Rate for Payer: NAPHCARE Commercial |
$844.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,295.36
|
| Rate for Payer: Quartz Beloit One Network |
$689.92
|
| Rate for Payer: Quartz Commercial |
$844.80
|
| Rate for Payer: WEA Trust Commercial |
$774.40
|
| Rate for Payer: WPS Commercial |
$1,042.91
|
|
|
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 |
$394.24 |
| Max. Negotiated Rate |
$5,632.00 |
| Rate for Payer: Aetna Commercial |
$1,267.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,210.88
|
| Rate for Payer: Aetna Managed Medicare |
$394.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$915.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$675.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$746.24
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,295.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$787.92
|
| Rate for Payer: Health EOS Commercial |
$1,253.12
|
| Rate for Payer: HFN Commercial |
$1,295.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,056.00
|
| Rate for Payer: Multiplan Commercial |
$1,126.40
|
| Rate for Payer: NAPHCARE Commercial |
$844.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,295.36
|
| Rate for Payer: Quartz Beloit One Network |
$689.92
|
| Rate for Payer: Quartz Commercial |
$915.20
|
| Rate for Payer: Quartz Medicare Advantage |
$844.80
|
| Rate for Payer: The Alliance Commercial |
$5,632.00
|
| Rate for Payer: WEA Trust Commercial |
$774.40
|
| Rate for Payer: WPS Commercial |
$1,042.91
|
|
|
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 |
$394.24 |
| Max. Negotiated Rate |
$5,632.00 |
| Rate for Payer: Aetna Commercial |
$1,267.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,210.88
|
| Rate for Payer: Aetna Managed Medicare |
$394.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$915.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$675.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$746.24
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,295.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$787.92
|
| Rate for Payer: Health EOS Commercial |
$1,253.12
|
| Rate for Payer: HFN Commercial |
$1,295.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,056.00
|
| Rate for Payer: Multiplan Commercial |
$1,126.40
|
| Rate for Payer: NAPHCARE Commercial |
$844.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,295.36
|
| Rate for Payer: Quartz Beloit One Network |
$689.92
|
| Rate for Payer: Quartz Commercial |
$915.20
|
| Rate for Payer: Quartz Medicare Advantage |
$844.80
|
| Rate for Payer: The Alliance Commercial |
$5,632.00
|
| Rate for Payer: WEA Trust Commercial |
$774.40
|
| Rate for Payer: WPS Commercial |
$1,042.91
|
|
|
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 |
$689.92 |
| Max. Negotiated Rate |
$1,295.36 |
| Rate for Payer: Aetna Commercial |
$1,267.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,210.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$746.24
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,295.36
|
| Rate for Payer: Health EOS Commercial |
$1,253.12
|
| Rate for Payer: HFN Commercial |
$1,295.36
|
| Rate for Payer: Multiplan Commercial |
$1,126.40
|
| Rate for Payer: NAPHCARE Commercial |
$844.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,295.36
|
| Rate for Payer: Quartz Beloit One Network |
$689.92
|
| Rate for Payer: Quartz Commercial |
$844.80
|
| Rate for Payer: WEA Trust Commercial |
$774.40
|
| Rate for Payer: WPS Commercial |
$1,042.91
|
|
|
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 |
$569.80 |
| Max. Negotiated Rate |
$8,140.00 |
| Rate for Payer: Aetna Commercial |
$1,831.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,750.10
|
| Rate for Payer: Aetna Managed Medicare |
$569.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,322.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,017.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$976.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,078.55
|
| Rate for Payer: Cash Price |
$610.50
|
| Rate for Payer: Cigna Commercial |
$1,872.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,138.79
|
| Rate for Payer: Health EOS Commercial |
$1,811.15
|
| Rate for Payer: HFN Commercial |
$1,872.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,526.25
|
| Rate for Payer: Multiplan Commercial |
$1,628.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,221.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,872.20
|
| Rate for Payer: Quartz Beloit One Network |
$997.15
|
| Rate for Payer: Quartz Commercial |
$1,322.75
|
| Rate for Payer: Quartz Medicare Advantage |
$1,221.00
|
| Rate for Payer: The Alliance Commercial |
$8,140.00
|
| Rate for Payer: WEA Trust Commercial |
$1,119.25
|
| Rate for Payer: WPS Commercial |
$1,507.32
|
|
|
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 |
$997.15 |
| Max. Negotiated Rate |
$1,872.20 |
| Rate for Payer: Aetna Commercial |
$1,831.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,750.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,078.55
|
| Rate for Payer: Cash Price |
$610.50
|
| Rate for Payer: Cigna Commercial |
$1,872.20
|
| Rate for Payer: Health EOS Commercial |
$1,811.15
|
| Rate for Payer: HFN Commercial |
$1,872.20
|
| Rate for Payer: Multiplan Commercial |
$1,628.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,221.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,872.20
|
| Rate for Payer: Quartz Beloit One Network |
$997.15
|
| Rate for Payer: Quartz Commercial |
$1,221.00
|
| Rate for Payer: WEA Trust Commercial |
$1,119.25
|
| Rate for Payer: WPS Commercial |
$1,507.32
|
|
|
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 |
$433.16 |
| Max. Negotiated Rate |
$813.28 |
| Rate for Payer: Aetna Commercial |
$795.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$760.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$468.52
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cigna Commercial |
$813.28
|
| Rate for Payer: Health EOS Commercial |
$786.76
|
| Rate for Payer: HFN Commercial |
$813.28
|
| Rate for Payer: Multiplan Commercial |
$707.20
|
| Rate for Payer: NAPHCARE Commercial |
$530.40
|
| Rate for Payer: Preferred Network Access Commercial |
$813.28
|
| Rate for Payer: Quartz Beloit One Network |
$433.16
|
| Rate for Payer: Quartz Commercial |
$530.40
|
| Rate for Payer: WEA Trust Commercial |
$486.20
|
| Rate for Payer: WPS Commercial |
$654.78
|
|
|
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 |
$247.52 |
| Max. Negotiated Rate |
$3,536.00 |
| Rate for Payer: Aetna Commercial |
$795.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$760.24
|
| Rate for Payer: Aetna Managed Medicare |
$247.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$574.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$442.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$424.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$468.52
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cigna Commercial |
$813.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$494.69
|
| Rate for Payer: Health EOS Commercial |
$786.76
|
| Rate for Payer: HFN Commercial |
$813.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$663.00
|
| Rate for Payer: Multiplan Commercial |
$707.20
|
| Rate for Payer: NAPHCARE Commercial |
$530.40
|
| Rate for Payer: Preferred Network Access Commercial |
$813.28
|
| Rate for Payer: Quartz Beloit One Network |
$433.16
|
| Rate for Payer: Quartz Commercial |
$574.60
|
| Rate for Payer: Quartz Medicare Advantage |
$530.40
|
| Rate for Payer: The Alliance Commercial |
$3,536.00
|
| Rate for Payer: WEA Trust Commercial |
$486.20
|
| Rate for Payer: WPS Commercial |
$654.78
|
|
|
SCREW MATRIX MIDFACE 5MM SELF-DRILLING TI 04.503.225.01
|
Facility
|
IP
|
$884.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5264662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$433.16 |
| Max. Negotiated Rate |
$813.28 |
| Rate for Payer: Aetna Commercial |
$795.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$760.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$468.52
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cigna Commercial |
$813.28
|
| Rate for Payer: Health EOS Commercial |
$786.76
|
| Rate for Payer: HFN Commercial |
$813.28
|
| Rate for Payer: Multiplan Commercial |
$707.20
|
| Rate for Payer: NAPHCARE Commercial |
$530.40
|
| Rate for Payer: Preferred Network Access Commercial |
$813.28
|
| Rate for Payer: Quartz Beloit One Network |
$433.16
|
| Rate for Payer: Quartz Commercial |
$530.40
|
| Rate for Payer: WEA Trust Commercial |
$486.20
|
| Rate for Payer: WPS Commercial |
$654.78
|
|
|
SCREW MATRIX MIDFACE 5MM SELF-DRILLING TI 04.503.225.01
|
Facility
|
OP
|
$884.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5264662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$247.52 |
| Max. Negotiated Rate |
$3,536.00 |
| Rate for Payer: Aetna Commercial |
$795.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$760.24
|
| Rate for Payer: Aetna Managed Medicare |
$247.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$574.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$442.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$424.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$468.52
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cigna Commercial |
$813.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$494.69
|
| Rate for Payer: Health EOS Commercial |
$786.76
|
| Rate for Payer: HFN Commercial |
$813.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$663.00
|
| Rate for Payer: Multiplan Commercial |
$707.20
|
| Rate for Payer: NAPHCARE Commercial |
$530.40
|
| Rate for Payer: Preferred Network Access Commercial |
$813.28
|
| Rate for Payer: Quartz Beloit One Network |
$433.16
|
| Rate for Payer: Quartz Commercial |
$574.60
|
| Rate for Payer: Quartz Medicare Advantage |
$530.40
|
| Rate for Payer: The Alliance Commercial |
$3,536.00
|
| Rate for Payer: WEA Trust Commercial |
$486.20
|
| Rate for Payer: WPS Commercial |
$654.78
|
|
|
SCREW MATRIX MIDFACE 5MM SELF-DRILLING TI 04.503.228.01
|
Facility
|
IP
|
$2,118.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226129
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.82 |
| Max. Negotiated Rate |
$1,948.56 |
| Rate for Payer: Aetna Commercial |
$1,906.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,821.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,122.54
|
| Rate for Payer: Cash Price |
$635.40
|
| Rate for Payer: Cigna Commercial |
$1,948.56
|
| Rate for Payer: Health EOS Commercial |
$1,885.02
|
| Rate for Payer: HFN Commercial |
$1,948.56
|
| Rate for Payer: Multiplan Commercial |
$1,694.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,270.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,948.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,037.82
|
| Rate for Payer: Quartz Commercial |
$1,270.80
|
| Rate for Payer: WEA Trust Commercial |
$1,164.90
|
| Rate for Payer: WPS Commercial |
$1,568.80
|
|
|
SCREW MATRIX MIDFACE 5MM SELF-DRILLING TI 04.503.228.01
|
Facility
|
OP
|
$2,118.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226129
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$593.04 |
| Max. Negotiated Rate |
$8,472.00 |
| Rate for Payer: Aetna Commercial |
$1,906.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,821.48
|
| Rate for Payer: Aetna Managed Medicare |
$593.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,376.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,059.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,016.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,122.54
|
| Rate for Payer: Cash Price |
$635.40
|
| Rate for Payer: Cigna Commercial |
$1,948.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,185.23
|
| Rate for Payer: Health EOS Commercial |
$1,885.02
|
| Rate for Payer: HFN Commercial |
$1,948.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,588.50
|
| Rate for Payer: Multiplan Commercial |
$1,694.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,270.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,948.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,037.82
|
| Rate for Payer: Quartz Commercial |
$1,376.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,270.80
|
| Rate for Payer: The Alliance Commercial |
$8,472.00
|
| Rate for Payer: WEA Trust Commercial |
$1,164.90
|
| Rate for Payer: WPS Commercial |
$1,568.80
|
|
|
SCREW MATRIX MIDFACE 5MM SELF-TAPPING TI 04.503.205.05
|
Facility
|
IP
|
$858.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5306829
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$420.42 |
| Max. Negotiated Rate |
$789.36 |
| Rate for Payer: Aetna Commercial |
$772.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$737.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$454.74
|
| Rate for Payer: Cash Price |
$257.40
|
| Rate for Payer: Cigna Commercial |
$789.36
|
| Rate for Payer: Health EOS Commercial |
$763.62
|
| Rate for Payer: HFN Commercial |
$789.36
|
| Rate for Payer: Multiplan Commercial |
$686.40
|
| Rate for Payer: NAPHCARE Commercial |
$514.80
|
| Rate for Payer: Preferred Network Access Commercial |
$789.36
|
| Rate for Payer: Quartz Beloit One Network |
$420.42
|
| Rate for Payer: Quartz Commercial |
$514.80
|
| Rate for Payer: WEA Trust Commercial |
$471.90
|
| Rate for Payer: WPS Commercial |
$635.52
|
|
|
SCREW MATRIX MIDFACE 5MM SELF-TAPPING TI 04.503.205.05
|
Facility
|
OP
|
$858.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5306829
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$240.24 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$772.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$737.88
|
| Rate for Payer: Aetna Managed Medicare |
$240.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$557.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$429.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$411.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$454.74
|
| Rate for Payer: Cash Price |
$257.40
|
| Rate for Payer: Cigna Commercial |
$789.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$480.14
|
| Rate for Payer: Health EOS Commercial |
$763.62
|
| Rate for Payer: HFN Commercial |
$789.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$643.50
|
| Rate for Payer: Multiplan Commercial |
$686.40
|
| Rate for Payer: NAPHCARE Commercial |
$514.80
|
| Rate for Payer: Preferred Network Access Commercial |
$789.36
|
| Rate for Payer: Quartz Beloit One Network |
$420.42
|
| Rate for Payer: Quartz Commercial |
$557.70
|
| Rate for Payer: Quartz Medicare Advantage |
$514.80
|
| Rate for Payer: The Alliance Commercial |
$3,432.00
|
| Rate for Payer: WEA Trust Commercial |
$471.90
|
| Rate for Payer: WPS Commercial |
$635.52
|
|
