|
IMPLANT BIOCARTILAGE 1CC ABS-1010-BC
|
Facility
|
IP
|
$7,160.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5240721
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,648.74 |
| Max. Negotiated Rate |
$6,850.69 |
| Rate for Payer: Aetna Commercial |
$6,701.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,403.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,946.59
|
| Rate for Payer: Cash Price |
$2,148.00
|
| Rate for Payer: Cigna Commercial |
$6,850.69
|
| Rate for Payer: Health EOS Commercial |
$6,627.30
|
| Rate for Payer: HFN Commercial |
$6,850.69
|
| Rate for Payer: Multiplan Commercial |
$5,957.12
|
| Rate for Payer: Preferred Network Access Commercial |
$6,850.69
|
| Rate for Payer: Quartz Beloit One Network |
$3,648.74
|
| Rate for Payer: Quartz Commercial |
$4,467.84
|
| Rate for Payer: WEA Trust Commercial |
$4,095.52
|
| Rate for Payer: WPS Commercial |
$5,515.35
|
|
|
IMPLANT BIOCARTILAGE 1CC ABS-1010-BC
|
Facility
|
OP
|
$7,160.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5240721
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,084.99 |
| Max. Negotiated Rate |
$6,850.69 |
| Rate for Payer: Aetna Commercial |
$6,701.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,403.90
|
| Rate for Payer: Aetna Managed Medicare |
$2,084.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,840.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,723.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,574.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,946.59
|
| Rate for Payer: Cash Price |
$2,148.00
|
| Rate for Payer: Cigna Commercial |
$6,850.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,167.12
|
| Rate for Payer: Health EOS Commercial |
$6,627.30
|
| Rate for Payer: HFN Commercial |
$6,850.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,584.80
|
| Rate for Payer: Multiplan Commercial |
$5,957.12
|
| Rate for Payer: NAPHCARE Commercial |
$4,467.84
|
| Rate for Payer: Preferred Network Access Commercial |
$6,850.69
|
| Rate for Payer: Quartz Beloit One Network |
$3,648.74
|
| Rate for Payer: Quartz Commercial |
$4,840.16
|
| Rate for Payer: Quartz Medicare Advantage |
$4,467.84
|
| Rate for Payer: The Alliance Commercial |
$3,723.20
|
| Rate for Payer: WEA Trust Commercial |
$4,095.52
|
| Rate for Payer: WPS Commercial |
$5,515.35
|
|
|
IMPLANT BREAST 286CC SILICONE
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2964631
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$756.29
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
IMPLANT BREAST 286CC SILICONE
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2964631
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$352.93 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Aetna Managed Medicare |
$352.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$819.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$630.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$605.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$705.38
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$945.36
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: NAPHCARE Commercial |
$756.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$819.31
|
| Rate for Payer: Quartz Medicare Advantage |
$756.29
|
| Rate for Payer: The Alliance Commercial |
$630.24
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
IMPLANT BREAST 371CC SILICONE
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2964632
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$756.29
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
IMPLANT BREAST 371CC SILICONE
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2964632
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$352.93 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Aetna Managed Medicare |
$352.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$819.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$630.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$605.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$705.38
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$945.36
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: NAPHCARE Commercial |
$756.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$819.31
|
| Rate for Payer: Quartz Medicare Advantage |
$756.29
|
| Rate for Payer: The Alliance Commercial |
$630.24
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
IMPLANT BREAST 421CC SILICONE
|
Facility
|
OP
|
$8,239.00
|
|
| Hospital Charge Code |
2964633
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,399.20 |
| Max. Negotiated Rate |
$7,883.08 |
| Rate for Payer: Aetna Commercial |
$7,711.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,368.96
|
| Rate for Payer: Aetna Managed Medicare |
$2,399.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,569.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,284.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,112.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,541.34
|
| Rate for Payer: Cash Price |
$2,471.70
|
| Rate for Payer: Cigna Commercial |
$7,883.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,795.10
|
| Rate for Payer: Health EOS Commercial |
$7,626.02
|
| Rate for Payer: HFN Commercial |
$7,883.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,426.42
|
| Rate for Payer: Multiplan Commercial |
$6,854.85
|
| Rate for Payer: NAPHCARE Commercial |
$5,141.14
|
| Rate for Payer: Preferred Network Access Commercial |
$7,883.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,198.59
|
| Rate for Payer: Quartz Commercial |
$5,569.56
|
| Rate for Payer: Quartz Medicare Advantage |
$5,141.14
|
| Rate for Payer: The Alliance Commercial |
$4,284.28
|
| Rate for Payer: WEA Trust Commercial |
$4,712.71
|
| Rate for Payer: WPS Commercial |
$6,346.50
|
|
|
IMPLANT BREAST 421CC SILICONE
|
Facility
|
IP
|
$8,239.00
|
|
| Hospital Charge Code |
2964633
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,198.59 |
| Max. Negotiated Rate |
$7,883.08 |
| Rate for Payer: Aetna Commercial |
$7,711.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,368.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,541.34
|
| Rate for Payer: Cash Price |
$2,471.70
|
| Rate for Payer: Cigna Commercial |
$7,883.08
|
| Rate for Payer: Health EOS Commercial |
$7,626.02
|
| Rate for Payer: HFN Commercial |
$7,883.08
|
| Rate for Payer: Multiplan Commercial |
$6,854.85
|
| Rate for Payer: Preferred Network Access Commercial |
$7,883.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,198.59
|
| Rate for Payer: Quartz Commercial |
$5,141.14
|
| Rate for Payer: WEA Trust Commercial |
$4,712.71
|
| Rate for Payer: WPS Commercial |
$6,346.50
|
|
|
IMPLANT BREAST 575CC SILICONE
|
Facility
|
OP
|
$8,239.00
|
|
| Hospital Charge Code |
2964634
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,399.20 |
| Max. Negotiated Rate |
$7,883.08 |
| Rate for Payer: Aetna Commercial |
$7,711.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,368.96
|
| Rate for Payer: Aetna Managed Medicare |
$2,399.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,569.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,284.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,112.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,541.34
|
| Rate for Payer: Cash Price |
$2,471.70
|
| Rate for Payer: Cigna Commercial |
$7,883.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,795.10
|
| Rate for Payer: Health EOS Commercial |
$7,626.02
|
| Rate for Payer: HFN Commercial |
$7,883.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,426.42
|
| Rate for Payer: Multiplan Commercial |
$6,854.85
|
| Rate for Payer: NAPHCARE Commercial |
$5,141.14
|
| Rate for Payer: Preferred Network Access Commercial |
$7,883.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,198.59
|
| Rate for Payer: Quartz Commercial |
$5,569.56
|
| Rate for Payer: Quartz Medicare Advantage |
$5,141.14
|
| Rate for Payer: The Alliance Commercial |
$4,284.28
|
| Rate for Payer: WEA Trust Commercial |
$4,712.71
|
| Rate for Payer: WPS Commercial |
$6,346.50
|
|
|
IMPLANT BREAST 575CC SILICONE
|
Facility
|
IP
|
$8,239.00
|
|
| Hospital Charge Code |
2964634
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,198.59 |
| Max. Negotiated Rate |
$7,883.08 |
| Rate for Payer: Aetna Commercial |
$7,711.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,368.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,541.34
|
| Rate for Payer: Cash Price |
$2,471.70
|
| Rate for Payer: Cigna Commercial |
$7,883.08
|
| Rate for Payer: Health EOS Commercial |
$7,626.02
|
| Rate for Payer: HFN Commercial |
$7,883.08
|
| Rate for Payer: Multiplan Commercial |
$6,854.85
|
| Rate for Payer: Preferred Network Access Commercial |
$7,883.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,198.59
|
| Rate for Payer: Quartz Commercial |
$5,141.14
|
| Rate for Payer: WEA Trust Commercial |
$4,712.71
|
| Rate for Payer: WPS Commercial |
$6,346.50
|
|
|
IMPLANT BREAST 700CC SILICONE
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2964635
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$756.29
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
IMPLANT BREAST 700CC SILICONE
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2964635
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$352.93 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Aetna Managed Medicare |
$352.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$819.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$630.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$605.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$705.38
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$945.36
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: NAPHCARE Commercial |
$756.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$819.31
|
| Rate for Payer: Quartz Medicare Advantage |
$756.29
|
| Rate for Payer: The Alliance Commercial |
$630.24
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
IMPLANT BREAST 752CC SILICONE
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2967898
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$352.93 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Aetna Managed Medicare |
$352.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$819.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$630.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$605.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$705.38
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$945.36
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: NAPHCARE Commercial |
$756.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$819.31
|
| Rate for Payer: Quartz Medicare Advantage |
$756.29
|
| Rate for Payer: The Alliance Commercial |
$630.24
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
IMPLANT BREAST 752CC SILICONE
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2967898
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$756.29
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
IMPLANT BREAST 800CC SILICON
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2964636
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$756.29
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
IMPLANT BREAST 800CC SILICON
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2964636
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$352.93 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Aetna Managed Medicare |
$352.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$819.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$630.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$605.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$705.38
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$945.36
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: NAPHCARE Commercial |
$756.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$819.31
|
| Rate for Payer: Quartz Medicare Advantage |
$756.29
|
| Rate for Payer: The Alliance Commercial |
$630.24
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
IMPLANT CHANDRAL DART 1.3 X 18MM AR-4005B-18
|
Facility
|
IP
|
$2,214.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5885643
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,128.25 |
| Max. Negotiated Rate |
$2,118.36 |
| Rate for Payer: Aetna Commercial |
$2,072.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,980.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,220.36
|
| Rate for Payer: Cash Price |
$664.20
|
| Rate for Payer: Cigna Commercial |
$2,118.36
|
| Rate for Payer: Health EOS Commercial |
$2,049.28
|
| Rate for Payer: HFN Commercial |
$2,118.36
|
| Rate for Payer: Multiplan Commercial |
$1,842.05
|
| Rate for Payer: Preferred Network Access Commercial |
$2,118.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,128.25
|
| Rate for Payer: Quartz Commercial |
$1,381.54
|
| Rate for Payer: WEA Trust Commercial |
$1,266.41
|
| Rate for Payer: WPS Commercial |
$1,705.44
|
|
|
IMPLANT CHANDRAL DART 1.3 X 18MM AR-4005B-18
|
Facility
|
OP
|
$2,214.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5885643
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$644.72 |
| Max. Negotiated Rate |
$2,118.36 |
| Rate for Payer: Aetna Commercial |
$2,072.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,980.20
|
| Rate for Payer: Aetna Managed Medicare |
$644.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,496.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,151.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,105.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,220.36
|
| Rate for Payer: Cash Price |
$664.20
|
| Rate for Payer: Cigna Commercial |
$2,118.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,288.55
|
| Rate for Payer: Health EOS Commercial |
$2,049.28
|
| Rate for Payer: HFN Commercial |
$2,118.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,726.92
|
| Rate for Payer: Multiplan Commercial |
$1,842.05
|
| Rate for Payer: NAPHCARE Commercial |
$1,381.54
|
| Rate for Payer: Preferred Network Access Commercial |
$2,118.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,128.25
|
| Rate for Payer: Quartz Commercial |
$1,496.66
|
| Rate for Payer: Quartz Medicare Advantage |
$1,381.54
|
| Rate for Payer: The Alliance Commercial |
$1,151.28
|
| Rate for Payer: WEA Trust Commercial |
$1,266.41
|
| Rate for Payer: WPS Commercial |
$1,705.44
|
|
|
IMPLANT DELIVERY SYSTEM DISTAL BICEPS REPAIR AR-2260
|
Facility
|
OP
|
$7,699.00
|
|
| Hospital Charge Code |
2964682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,241.95 |
| Max. Negotiated Rate |
$7,366.40 |
| Rate for Payer: Aetna Commercial |
$7,206.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,885.99
|
| Rate for Payer: Aetna Managed Medicare |
$2,241.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,204.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,003.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,843.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,243.69
|
| Rate for Payer: Cash Price |
$2,309.70
|
| Rate for Payer: Cigna Commercial |
$7,366.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,480.82
|
| Rate for Payer: Health EOS Commercial |
$7,126.19
|
| Rate for Payer: HFN Commercial |
$7,366.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,005.22
|
| Rate for Payer: Multiplan Commercial |
$6,405.57
|
| Rate for Payer: NAPHCARE Commercial |
$4,804.18
|
| Rate for Payer: Preferred Network Access Commercial |
$7,366.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,923.41
|
| Rate for Payer: Quartz Commercial |
$5,204.52
|
| Rate for Payer: Quartz Medicare Advantage |
$4,804.18
|
| Rate for Payer: The Alliance Commercial |
$4,003.48
|
| Rate for Payer: WEA Trust Commercial |
$4,403.83
|
| Rate for Payer: WPS Commercial |
$5,930.54
|
|
|
IMPLANT DELIVERY SYSTEM DISTAL BICEPS REPAIR AR-2260
|
Facility
|
IP
|
$7,699.00
|
|
| Hospital Charge Code |
2964682
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,923.41 |
| Max. Negotiated Rate |
$7,366.40 |
| Rate for Payer: Aetna Commercial |
$7,206.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,885.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,243.69
|
| Rate for Payer: Cash Price |
$2,309.70
|
| Rate for Payer: Cigna Commercial |
$7,366.40
|
| Rate for Payer: Health EOS Commercial |
$7,126.19
|
| Rate for Payer: HFN Commercial |
$7,366.40
|
| Rate for Payer: Multiplan Commercial |
$6,405.57
|
| Rate for Payer: Preferred Network Access Commercial |
$7,366.40
|
| Rate for Payer: Quartz Beloit One Network |
$3,923.41
|
| Rate for Payer: Quartz Commercial |
$4,804.18
|
| Rate for Payer: WEA Trust Commercial |
$4,403.83
|
| Rate for Payer: WPS Commercial |
$5,930.54
|
|
|
IMPLANT DELIVERY SYSTEM DISTAL BICEPS REPAIR BC AR-2260BC
|
Facility
|
IP
|
$8,695.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5520889
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,430.97 |
| Max. Negotiated Rate |
$8,319.38 |
| Rate for Payer: Aetna Commercial |
$8,138.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,776.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,792.68
|
| Rate for Payer: Cash Price |
$2,608.50
|
| Rate for Payer: Cigna Commercial |
$8,319.38
|
| Rate for Payer: Health EOS Commercial |
$8,048.09
|
| Rate for Payer: HFN Commercial |
$8,319.38
|
| Rate for Payer: Multiplan Commercial |
$7,234.24
|
| Rate for Payer: Preferred Network Access Commercial |
$8,319.38
|
| Rate for Payer: Quartz Beloit One Network |
$4,430.97
|
| Rate for Payer: Quartz Commercial |
$5,425.68
|
| Rate for Payer: WEA Trust Commercial |
$4,973.54
|
| Rate for Payer: WPS Commercial |
$6,697.76
|
|
|
IMPLANT DELIVERY SYSTEM DISTAL BICEPS REPAIR BC AR-2260BC
|
Facility
|
OP
|
$8,695.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5520889
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,531.98 |
| Max. Negotiated Rate |
$8,319.38 |
| Rate for Payer: Aetna Commercial |
$8,138.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,776.81
|
| Rate for Payer: Aetna Managed Medicare |
$2,531.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,877.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,521.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,340.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,792.68
|
| Rate for Payer: Cash Price |
$2,608.50
|
| Rate for Payer: Cigna Commercial |
$8,319.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,060.49
|
| Rate for Payer: Health EOS Commercial |
$8,048.09
|
| Rate for Payer: HFN Commercial |
$8,319.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,782.10
|
| Rate for Payer: Multiplan Commercial |
$7,234.24
|
| Rate for Payer: NAPHCARE Commercial |
$5,425.68
|
| Rate for Payer: Preferred Network Access Commercial |
$8,319.38
|
| Rate for Payer: Quartz Beloit One Network |
$4,430.97
|
| Rate for Payer: Quartz Commercial |
$5,877.82
|
| Rate for Payer: Quartz Medicare Advantage |
$5,425.68
|
| Rate for Payer: The Alliance Commercial |
$4,521.40
|
| Rate for Payer: WEA Trust Commercial |
$4,973.54
|
| Rate for Payer: WPS Commercial |
$6,697.76
|
|
|
IMPLANT DIGIFUSE 2.0MM X 10 DEG ANGLE DF2010
|
Facility
|
OP
|
$11,306.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5729623
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,292.31 |
| Max. Negotiated Rate |
$10,817.58 |
| Rate for Payer: Aetna Commercial |
$10,582.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,112.09
|
| Rate for Payer: Aetna Managed Medicare |
$3,292.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,642.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,879.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,643.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,231.87
|
| Rate for Payer: Cash Price |
$3,391.80
|
| Rate for Payer: Cigna Commercial |
$10,817.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,580.09
|
| Rate for Payer: Health EOS Commercial |
$10,464.83
|
| Rate for Payer: HFN Commercial |
$10,817.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,818.68
|
| Rate for Payer: Multiplan Commercial |
$9,406.59
|
| Rate for Payer: NAPHCARE Commercial |
$7,054.94
|
| Rate for Payer: Preferred Network Access Commercial |
$10,817.58
|
| Rate for Payer: Quartz Beloit One Network |
$5,761.54
|
| Rate for Payer: Quartz Commercial |
$7,642.86
|
| Rate for Payer: Quartz Medicare Advantage |
$7,054.94
|
| Rate for Payer: The Alliance Commercial |
$5,879.12
|
| Rate for Payer: WEA Trust Commercial |
$6,467.03
|
| Rate for Payer: WPS Commercial |
$8,709.01
|
|
|
IMPLANT DIGIFUSE 2.0MM X 10 DEG ANGLE DF2010
|
Facility
|
IP
|
$11,306.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5729623
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,761.54 |
| Max. Negotiated Rate |
$10,817.58 |
| Rate for Payer: Aetna Commercial |
$10,582.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,112.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,231.87
|
| Rate for Payer: Cash Price |
$3,391.80
|
| Rate for Payer: Cigna Commercial |
$10,817.58
|
| Rate for Payer: Health EOS Commercial |
$10,464.83
|
| Rate for Payer: HFN Commercial |
$10,817.58
|
| Rate for Payer: Multiplan Commercial |
$9,406.59
|
| Rate for Payer: Preferred Network Access Commercial |
$10,817.58
|
| Rate for Payer: Quartz Beloit One Network |
$5,761.54
|
| Rate for Payer: Quartz Commercial |
$7,054.94
|
| Rate for Payer: WEA Trust Commercial |
$6,467.03
|
| Rate for Payer: WPS Commercial |
$8,709.01
|
|
|
IMPLANT DIGIFUSE 2.5MM 10 DEGREE DF2510
|
Facility
|
OP
|
$6,393.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5627642
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,861.64 |
| Max. Negotiated Rate |
$6,116.82 |
| Rate for Payer: Aetna Commercial |
$5,983.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,717.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,861.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,321.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,324.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,191.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,523.82
|
| Rate for Payer: Cash Price |
$1,917.90
|
| Rate for Payer: Cigna Commercial |
$6,116.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,720.73
|
| Rate for Payer: Health EOS Commercial |
$5,917.36
|
| Rate for Payer: HFN Commercial |
$6,116.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,986.54
|
| Rate for Payer: Multiplan Commercial |
$5,318.98
|
| Rate for Payer: NAPHCARE Commercial |
$3,989.23
|
| Rate for Payer: Preferred Network Access Commercial |
$6,116.82
|
| Rate for Payer: Quartz Beloit One Network |
$3,257.87
|
| Rate for Payer: Quartz Commercial |
$4,321.67
|
| Rate for Payer: Quartz Medicare Advantage |
$3,989.23
|
| Rate for Payer: The Alliance Commercial |
$3,324.36
|
| Rate for Payer: WEA Trust Commercial |
$3,656.80
|
| Rate for Payer: WPS Commercial |
$4,924.53
|
|
