|
IMPLANT M-P JOINT GREAT TOE 21.5MM 14958
|
Facility
|
OP
|
$7,544.00
|
|
|
Service Code
|
HCPCS L8642
|
| Hospital Charge Code |
5200639
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,594.03 |
| Max. Negotiated Rate |
$7,218.10 |
| Rate for Payer: Aetna Commercial |
$7,061.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,747.35
|
| Rate for Payer: Aetna Managed Medicare |
$2,196.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,099.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,922.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,765.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,158.25
|
| Rate for Payer: Cash Price |
$2,263.20
|
| Rate for Payer: Cash Price |
$2,263.20
|
| Rate for Payer: Cigna Commercial |
$7,218.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,390.61
|
| Rate for Payer: Health EOS Commercial |
$6,982.73
|
| Rate for Payer: HFN Commercial |
$7,218.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,884.32
|
| Rate for Payer: Multiplan Commercial |
$6,276.61
|
| Rate for Payer: NAPHCARE Commercial |
$4,707.46
|
| Rate for Payer: Preferred Network Access Commercial |
$7,218.10
|
| Rate for Payer: Quartz Beloit One Network |
$3,844.42
|
| Rate for Payer: Quartz Commercial |
$5,099.74
|
| Rate for Payer: Quartz Medicare Advantage |
$4,707.46
|
| Rate for Payer: The Alliance Commercial |
$1,594.03
|
| Rate for Payer: WEA Trust Commercial |
$4,315.17
|
| Rate for Payer: WPS Commercial |
$5,811.14
|
|
|
IMPLANT M-P JOINT GREAT TOE LG 10414
|
Facility
|
IP
|
$10,102.00
|
|
|
Service Code
|
HCPCS L8642
|
| Hospital Charge Code |
3879346
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,147.98 |
| Max. Negotiated Rate |
$9,665.59 |
| Rate for Payer: Aetna Commercial |
$9,455.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,035.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,568.22
|
| Rate for Payer: Cash Price |
$3,030.60
|
| Rate for Payer: Cigna Commercial |
$9,665.59
|
| Rate for Payer: Health EOS Commercial |
$9,350.41
|
| Rate for Payer: HFN Commercial |
$9,665.59
|
| Rate for Payer: Multiplan Commercial |
$8,404.86
|
| Rate for Payer: Preferred Network Access Commercial |
$9,665.59
|
| Rate for Payer: Quartz Beloit One Network |
$5,147.98
|
| Rate for Payer: Quartz Commercial |
$6,303.65
|
| Rate for Payer: WEA Trust Commercial |
$5,778.34
|
| Rate for Payer: WPS Commercial |
$7,781.57
|
|
|
IMPLANT M-P JOINT GREAT TOE LG 10414
|
Facility
|
OP
|
$10,102.00
|
|
|
Service Code
|
HCPCS L8642
|
| Hospital Charge Code |
3879346
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,594.03 |
| Max. Negotiated Rate |
$9,665.59 |
| Rate for Payer: Aetna Commercial |
$9,455.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,035.23
|
| Rate for Payer: Aetna Managed Medicare |
$2,941.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,828.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,253.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,042.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,568.22
|
| Rate for Payer: Cash Price |
$3,030.60
|
| Rate for Payer: Cash Price |
$3,030.60
|
| Rate for Payer: Cigna Commercial |
$9,665.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,879.36
|
| Rate for Payer: Health EOS Commercial |
$9,350.41
|
| Rate for Payer: HFN Commercial |
$9,665.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,879.56
|
| Rate for Payer: Multiplan Commercial |
$8,404.86
|
| Rate for Payer: NAPHCARE Commercial |
$6,303.65
|
| Rate for Payer: Preferred Network Access Commercial |
$9,665.59
|
| Rate for Payer: Quartz Beloit One Network |
$5,147.98
|
| Rate for Payer: Quartz Commercial |
$6,828.95
|
| Rate for Payer: Quartz Medicare Advantage |
$6,303.65
|
| Rate for Payer: The Alliance Commercial |
$1,594.03
|
| Rate for Payer: WEA Trust Commercial |
$5,778.34
|
| Rate for Payer: WPS Commercial |
$7,781.57
|
|
|
IMPLANT M-P JOINT GREAT TOE ML 21.5MM 14960
|
Facility
|
IP
|
$10,102.00
|
|
|
Service Code
|
HCPCS L8642
|
| Hospital Charge Code |
5179245
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,147.98 |
| Max. Negotiated Rate |
$9,665.59 |
| Rate for Payer: Aetna Commercial |
$9,455.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,035.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,568.22
|
| Rate for Payer: Cash Price |
$3,030.60
|
| Rate for Payer: Cigna Commercial |
$9,665.59
|
| Rate for Payer: Health EOS Commercial |
$9,350.41
|
| Rate for Payer: HFN Commercial |
$9,665.59
|
| Rate for Payer: Multiplan Commercial |
$8,404.86
|
| Rate for Payer: Preferred Network Access Commercial |
$9,665.59
|
| Rate for Payer: Quartz Beloit One Network |
$5,147.98
|
| Rate for Payer: Quartz Commercial |
$6,303.65
|
| Rate for Payer: WEA Trust Commercial |
$5,778.34
|
| Rate for Payer: WPS Commercial |
$7,781.57
|
|
|
IMPLANT M-P JOINT GREAT TOE ML 21.5MM 14960
|
Facility
|
OP
|
$10,102.00
|
|
|
Service Code
|
HCPCS L8642
|
| Hospital Charge Code |
5179245
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,594.03 |
| Max. Negotiated Rate |
$9,665.59 |
| Rate for Payer: Aetna Commercial |
$9,455.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,035.23
|
| Rate for Payer: Aetna Managed Medicare |
$2,941.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,828.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,253.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,042.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,568.22
|
| Rate for Payer: Cash Price |
$3,030.60
|
| Rate for Payer: Cash Price |
$3,030.60
|
| Rate for Payer: Cigna Commercial |
$9,665.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,879.36
|
| Rate for Payer: Health EOS Commercial |
$9,350.41
|
| Rate for Payer: HFN Commercial |
$9,665.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,879.56
|
| Rate for Payer: Multiplan Commercial |
$8,404.86
|
| Rate for Payer: NAPHCARE Commercial |
$6,303.65
|
| Rate for Payer: Preferred Network Access Commercial |
$9,665.59
|
| Rate for Payer: Quartz Beloit One Network |
$5,147.98
|
| Rate for Payer: Quartz Commercial |
$6,828.95
|
| Rate for Payer: Quartz Medicare Advantage |
$6,303.65
|
| Rate for Payer: The Alliance Commercial |
$1,594.03
|
| Rate for Payer: WEA Trust Commercial |
$5,778.34
|
| Rate for Payer: WPS Commercial |
$7,781.57
|
|
|
IMPLANT M-P JOINT GREAT TOE MS 18.5MM 17034
|
Facility
|
OP
|
$10,102.00
|
|
|
Service Code
|
HCPCS L8642
|
| Hospital Charge Code |
5264939
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,594.03 |
| Max. Negotiated Rate |
$9,665.59 |
| Rate for Payer: Aetna Commercial |
$9,455.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,035.23
|
| Rate for Payer: Aetna Managed Medicare |
$2,941.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,828.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,253.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,042.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,568.22
|
| Rate for Payer: Cash Price |
$3,030.60
|
| Rate for Payer: Cash Price |
$3,030.60
|
| Rate for Payer: Cigna Commercial |
$9,665.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,879.36
|
| Rate for Payer: Health EOS Commercial |
$9,350.41
|
| Rate for Payer: HFN Commercial |
$9,665.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,879.56
|
| Rate for Payer: Multiplan Commercial |
$8,404.86
|
| Rate for Payer: NAPHCARE Commercial |
$6,303.65
|
| Rate for Payer: Preferred Network Access Commercial |
$9,665.59
|
| Rate for Payer: Quartz Beloit One Network |
$5,147.98
|
| Rate for Payer: Quartz Commercial |
$6,828.95
|
| Rate for Payer: Quartz Medicare Advantage |
$6,303.65
|
| Rate for Payer: The Alliance Commercial |
$1,594.03
|
| Rate for Payer: WEA Trust Commercial |
$5,778.34
|
| Rate for Payer: WPS Commercial |
$7,781.57
|
|
|
IMPLANT M-P JOINT GREAT TOE MS 18.5MM 17034
|
Facility
|
IP
|
$10,102.00
|
|
|
Service Code
|
HCPCS L8642
|
| Hospital Charge Code |
5264939
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,147.98 |
| Max. Negotiated Rate |
$9,665.59 |
| Rate for Payer: Aetna Commercial |
$9,455.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,035.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,568.22
|
| Rate for Payer: Cash Price |
$3,030.60
|
| Rate for Payer: Cigna Commercial |
$9,665.59
|
| Rate for Payer: Health EOS Commercial |
$9,350.41
|
| Rate for Payer: HFN Commercial |
$9,665.59
|
| Rate for Payer: Multiplan Commercial |
$8,404.86
|
| Rate for Payer: Preferred Network Access Commercial |
$9,665.59
|
| Rate for Payer: Quartz Beloit One Network |
$5,147.98
|
| Rate for Payer: Quartz Commercial |
$6,303.65
|
| Rate for Payer: WEA Trust Commercial |
$5,778.34
|
| Rate for Payer: WPS Commercial |
$7,781.57
|
|
|
IMPLANT M-P JOINT POROUS COATED SMALL 10412
|
Facility
|
IP
|
$6,559.00
|
|
| Hospital Charge Code |
2969378
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,342.47 |
| Max. Negotiated Rate |
$6,275.65 |
| Rate for Payer: Aetna Commercial |
$6,139.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,866.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,615.32
|
| Rate for Payer: Cash Price |
$1,967.70
|
| Rate for Payer: Cigna Commercial |
$6,275.65
|
| Rate for Payer: Health EOS Commercial |
$6,071.01
|
| Rate for Payer: HFN Commercial |
$6,275.65
|
| Rate for Payer: Multiplan Commercial |
$5,457.09
|
| Rate for Payer: Preferred Network Access Commercial |
$6,275.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,342.47
|
| Rate for Payer: Quartz Commercial |
$4,092.82
|
| Rate for Payer: WEA Trust Commercial |
$3,751.75
|
| Rate for Payer: WPS Commercial |
$5,052.40
|
|
|
IMPLANT M-P JOINT POROUS COATED SMALL 10412
|
Facility
|
OP
|
$6,559.00
|
|
| Hospital Charge Code |
2969378
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,909.98 |
| Max. Negotiated Rate |
$6,275.65 |
| Rate for Payer: Aetna Commercial |
$6,139.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,866.37
|
| Rate for Payer: Aetna Managed Medicare |
$1,909.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,433.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,410.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,274.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,615.32
|
| Rate for Payer: Cash Price |
$1,967.70
|
| Rate for Payer: Cigna Commercial |
$6,275.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,817.34
|
| Rate for Payer: Health EOS Commercial |
$6,071.01
|
| Rate for Payer: HFN Commercial |
$6,275.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,116.02
|
| Rate for Payer: Multiplan Commercial |
$5,457.09
|
| Rate for Payer: NAPHCARE Commercial |
$4,092.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6,275.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,342.47
|
| Rate for Payer: Quartz Commercial |
$4,433.88
|
| Rate for Payer: Quartz Medicare Advantage |
$4,092.82
|
| Rate for Payer: The Alliance Commercial |
$3,410.68
|
| Rate for Payer: WEA Trust Commercial |
$3,751.75
|
| Rate for Payer: WPS Commercial |
$5,052.40
|
|
|
IMPLANT MPT FUSION SMALL 0DEG RT ORTHOLOC 587110RT
|
Facility
|
IP
|
$11,873.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6169639
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,050.48 |
| Max. Negotiated Rate |
$11,360.09 |
| Rate for Payer: Aetna Commercial |
$11,113.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,619.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,544.40
|
| Rate for Payer: Cash Price |
$3,561.90
|
| Rate for Payer: Cigna Commercial |
$11,360.09
|
| Rate for Payer: Health EOS Commercial |
$10,989.65
|
| Rate for Payer: HFN Commercial |
$11,360.09
|
| Rate for Payer: Multiplan Commercial |
$9,878.34
|
| Rate for Payer: Preferred Network Access Commercial |
$11,360.09
|
| Rate for Payer: Quartz Beloit One Network |
$6,050.48
|
| Rate for Payer: Quartz Commercial |
$7,408.75
|
| Rate for Payer: WEA Trust Commercial |
$6,791.36
|
| Rate for Payer: WPS Commercial |
$9,145.77
|
|
|
IMPLANT MPT FUSION SMALL 0DEG RT ORTHOLOC 587110RT
|
Facility
|
OP
|
$11,873.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6169639
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,457.42 |
| Max. Negotiated Rate |
$11,360.09 |
| Rate for Payer: Aetna Commercial |
$11,113.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,619.21
|
| Rate for Payer: Aetna Managed Medicare |
$3,457.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,026.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,173.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,927.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,544.40
|
| Rate for Payer: Cash Price |
$3,561.90
|
| Rate for Payer: Cigna Commercial |
$11,360.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,910.09
|
| Rate for Payer: Health EOS Commercial |
$10,989.65
|
| Rate for Payer: HFN Commercial |
$11,360.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,260.94
|
| Rate for Payer: Multiplan Commercial |
$9,878.34
|
| Rate for Payer: NAPHCARE Commercial |
$7,408.75
|
| Rate for Payer: Preferred Network Access Commercial |
$11,360.09
|
| Rate for Payer: Quartz Beloit One Network |
$6,050.48
|
| Rate for Payer: Quartz Commercial |
$8,026.15
|
| Rate for Payer: Quartz Medicare Advantage |
$7,408.75
|
| Rate for Payer: The Alliance Commercial |
$6,173.96
|
| Rate for Payer: WEA Trust Commercial |
$6,791.36
|
| Rate for Payer: WPS Commercial |
$9,145.77
|
|
|
IMPLANT MPT FUSION SMALL 10DEG RT ORTHOLOC 587111RT
|
Facility
|
OP
|
$5,884.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5459795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,713.42 |
| Max. Negotiated Rate |
$5,629.81 |
| Rate for Payer: Aetna Commercial |
$5,507.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,262.65
|
| Rate for Payer: Aetna Managed Medicare |
$1,713.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,977.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,059.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,937.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,243.26
|
| Rate for Payer: Cash Price |
$1,765.20
|
| Rate for Payer: Cigna Commercial |
$5,629.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,424.49
|
| Rate for Payer: Health EOS Commercial |
$5,446.23
|
| Rate for Payer: HFN Commercial |
$5,629.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,589.52
|
| Rate for Payer: Multiplan Commercial |
$4,895.49
|
| Rate for Payer: NAPHCARE Commercial |
$3,671.62
|
| Rate for Payer: Preferred Network Access Commercial |
$5,629.81
|
| Rate for Payer: Quartz Beloit One Network |
$2,998.49
|
| Rate for Payer: Quartz Commercial |
$3,977.58
|
| Rate for Payer: Quartz Medicare Advantage |
$3,671.62
|
| Rate for Payer: The Alliance Commercial |
$3,059.68
|
| Rate for Payer: WEA Trust Commercial |
$3,365.65
|
| Rate for Payer: WPS Commercial |
$4,532.45
|
|
|
IMPLANT MPT FUSION SMALL 10DEG RT ORTHOLOC 587111RT
|
Facility
|
IP
|
$5,884.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5459795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,998.49 |
| Max. Negotiated Rate |
$5,629.81 |
| Rate for Payer: Aetna Commercial |
$5,507.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,262.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,243.26
|
| Rate for Payer: Cash Price |
$1,765.20
|
| Rate for Payer: Cigna Commercial |
$5,629.81
|
| Rate for Payer: Health EOS Commercial |
$5,446.23
|
| Rate for Payer: HFN Commercial |
$5,629.81
|
| Rate for Payer: Multiplan Commercial |
$4,895.49
|
| Rate for Payer: Preferred Network Access Commercial |
$5,629.81
|
| Rate for Payer: Quartz Beloit One Network |
$2,998.49
|
| Rate for Payer: Quartz Commercial |
$3,671.62
|
| Rate for Payer: WEA Trust Commercial |
$3,365.65
|
| Rate for Payer: WPS Commercial |
$4,532.45
|
|
|
IMPLANT MPT FUSION SMALL 5DEG RT ORTHOLOC 587115RT
|
Facility
|
IP
|
$12,708.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415906
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,476.00 |
| Max. Negotiated Rate |
$12,159.01 |
| Rate for Payer: Aetna Commercial |
$11,894.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,366.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,004.65
|
| Rate for Payer: Cash Price |
$3,812.40
|
| Rate for Payer: Cigna Commercial |
$12,159.01
|
| Rate for Payer: Health EOS Commercial |
$11,762.52
|
| Rate for Payer: HFN Commercial |
$12,159.01
|
| Rate for Payer: Multiplan Commercial |
$10,573.06
|
| Rate for Payer: Preferred Network Access Commercial |
$12,159.01
|
| Rate for Payer: Quartz Beloit One Network |
$6,476.00
|
| Rate for Payer: Quartz Commercial |
$7,929.79
|
| Rate for Payer: WEA Trust Commercial |
$7,268.98
|
| Rate for Payer: WPS Commercial |
$9,788.97
|
|
|
IMPLANT MPT FUSION SMALL 5DEG RT ORTHOLOC 587115RT
|
Facility
|
OP
|
$12,708.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415906
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,700.57 |
| Max. Negotiated Rate |
$12,159.01 |
| Rate for Payer: Aetna Commercial |
$11,894.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,366.04
|
| Rate for Payer: Aetna Managed Medicare |
$3,700.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,590.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,608.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,343.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,004.65
|
| Rate for Payer: Cash Price |
$3,812.40
|
| Rate for Payer: Cigna Commercial |
$12,159.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,396.06
|
| Rate for Payer: Health EOS Commercial |
$11,762.52
|
| Rate for Payer: HFN Commercial |
$12,159.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,912.24
|
| Rate for Payer: Multiplan Commercial |
$10,573.06
|
| Rate for Payer: NAPHCARE Commercial |
$7,929.79
|
| Rate for Payer: Preferred Network Access Commercial |
$12,159.01
|
| Rate for Payer: Quartz Beloit One Network |
$6,476.00
|
| Rate for Payer: Quartz Commercial |
$8,590.61
|
| Rate for Payer: Quartz Medicare Advantage |
$7,929.79
|
| Rate for Payer: The Alliance Commercial |
$6,608.16
|
| Rate for Payer: WEA Trust Commercial |
$7,268.98
|
| Rate for Payer: WPS Commercial |
$9,788.97
|
|
|
IMPLANT OSTEOCHONDRAL CARTIVA 10MM CAR-10-US
|
Facility
|
OP
|
$20,714.00
|
|
|
Service Code
|
HCPCS L8642
|
| Hospital Charge Code |
5478767
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,594.03 |
| Max. Negotiated Rate |
$19,819.16 |
| Rate for Payer: Aetna Commercial |
$19,388.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,526.60
|
| Rate for Payer: Aetna Managed Medicare |
$6,031.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,002.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,771.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,340.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,417.56
|
| Rate for Payer: Cash Price |
$6,214.20
|
| Rate for Payer: Cash Price |
$6,214.20
|
| Rate for Payer: Cigna Commercial |
$19,819.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,055.55
|
| Rate for Payer: Health EOS Commercial |
$19,172.88
|
| Rate for Payer: HFN Commercial |
$19,819.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,156.92
|
| Rate for Payer: Multiplan Commercial |
$17,234.05
|
| Rate for Payer: NAPHCARE Commercial |
$12,925.54
|
| Rate for Payer: Preferred Network Access Commercial |
$19,819.16
|
| Rate for Payer: Quartz Beloit One Network |
$10,555.85
|
| Rate for Payer: Quartz Commercial |
$14,002.66
|
| Rate for Payer: Quartz Medicare Advantage |
$12,925.54
|
| Rate for Payer: The Alliance Commercial |
$1,594.03
|
| Rate for Payer: WEA Trust Commercial |
$11,848.41
|
| Rate for Payer: WPS Commercial |
$15,955.99
|
|
|
IMPLANT OSTEOCHONDRAL CARTIVA 10MM CAR-10-US
|
Facility
|
IP
|
$20,714.00
|
|
|
Service Code
|
HCPCS L8642
|
| Hospital Charge Code |
5478767
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,555.85 |
| Max. Negotiated Rate |
$19,819.16 |
| Rate for Payer: Aetna Commercial |
$19,388.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,526.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,417.56
|
| Rate for Payer: Cash Price |
$6,214.20
|
| Rate for Payer: Cigna Commercial |
$19,819.16
|
| Rate for Payer: Health EOS Commercial |
$19,172.88
|
| Rate for Payer: HFN Commercial |
$19,819.16
|
| Rate for Payer: Multiplan Commercial |
$17,234.05
|
| Rate for Payer: Preferred Network Access Commercial |
$19,819.16
|
| Rate for Payer: Quartz Beloit One Network |
$10,555.85
|
| Rate for Payer: Quartz Commercial |
$12,925.54
|
| Rate for Payer: WEA Trust Commercial |
$11,848.41
|
| Rate for Payer: WPS Commercial |
$15,955.99
|
|
|
IMPLANT OSTEOCHONDRAL CARTIVA 8MM CAR-08-US
|
Facility
|
OP
|
$19,562.00
|
|
|
Service Code
|
HCPCS L8642
|
| Hospital Charge Code |
5478764
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,594.03 |
| Max. Negotiated Rate |
$18,716.92 |
| Rate for Payer: Aetna Commercial |
$18,310.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,496.25
|
| Rate for Payer: Aetna Managed Medicare |
$5,696.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,223.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,172.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,765.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,782.57
|
| Rate for Payer: Cash Price |
$5,868.60
|
| Rate for Payer: Cash Price |
$5,868.60
|
| Rate for Payer: Cigna Commercial |
$18,716.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,385.08
|
| Rate for Payer: Health EOS Commercial |
$18,106.59
|
| Rate for Payer: HFN Commercial |
$18,716.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,258.36
|
| Rate for Payer: Multiplan Commercial |
$16,275.58
|
| Rate for Payer: NAPHCARE Commercial |
$12,206.69
|
| Rate for Payer: Preferred Network Access Commercial |
$18,716.92
|
| Rate for Payer: Quartz Beloit One Network |
$9,968.80
|
| Rate for Payer: Quartz Commercial |
$13,223.91
|
| Rate for Payer: Quartz Medicare Advantage |
$12,206.69
|
| Rate for Payer: The Alliance Commercial |
$1,594.03
|
| Rate for Payer: WEA Trust Commercial |
$11,189.46
|
| Rate for Payer: WPS Commercial |
$15,068.61
|
|
|
IMPLANT OSTEOCHONDRAL CARTIVA 8MM CAR-08-US
|
Facility
|
IP
|
$19,562.00
|
|
|
Service Code
|
HCPCS L8642
|
| Hospital Charge Code |
5478764
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,968.80 |
| Max. Negotiated Rate |
$18,716.92 |
| Rate for Payer: Aetna Commercial |
$18,310.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,496.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,782.57
|
| Rate for Payer: Cash Price |
$5,868.60
|
| Rate for Payer: Cigna Commercial |
$18,716.92
|
| Rate for Payer: Health EOS Commercial |
$18,106.59
|
| Rate for Payer: HFN Commercial |
$18,716.92
|
| Rate for Payer: Multiplan Commercial |
$16,275.58
|
| Rate for Payer: Preferred Network Access Commercial |
$18,716.92
|
| Rate for Payer: Quartz Beloit One Network |
$9,968.80
|
| Rate for Payer: Quartz Commercial |
$12,206.69
|
| Rate for Payer: WEA Trust Commercial |
$11,189.46
|
| Rate for Payer: WPS Commercial |
$15,068.61
|
|
|
IMPLANT PEEK ANGLED DUOFIT 11MM A60SP101
|
Facility
|
IP
|
$7,352.00
|
|
|
Service Code
|
HCPCS L8641
|
| Hospital Charge Code |
6021639
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,746.58 |
| Max. Negotiated Rate |
$7,034.39 |
| Rate for Payer: Aetna Commercial |
$6,881.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,575.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,052.42
|
| Rate for Payer: Cash Price |
$2,205.60
|
| Rate for Payer: Cigna Commercial |
$7,034.39
|
| Rate for Payer: Health EOS Commercial |
$6,805.01
|
| Rate for Payer: HFN Commercial |
$7,034.39
|
| Rate for Payer: Multiplan Commercial |
$6,116.86
|
| Rate for Payer: Preferred Network Access Commercial |
$7,034.39
|
| Rate for Payer: Quartz Beloit One Network |
$3,746.58
|
| Rate for Payer: Quartz Commercial |
$4,587.65
|
| Rate for Payer: WEA Trust Commercial |
$4,205.34
|
| Rate for Payer: WPS Commercial |
$5,663.25
|
|
|
IMPLANT PEEK ANGLED DUOFIT 11MM A60SP101
|
Facility
|
OP
|
$7,352.00
|
|
|
Service Code
|
HCPCS L8641
|
| Hospital Charge Code |
6021639
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,782.77 |
| Max. Negotiated Rate |
$7,034.39 |
| Rate for Payer: Aetna Commercial |
$6,881.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,575.63
|
| Rate for Payer: Aetna Managed Medicare |
$2,140.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,969.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,823.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,670.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,052.42
|
| Rate for Payer: Cash Price |
$2,205.60
|
| Rate for Payer: Cash Price |
$2,205.60
|
| Rate for Payer: Cigna Commercial |
$7,034.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,278.86
|
| Rate for Payer: Health EOS Commercial |
$6,805.01
|
| Rate for Payer: HFN Commercial |
$7,034.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,734.56
|
| Rate for Payer: Multiplan Commercial |
$6,116.86
|
| Rate for Payer: NAPHCARE Commercial |
$4,587.65
|
| Rate for Payer: Preferred Network Access Commercial |
$7,034.39
|
| Rate for Payer: Quartz Beloit One Network |
$3,746.58
|
| Rate for Payer: Quartz Commercial |
$4,969.95
|
| Rate for Payer: Quartz Medicare Advantage |
$4,587.65
|
| Rate for Payer: The Alliance Commercial |
$1,782.77
|
| Rate for Payer: WEA Trust Commercial |
$4,205.34
|
| Rate for Payer: WPS Commercial |
$5,663.25
|
|
|
IMPLANT PROPEL MOMETASONE CONTOUR 50011
|
Facility
|
IP
|
$7,261.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
5206657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,700.21 |
| Max. Negotiated Rate |
$6,947.32 |
| Rate for Payer: Aetna Commercial |
$6,796.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,494.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,002.26
|
| Rate for Payer: Cash Price |
$2,178.30
|
| Rate for Payer: Cigna Commercial |
$6,947.32
|
| Rate for Payer: Health EOS Commercial |
$6,720.78
|
| Rate for Payer: HFN Commercial |
$6,947.32
|
| Rate for Payer: Multiplan Commercial |
$6,041.15
|
| Rate for Payer: Preferred Network Access Commercial |
$6,947.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,700.21
|
| Rate for Payer: Quartz Commercial |
$4,530.86
|
| Rate for Payer: WEA Trust Commercial |
$4,153.29
|
| Rate for Payer: WPS Commercial |
$5,593.15
|
|
|
IMPLANT PROPEL MOMETASONE CONTOUR 50011
|
Facility
|
OP
|
$7,261.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
5206657
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,114.40 |
| Max. Negotiated Rate |
$6,947.32 |
| Rate for Payer: Aetna Commercial |
$6,796.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,494.24
|
| Rate for Payer: Aetna Managed Medicare |
$2,114.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,908.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,775.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,624.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,002.26
|
| Rate for Payer: Cash Price |
$2,178.30
|
| Rate for Payer: Cigna Commercial |
$6,947.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,225.90
|
| Rate for Payer: Health EOS Commercial |
$6,720.78
|
| Rate for Payer: HFN Commercial |
$6,947.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,663.58
|
| Rate for Payer: Multiplan Commercial |
$6,041.15
|
| Rate for Payer: NAPHCARE Commercial |
$4,530.86
|
| Rate for Payer: Preferred Network Access Commercial |
$6,947.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,700.21
|
| Rate for Payer: Quartz Commercial |
$4,908.44
|
| Rate for Payer: Quartz Medicare Advantage |
$4,530.86
|
| Rate for Payer: The Alliance Commercial |
$3,775.72
|
| Rate for Payer: WEA Trust Commercial |
$4,153.29
|
| Rate for Payer: WPS Commercial |
$5,593.15
|
|
|
IMPLANT PROPEL MOMETASONE FUROATE 70011
|
Facility
|
OP
|
$5,442.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
4519915
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,584.71 |
| Max. Negotiated Rate |
$5,206.91 |
| Rate for Payer: Aetna Commercial |
$5,093.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,867.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,584.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,678.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,829.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,716.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,999.63
|
| Rate for Payer: Cash Price |
$1,632.60
|
| Rate for Payer: Cigna Commercial |
$5,206.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,167.24
|
| Rate for Payer: Health EOS Commercial |
$5,037.12
|
| Rate for Payer: HFN Commercial |
$5,206.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,244.76
|
| Rate for Payer: Multiplan Commercial |
$4,527.74
|
| Rate for Payer: NAPHCARE Commercial |
$3,395.81
|
| Rate for Payer: Preferred Network Access Commercial |
$5,206.91
|
| Rate for Payer: Quartz Beloit One Network |
$2,773.24
|
| Rate for Payer: Quartz Commercial |
$3,678.79
|
| Rate for Payer: Quartz Medicare Advantage |
$3,395.81
|
| Rate for Payer: The Alliance Commercial |
$2,829.84
|
| Rate for Payer: WEA Trust Commercial |
$3,112.82
|
| Rate for Payer: WPS Commercial |
$4,191.97
|
|
|
IMPLANT PROPEL MOMETASONE FUROATE 70011
|
Facility
|
IP
|
$5,442.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
4519915
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,773.24 |
| Max. Negotiated Rate |
$5,206.91 |
| Rate for Payer: Aetna Commercial |
$5,093.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,867.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,999.63
|
| Rate for Payer: Cash Price |
$1,632.60
|
| Rate for Payer: Cigna Commercial |
$5,206.91
|
| Rate for Payer: Health EOS Commercial |
$5,037.12
|
| Rate for Payer: HFN Commercial |
$5,206.91
|
| Rate for Payer: Multiplan Commercial |
$4,527.74
|
| Rate for Payer: Preferred Network Access Commercial |
$5,206.91
|
| Rate for Payer: Quartz Beloit One Network |
$2,773.24
|
| Rate for Payer: Quartz Commercial |
$3,395.81
|
| Rate for Payer: WEA Trust Commercial |
$3,112.82
|
| Rate for Payer: WPS Commercial |
$4,191.97
|
|
