|
IMPLANT PROPEL MOMETASONE FUROATE MINI 60044
|
Facility
|
OP
|
$5,651.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
4519916
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,645.57 |
| Max. Negotiated Rate |
$5,406.88 |
| Rate for Payer: Aetna Commercial |
$5,289.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,054.25
|
| Rate for Payer: Aetna Managed Medicare |
$1,645.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,820.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,938.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,820.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,114.83
|
| Rate for Payer: Cash Price |
$1,695.30
|
| Rate for Payer: Cigna Commercial |
$5,406.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,288.88
|
| Rate for Payer: Health EOS Commercial |
$5,230.57
|
| Rate for Payer: HFN Commercial |
$5,406.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,407.78
|
| Rate for Payer: Multiplan Commercial |
$4,701.63
|
| Rate for Payer: NAPHCARE Commercial |
$3,526.22
|
| Rate for Payer: Preferred Network Access Commercial |
$5,406.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,879.75
|
| Rate for Payer: Quartz Commercial |
$3,820.08
|
| Rate for Payer: Quartz Medicare Advantage |
$3,526.22
|
| Rate for Payer: The Alliance Commercial |
$2,938.52
|
| Rate for Payer: WEA Trust Commercial |
$3,232.37
|
| Rate for Payer: WPS Commercial |
$4,352.97
|
|
|
IMPLANT PROPEL MOMETASONE FUROATE MINI 60044
|
Facility
|
IP
|
$5,651.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
4519916
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,879.75 |
| Max. Negotiated Rate |
$5,406.88 |
| Rate for Payer: Aetna Commercial |
$5,289.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,054.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,114.83
|
| Rate for Payer: Cash Price |
$1,695.30
|
| Rate for Payer: Cigna Commercial |
$5,406.88
|
| Rate for Payer: Health EOS Commercial |
$5,230.57
|
| Rate for Payer: HFN Commercial |
$5,406.88
|
| Rate for Payer: Multiplan Commercial |
$4,701.63
|
| Rate for Payer: Preferred Network Access Commercial |
$5,406.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,879.75
|
| Rate for Payer: Quartz Commercial |
$3,526.22
|
| Rate for Payer: WEA Trust Commercial |
$3,232.37
|
| Rate for Payer: WPS Commercial |
$4,352.97
|
|
|
IMPLANT RTS FLEXIBLE 1ST MPJ WITH GROMMETS SZ 1 M30 SE010
|
Facility
|
IP
|
$10,263.00
|
|
|
Service Code
|
HCPCS L8641
|
| Hospital Charge Code |
6131656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,230.02 |
| Max. Negotiated Rate |
$9,819.64 |
| Rate for Payer: Aetna Commercial |
$9,606.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,179.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,656.97
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cigna Commercial |
$9,819.64
|
| Rate for Payer: Health EOS Commercial |
$9,499.43
|
| Rate for Payer: HFN Commercial |
$9,819.64
|
| Rate for Payer: Multiplan Commercial |
$8,538.82
|
| Rate for Payer: Preferred Network Access Commercial |
$9,819.64
|
| Rate for Payer: Quartz Beloit One Network |
$5,230.02
|
| Rate for Payer: Quartz Commercial |
$6,404.11
|
| Rate for Payer: WEA Trust Commercial |
$5,870.44
|
| Rate for Payer: WPS Commercial |
$7,905.59
|
|
|
IMPLANT RTS FLEXIBLE 1ST MPJ WITH GROMMETS SZ 1 M30 SE010
|
Facility
|
OP
|
$10,263.00
|
|
|
Service Code
|
HCPCS L8641
|
| Hospital Charge Code |
6131656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,782.77 |
| Max. Negotiated Rate |
$9,819.64 |
| Rate for Payer: Aetna Commercial |
$9,606.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,179.23
|
| Rate for Payer: Aetna Managed Medicare |
$2,988.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,937.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,336.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,123.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,656.97
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cigna Commercial |
$9,819.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,973.07
|
| Rate for Payer: Health EOS Commercial |
$9,499.43
|
| Rate for Payer: HFN Commercial |
$9,819.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,005.14
|
| Rate for Payer: Multiplan Commercial |
$8,538.82
|
| Rate for Payer: NAPHCARE Commercial |
$6,404.11
|
| Rate for Payer: Preferred Network Access Commercial |
$9,819.64
|
| Rate for Payer: Quartz Beloit One Network |
$5,230.02
|
| Rate for Payer: Quartz Commercial |
$6,937.79
|
| Rate for Payer: Quartz Medicare Advantage |
$6,404.11
|
| Rate for Payer: The Alliance Commercial |
$1,782.77
|
| Rate for Payer: WEA Trust Commercial |
$5,870.44
|
| Rate for Payer: WPS Commercial |
$7,905.59
|
|
|
IMPLANT RTS FLEXIBLE 1ST MPJ WITH GROMMETS SZ 2 M30 SE020
|
Facility
|
IP
|
$10,263.00
|
|
|
Service Code
|
HCPCS L8641
|
| Hospital Charge Code |
6131655
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,230.02 |
| Max. Negotiated Rate |
$9,819.64 |
| Rate for Payer: Aetna Commercial |
$9,606.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,179.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,656.97
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cigna Commercial |
$9,819.64
|
| Rate for Payer: Health EOS Commercial |
$9,499.43
|
| Rate for Payer: HFN Commercial |
$9,819.64
|
| Rate for Payer: Multiplan Commercial |
$8,538.82
|
| Rate for Payer: Preferred Network Access Commercial |
$9,819.64
|
| Rate for Payer: Quartz Beloit One Network |
$5,230.02
|
| Rate for Payer: Quartz Commercial |
$6,404.11
|
| Rate for Payer: WEA Trust Commercial |
$5,870.44
|
| Rate for Payer: WPS Commercial |
$7,905.59
|
|
|
IMPLANT RTS FLEXIBLE 1ST MPJ WITH GROMMETS SZ 2 M30 SE020
|
Facility
|
OP
|
$10,263.00
|
|
|
Service Code
|
HCPCS L8641
|
| Hospital Charge Code |
6131655
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,782.77 |
| Max. Negotiated Rate |
$9,819.64 |
| Rate for Payer: Aetna Commercial |
$9,606.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,179.23
|
| Rate for Payer: Aetna Managed Medicare |
$2,988.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,937.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,336.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,123.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,656.97
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cigna Commercial |
$9,819.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,973.07
|
| Rate for Payer: Health EOS Commercial |
$9,499.43
|
| Rate for Payer: HFN Commercial |
$9,819.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,005.14
|
| Rate for Payer: Multiplan Commercial |
$8,538.82
|
| Rate for Payer: NAPHCARE Commercial |
$6,404.11
|
| Rate for Payer: Preferred Network Access Commercial |
$9,819.64
|
| Rate for Payer: Quartz Beloit One Network |
$5,230.02
|
| Rate for Payer: Quartz Commercial |
$6,937.79
|
| Rate for Payer: Quartz Medicare Advantage |
$6,404.11
|
| Rate for Payer: The Alliance Commercial |
$1,782.77
|
| Rate for Payer: WEA Trust Commercial |
$5,870.44
|
| Rate for Payer: WPS Commercial |
$7,905.59
|
|
|
IMPLANT RTS LESSER MTP M40 SE010
|
Facility
|
IP
|
$10,263.00
|
|
|
Service Code
|
HCPCS L8641
|
| Hospital Charge Code |
6021632
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,230.02 |
| Max. Negotiated Rate |
$9,819.64 |
| Rate for Payer: Aetna Commercial |
$9,606.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,179.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,656.97
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cigna Commercial |
$9,819.64
|
| Rate for Payer: Health EOS Commercial |
$9,499.43
|
| Rate for Payer: HFN Commercial |
$9,819.64
|
| Rate for Payer: Multiplan Commercial |
$8,538.82
|
| Rate for Payer: Preferred Network Access Commercial |
$9,819.64
|
| Rate for Payer: Quartz Beloit One Network |
$5,230.02
|
| Rate for Payer: Quartz Commercial |
$6,404.11
|
| Rate for Payer: WEA Trust Commercial |
$5,870.44
|
| Rate for Payer: WPS Commercial |
$7,905.59
|
|
|
IMPLANT RTS LESSER MTP M40 SE010
|
Facility
|
OP
|
$10,263.00
|
|
|
Service Code
|
HCPCS L8641
|
| Hospital Charge Code |
6021632
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,782.77 |
| Max. Negotiated Rate |
$9,819.64 |
| Rate for Payer: Aetna Commercial |
$9,606.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,179.23
|
| Rate for Payer: Aetna Managed Medicare |
$2,988.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,937.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,336.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,123.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,656.97
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cigna Commercial |
$9,819.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,973.07
|
| Rate for Payer: Health EOS Commercial |
$9,499.43
|
| Rate for Payer: HFN Commercial |
$9,819.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,005.14
|
| Rate for Payer: Multiplan Commercial |
$8,538.82
|
| Rate for Payer: NAPHCARE Commercial |
$6,404.11
|
| Rate for Payer: Preferred Network Access Commercial |
$9,819.64
|
| Rate for Payer: Quartz Beloit One Network |
$5,230.02
|
| Rate for Payer: Quartz Commercial |
$6,937.79
|
| Rate for Payer: Quartz Medicare Advantage |
$6,404.11
|
| Rate for Payer: The Alliance Commercial |
$1,782.77
|
| Rate for Payer: WEA Trust Commercial |
$5,870.44
|
| Rate for Payer: WPS Commercial |
$7,905.59
|
|
|
IMPLANT RTS LESSER MTP M40 SE020
|
Facility
|
OP
|
$10,263.00
|
|
|
Service Code
|
HCPCS L8641
|
| Hospital Charge Code |
6021633
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,782.77 |
| Max. Negotiated Rate |
$9,819.64 |
| Rate for Payer: Aetna Commercial |
$9,606.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,179.23
|
| Rate for Payer: Aetna Managed Medicare |
$2,988.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,937.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,336.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,123.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,656.97
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cigna Commercial |
$9,819.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,973.07
|
| Rate for Payer: Health EOS Commercial |
$9,499.43
|
| Rate for Payer: HFN Commercial |
$9,819.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,005.14
|
| Rate for Payer: Multiplan Commercial |
$8,538.82
|
| Rate for Payer: NAPHCARE Commercial |
$6,404.11
|
| Rate for Payer: Preferred Network Access Commercial |
$9,819.64
|
| Rate for Payer: Quartz Beloit One Network |
$5,230.02
|
| Rate for Payer: Quartz Commercial |
$6,937.79
|
| Rate for Payer: Quartz Medicare Advantage |
$6,404.11
|
| Rate for Payer: The Alliance Commercial |
$1,782.77
|
| Rate for Payer: WEA Trust Commercial |
$5,870.44
|
| Rate for Payer: WPS Commercial |
$7,905.59
|
|
|
IMPLANT RTS LESSER MTP M40 SE020
|
Facility
|
IP
|
$10,263.00
|
|
|
Service Code
|
HCPCS L8641
|
| Hospital Charge Code |
6021633
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,230.02 |
| Max. Negotiated Rate |
$9,819.64 |
| Rate for Payer: Aetna Commercial |
$9,606.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,179.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,656.97
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cigna Commercial |
$9,819.64
|
| Rate for Payer: Health EOS Commercial |
$9,499.43
|
| Rate for Payer: HFN Commercial |
$9,819.64
|
| Rate for Payer: Multiplan Commercial |
$8,538.82
|
| Rate for Payer: Preferred Network Access Commercial |
$9,819.64
|
| Rate for Payer: Quartz Beloit One Network |
$5,230.02
|
| Rate for Payer: Quartz Commercial |
$6,404.11
|
| Rate for Payer: WEA Trust Commercial |
$5,870.44
|
| Rate for Payer: WPS Commercial |
$7,905.59
|
|
|
IMPLANT RTS LESSER MTP M40 SE030
|
Facility
|
IP
|
$10,263.00
|
|
|
Service Code
|
HCPCS L8641
|
| Hospital Charge Code |
6021634
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,230.02 |
| Max. Negotiated Rate |
$9,819.64 |
| Rate for Payer: Aetna Commercial |
$9,606.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,179.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,656.97
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cigna Commercial |
$9,819.64
|
| Rate for Payer: Health EOS Commercial |
$9,499.43
|
| Rate for Payer: HFN Commercial |
$9,819.64
|
| Rate for Payer: Multiplan Commercial |
$8,538.82
|
| Rate for Payer: Preferred Network Access Commercial |
$9,819.64
|
| Rate for Payer: Quartz Beloit One Network |
$5,230.02
|
| Rate for Payer: Quartz Commercial |
$6,404.11
|
| Rate for Payer: WEA Trust Commercial |
$5,870.44
|
| Rate for Payer: WPS Commercial |
$7,905.59
|
|
|
IMPLANT RTS LESSER MTP M40 SE030
|
Facility
|
OP
|
$10,263.00
|
|
|
Service Code
|
HCPCS L8641
|
| Hospital Charge Code |
6021634
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,782.77 |
| Max. Negotiated Rate |
$9,819.64 |
| Rate for Payer: Aetna Commercial |
$9,606.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,179.23
|
| Rate for Payer: Aetna Managed Medicare |
$2,988.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,937.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,336.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,123.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,656.97
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cigna Commercial |
$9,819.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,973.07
|
| Rate for Payer: Health EOS Commercial |
$9,499.43
|
| Rate for Payer: HFN Commercial |
$9,819.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,005.14
|
| Rate for Payer: Multiplan Commercial |
$8,538.82
|
| Rate for Payer: NAPHCARE Commercial |
$6,404.11
|
| Rate for Payer: Preferred Network Access Commercial |
$9,819.64
|
| Rate for Payer: Quartz Beloit One Network |
$5,230.02
|
| Rate for Payer: Quartz Commercial |
$6,937.79
|
| Rate for Payer: Quartz Medicare Advantage |
$6,404.11
|
| Rate for Payer: The Alliance Commercial |
$1,782.77
|
| Rate for Payer: WEA Trust Commercial |
$5,870.44
|
| Rate for Payer: WPS Commercial |
$7,905.59
|
|
|
IMPLANT SIZER RTS SZ 1-4 M03 S0001
|
Facility
|
OP
|
$1,846.00
|
|
| Hospital Charge Code |
6131657
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$537.56 |
| Max. Negotiated Rate |
$1,766.25 |
| Rate for Payer: Aetna Commercial |
$1,727.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,651.06
|
| Rate for Payer: Aetna Managed Medicare |
$537.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,247.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$959.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$921.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,017.52
|
| Rate for Payer: Cash Price |
$553.80
|
| Rate for Payer: Cigna Commercial |
$1,766.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,074.37
|
| Rate for Payer: Health EOS Commercial |
$1,708.66
|
| Rate for Payer: HFN Commercial |
$1,766.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,439.88
|
| Rate for Payer: Multiplan Commercial |
$1,535.87
|
| Rate for Payer: NAPHCARE Commercial |
$1,151.90
|
| Rate for Payer: Preferred Network Access Commercial |
$1,766.25
|
| Rate for Payer: Quartz Beloit One Network |
$940.72
|
| Rate for Payer: Quartz Commercial |
$1,247.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,151.90
|
| Rate for Payer: The Alliance Commercial |
$959.92
|
| Rate for Payer: WEA Trust Commercial |
$1,055.91
|
| Rate for Payer: WPS Commercial |
$1,421.97
|
|
|
IMPLANT SIZER RTS SZ 1-4 M03 S0001
|
Facility
|
IP
|
$1,846.00
|
|
| Hospital Charge Code |
6131657
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$940.72 |
| Max. Negotiated Rate |
$1,766.25 |
| Rate for Payer: Aetna Commercial |
$1,727.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,651.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,017.52
|
| Rate for Payer: Cash Price |
$553.80
|
| Rate for Payer: Cigna Commercial |
$1,766.25
|
| Rate for Payer: Health EOS Commercial |
$1,708.66
|
| Rate for Payer: HFN Commercial |
$1,766.25
|
| Rate for Payer: Multiplan Commercial |
$1,535.87
|
| Rate for Payer: Preferred Network Access Commercial |
$1,766.25
|
| Rate for Payer: Quartz Beloit One Network |
$940.72
|
| Rate for Payer: Quartz Commercial |
$1,151.90
|
| Rate for Payer: WEA Trust Commercial |
$1,055.91
|
| Rate for Payer: WPS Commercial |
$1,421.97
|
|
|
IMPLANT SMART TOE 11MM STOXS-11
|
Facility
|
IP
|
$6,362.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3072565
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,242.08 |
| Max. Negotiated Rate |
$6,087.16 |
| Rate for Payer: Aetna Commercial |
$5,954.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,690.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,506.73
|
| Rate for Payer: Cash Price |
$1,908.60
|
| Rate for Payer: Cigna Commercial |
$6,087.16
|
| Rate for Payer: Health EOS Commercial |
$5,888.67
|
| Rate for Payer: HFN Commercial |
$6,087.16
|
| Rate for Payer: Multiplan Commercial |
$5,293.18
|
| Rate for Payer: Preferred Network Access Commercial |
$6,087.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,242.08
|
| Rate for Payer: Quartz Commercial |
$3,969.89
|
| Rate for Payer: WEA Trust Commercial |
$3,639.06
|
| Rate for Payer: WPS Commercial |
$4,900.65
|
|
|
IMPLANT SMART TOE 11MM STOXS-11
|
Facility
|
OP
|
$6,362.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3072565
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,852.61 |
| Max. Negotiated Rate |
$6,087.16 |
| Rate for Payer: Aetna Commercial |
$5,954.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,690.17
|
| Rate for Payer: Aetna Managed Medicare |
$1,852.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,300.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,308.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,175.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,506.73
|
| Rate for Payer: Cash Price |
$1,908.60
|
| Rate for Payer: Cigna Commercial |
$6,087.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,702.68
|
| Rate for Payer: Health EOS Commercial |
$5,888.67
|
| Rate for Payer: HFN Commercial |
$6,087.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,962.36
|
| Rate for Payer: Multiplan Commercial |
$5,293.18
|
| Rate for Payer: NAPHCARE Commercial |
$3,969.89
|
| Rate for Payer: Preferred Network Access Commercial |
$6,087.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,242.08
|
| Rate for Payer: Quartz Commercial |
$4,300.71
|
| Rate for Payer: Quartz Medicare Advantage |
$3,969.89
|
| Rate for Payer: The Alliance Commercial |
$3,308.24
|
| Rate for Payer: WEA Trust Commercial |
$3,639.06
|
| Rate for Payer: WPS Commercial |
$4,900.65
|
|
|
IMPLANT SMART TOE 13MM STOXS-13
|
Facility
|
IP
|
$7,285.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2965386
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,712.44 |
| Max. Negotiated Rate |
$6,970.29 |
| Rate for Payer: Aetna Commercial |
$6,818.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,515.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,015.49
|
| Rate for Payer: Cash Price |
$2,185.50
|
| Rate for Payer: Cigna Commercial |
$6,970.29
|
| Rate for Payer: Health EOS Commercial |
$6,743.00
|
| Rate for Payer: HFN Commercial |
$6,970.29
|
| Rate for Payer: Multiplan Commercial |
$6,061.12
|
| Rate for Payer: Preferred Network Access Commercial |
$6,970.29
|
| Rate for Payer: Quartz Beloit One Network |
$3,712.44
|
| Rate for Payer: Quartz Commercial |
$4,545.84
|
| Rate for Payer: WEA Trust Commercial |
$4,167.02
|
| Rate for Payer: WPS Commercial |
$5,611.64
|
|
|
IMPLANT SMART TOE 13MM STOXS-13
|
Facility
|
OP
|
$7,285.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2965386
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,121.39 |
| Max. Negotiated Rate |
$6,970.29 |
| Rate for Payer: Aetna Commercial |
$6,818.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,515.70
|
| Rate for Payer: Aetna Managed Medicare |
$2,121.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,924.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,788.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,636.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,015.49
|
| Rate for Payer: Cash Price |
$2,185.50
|
| Rate for Payer: Cigna Commercial |
$6,970.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,239.87
|
| Rate for Payer: Health EOS Commercial |
$6,743.00
|
| Rate for Payer: HFN Commercial |
$6,970.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,682.30
|
| Rate for Payer: Multiplan Commercial |
$6,061.12
|
| Rate for Payer: NAPHCARE Commercial |
$4,545.84
|
| Rate for Payer: Preferred Network Access Commercial |
$6,970.29
|
| Rate for Payer: Quartz Beloit One Network |
$3,712.44
|
| Rate for Payer: Quartz Commercial |
$4,924.66
|
| Rate for Payer: Quartz Medicare Advantage |
$4,545.84
|
| Rate for Payer: The Alliance Commercial |
$3,788.20
|
| Rate for Payer: WEA Trust Commercial |
$4,167.02
|
| Rate for Payer: WPS Commercial |
$5,611.64
|
|
|
IMPLANT SMART TOE 16MM ANGLED STOA-16P
|
Facility
|
OP
|
$4,931.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966083
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,435.91 |
| Max. Negotiated Rate |
$4,717.98 |
| Rate for Payer: Aetna Commercial |
$4,615.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,410.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,435.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,333.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,564.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,461.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,717.97
|
| Rate for Payer: Cash Price |
$1,479.30
|
| Rate for Payer: Cigna Commercial |
$4,717.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,869.84
|
| Rate for Payer: Health EOS Commercial |
$4,564.13
|
| Rate for Payer: HFN Commercial |
$4,717.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,846.18
|
| Rate for Payer: Multiplan Commercial |
$4,102.59
|
| Rate for Payer: NAPHCARE Commercial |
$3,076.94
|
| Rate for Payer: Preferred Network Access Commercial |
$4,717.98
|
| Rate for Payer: Quartz Beloit One Network |
$2,512.84
|
| Rate for Payer: Quartz Commercial |
$3,333.36
|
| Rate for Payer: Quartz Medicare Advantage |
$3,076.94
|
| Rate for Payer: The Alliance Commercial |
$2,564.12
|
| Rate for Payer: WEA Trust Commercial |
$2,820.53
|
| Rate for Payer: WPS Commercial |
$3,798.35
|
|
|
IMPLANT SMART TOE 16MM ANGLED STOA-16P
|
Facility
|
IP
|
$4,931.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966083
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,512.84 |
| Max. Negotiated Rate |
$4,717.98 |
| Rate for Payer: Aetna Commercial |
$4,615.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,410.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,717.97
|
| Rate for Payer: Cash Price |
$1,479.30
|
| Rate for Payer: Cigna Commercial |
$4,717.98
|
| Rate for Payer: Health EOS Commercial |
$4,564.13
|
| Rate for Payer: HFN Commercial |
$4,717.98
|
| Rate for Payer: Multiplan Commercial |
$4,102.59
|
| Rate for Payer: Preferred Network Access Commercial |
$4,717.98
|
| Rate for Payer: Quartz Beloit One Network |
$2,512.84
|
| Rate for Payer: Quartz Commercial |
$3,076.94
|
| Rate for Payer: WEA Trust Commercial |
$2,820.53
|
| Rate for Payer: WPS Commercial |
$3,798.35
|
|
|
IMPLANT SMART TOE 16MM STO-16P
|
Facility
|
OP
|
$4,930.00
|
|
|
Service Code
|
HCPCS L8642
|
| Hospital Charge Code |
2966082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,435.62 |
| Max. Negotiated Rate |
$4,717.02 |
| Rate for Payer: Aetna Commercial |
$4,614.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,409.39
|
| Rate for Payer: Aetna Managed Medicare |
$1,435.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,332.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,563.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,461.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,717.42
|
| Rate for Payer: Cash Price |
$1,479.00
|
| Rate for Payer: Cash Price |
$1,479.00
|
| Rate for Payer: Cigna Commercial |
$4,717.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,869.26
|
| Rate for Payer: Health EOS Commercial |
$4,563.21
|
| Rate for Payer: HFN Commercial |
$4,717.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,845.40
|
| Rate for Payer: Multiplan Commercial |
$4,101.76
|
| Rate for Payer: NAPHCARE Commercial |
$3,076.32
|
| Rate for Payer: Preferred Network Access Commercial |
$4,717.02
|
| Rate for Payer: Quartz Beloit One Network |
$2,512.33
|
| Rate for Payer: Quartz Commercial |
$3,332.68
|
| Rate for Payer: Quartz Medicare Advantage |
$3,076.32
|
| Rate for Payer: The Alliance Commercial |
$1,594.03
|
| Rate for Payer: WEA Trust Commercial |
$2,819.96
|
| Rate for Payer: WPS Commercial |
$3,797.58
|
|
|
IMPLANT SMART TOE 16MM STO-16P
|
Facility
|
IP
|
$4,930.00
|
|
|
Service Code
|
HCPCS L8642
|
| Hospital Charge Code |
2966082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,512.33 |
| Max. Negotiated Rate |
$4,717.02 |
| Rate for Payer: Aetna Commercial |
$4,614.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,409.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,717.42
|
| Rate for Payer: Cash Price |
$1,479.00
|
| Rate for Payer: Cigna Commercial |
$4,717.02
|
| Rate for Payer: Health EOS Commercial |
$4,563.21
|
| Rate for Payer: HFN Commercial |
$4,717.02
|
| Rate for Payer: Multiplan Commercial |
$4,101.76
|
| Rate for Payer: Preferred Network Access Commercial |
$4,717.02
|
| Rate for Payer: Quartz Beloit One Network |
$2,512.33
|
| Rate for Payer: Quartz Commercial |
$3,076.32
|
| Rate for Payer: WEA Trust Commercial |
$2,819.96
|
| Rate for Payer: WPS Commercial |
$3,797.58
|
|
|
IMPLANT SMART TOE 19MM ANGLED STOA-19P
|
Facility
|
IP
|
$4,931.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966085
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,512.84 |
| Max. Negotiated Rate |
$4,717.98 |
| Rate for Payer: Aetna Commercial |
$4,615.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,410.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,717.97
|
| Rate for Payer: Cash Price |
$1,479.30
|
| Rate for Payer: Cigna Commercial |
$4,717.98
|
| Rate for Payer: Health EOS Commercial |
$4,564.13
|
| Rate for Payer: HFN Commercial |
$4,717.98
|
| Rate for Payer: Multiplan Commercial |
$4,102.59
|
| Rate for Payer: Preferred Network Access Commercial |
$4,717.98
|
| Rate for Payer: Quartz Beloit One Network |
$2,512.84
|
| Rate for Payer: Quartz Commercial |
$3,076.94
|
| Rate for Payer: WEA Trust Commercial |
$2,820.53
|
| Rate for Payer: WPS Commercial |
$3,798.35
|
|
|
IMPLANT SMART TOE 19MM ANGLED STOA-19P
|
Facility
|
OP
|
$4,931.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966085
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,435.91 |
| Max. Negotiated Rate |
$4,717.98 |
| Rate for Payer: Aetna Commercial |
$4,615.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,410.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,435.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,333.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,564.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,461.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,717.97
|
| Rate for Payer: Cash Price |
$1,479.30
|
| Rate for Payer: Cigna Commercial |
$4,717.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,869.84
|
| Rate for Payer: Health EOS Commercial |
$4,564.13
|
| Rate for Payer: HFN Commercial |
$4,717.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,846.18
|
| Rate for Payer: Multiplan Commercial |
$4,102.59
|
| Rate for Payer: NAPHCARE Commercial |
$3,076.94
|
| Rate for Payer: Preferred Network Access Commercial |
$4,717.98
|
| Rate for Payer: Quartz Beloit One Network |
$2,512.84
|
| Rate for Payer: Quartz Commercial |
$3,333.36
|
| Rate for Payer: Quartz Medicare Advantage |
$3,076.94
|
| Rate for Payer: The Alliance Commercial |
$2,564.12
|
| Rate for Payer: WEA Trust Commercial |
$2,820.53
|
| Rate for Payer: WPS Commercial |
$3,798.35
|
|
|
IMPLANT SMART TOE 19MM STO-19P
|
Facility
|
OP
|
$4,931.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,435.91 |
| Max. Negotiated Rate |
$4,717.98 |
| Rate for Payer: Aetna Commercial |
$4,615.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,410.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,435.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,333.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,564.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,461.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,717.97
|
| Rate for Payer: Cash Price |
$1,479.30
|
| Rate for Payer: Cigna Commercial |
$4,717.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,869.84
|
| Rate for Payer: Health EOS Commercial |
$4,564.13
|
| Rate for Payer: HFN Commercial |
$4,717.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,846.18
|
| Rate for Payer: Multiplan Commercial |
$4,102.59
|
| Rate for Payer: NAPHCARE Commercial |
$3,076.94
|
| Rate for Payer: Preferred Network Access Commercial |
$4,717.98
|
| Rate for Payer: Quartz Beloit One Network |
$2,512.84
|
| Rate for Payer: Quartz Commercial |
$3,333.36
|
| Rate for Payer: Quartz Medicare Advantage |
$3,076.94
|
| Rate for Payer: The Alliance Commercial |
$2,564.12
|
| Rate for Payer: WEA Trust Commercial |
$2,820.53
|
| Rate for Payer: WPS Commercial |
$3,798.35
|
|
