|
IMPLANT M-P JOINT POROUS COATED SMALL 10412
|
Facility
|
IP
|
$6,559.00
|
|
| Hospital Charge Code |
2969378
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,213.91 |
| Max. Negotiated Rate |
$6,034.28 |
| Rate for Payer: Aetna Commercial |
$5,903.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,640.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,476.27
|
| Rate for Payer: Cash Price |
$1,967.70
|
| Rate for Payer: Cigna Commercial |
$6,034.28
|
| Rate for Payer: Health EOS Commercial |
$5,837.51
|
| Rate for Payer: HFN Commercial |
$6,034.28
|
| Rate for Payer: Multiplan Commercial |
$5,247.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,935.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,034.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,213.91
|
| Rate for Payer: Quartz Commercial |
$3,935.40
|
| Rate for Payer: WEA Trust Commercial |
$3,607.45
|
| Rate for Payer: WPS Commercial |
$4,858.25
|
|
|
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 |
$3,324.44 |
| Max. Negotiated Rate |
$47,492.00 |
| Rate for Payer: Aetna Commercial |
$10,685.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,210.78
|
| Rate for Payer: Aetna Managed Medicare |
$3,324.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,717.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,936.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,699.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,292.69
|
| Rate for Payer: Cash Price |
$3,561.90
|
| Rate for Payer: Cigna Commercial |
$10,923.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,644.13
|
| Rate for Payer: Health EOS Commercial |
$10,566.97
|
| Rate for Payer: HFN Commercial |
$10,923.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,904.75
|
| Rate for Payer: Multiplan Commercial |
$9,498.40
|
| Rate for Payer: NAPHCARE Commercial |
$7,123.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,923.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,817.77
|
| Rate for Payer: Quartz Commercial |
$7,717.45
|
| Rate for Payer: Quartz Medicare Advantage |
$7,123.80
|
| Rate for Payer: The Alliance Commercial |
$47,492.00
|
| Rate for Payer: WEA Trust Commercial |
$6,530.15
|
| Rate for Payer: WPS Commercial |
$8,794.33
|
|
|
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 |
$5,817.77 |
| Max. Negotiated Rate |
$10,923.16 |
| Rate for Payer: Aetna Commercial |
$10,685.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,210.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,292.69
|
| Rate for Payer: Cash Price |
$3,561.90
|
| Rate for Payer: Cigna Commercial |
$10,923.16
|
| Rate for Payer: Health EOS Commercial |
$10,566.97
|
| Rate for Payer: HFN Commercial |
$10,923.16
|
| Rate for Payer: Multiplan Commercial |
$9,498.40
|
| Rate for Payer: NAPHCARE Commercial |
$7,123.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10,923.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,817.77
|
| Rate for Payer: Quartz Commercial |
$7,123.80
|
| Rate for Payer: WEA Trust Commercial |
$6,530.15
|
| Rate for Payer: WPS Commercial |
$8,794.33
|
|
|
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 |
$1,647.52 |
| Max. Negotiated Rate |
$23,536.00 |
| Rate for Payer: Aetna Commercial |
$5,295.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,060.24
|
| Rate for Payer: Aetna Managed Medicare |
$1,647.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,824.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,942.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,824.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,118.52
|
| Rate for Payer: Cash Price |
$1,765.20
|
| Rate for Payer: Cigna Commercial |
$5,413.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,292.69
|
| Rate for Payer: Health EOS Commercial |
$5,236.76
|
| Rate for Payer: HFN Commercial |
$5,413.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,413.00
|
| Rate for Payer: Multiplan Commercial |
$4,707.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,530.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,413.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,883.16
|
| Rate for Payer: Quartz Commercial |
$3,824.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,530.40
|
| Rate for Payer: The Alliance Commercial |
$23,536.00
|
| Rate for Payer: WEA Trust Commercial |
$3,236.20
|
| Rate for Payer: WPS Commercial |
$4,358.28
|
|
|
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 |
$2,883.16 |
| Max. Negotiated Rate |
$5,413.28 |
| Rate for Payer: Aetna Commercial |
$5,295.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,060.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,118.52
|
| Rate for Payer: Cash Price |
$1,765.20
|
| Rate for Payer: Cigna Commercial |
$5,413.28
|
| Rate for Payer: Health EOS Commercial |
$5,236.76
|
| Rate for Payer: HFN Commercial |
$5,413.28
|
| Rate for Payer: Multiplan Commercial |
$4,707.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,530.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,413.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,883.16
|
| Rate for Payer: Quartz Commercial |
$3,530.40
|
| Rate for Payer: WEA Trust Commercial |
$3,236.20
|
| Rate for Payer: WPS Commercial |
$4,358.28
|
|
|
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 |
$6,226.92 |
| Max. Negotiated Rate |
$11,691.36 |
| Rate for Payer: Aetna Commercial |
$11,437.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,928.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,735.24
|
| Rate for Payer: Cash Price |
$3,812.40
|
| Rate for Payer: Cigna Commercial |
$11,691.36
|
| Rate for Payer: Health EOS Commercial |
$11,310.12
|
| Rate for Payer: HFN Commercial |
$11,691.36
|
| Rate for Payer: Multiplan Commercial |
$10,166.40
|
| Rate for Payer: NAPHCARE Commercial |
$7,624.80
|
| Rate for Payer: Preferred Network Access Commercial |
$11,691.36
|
| Rate for Payer: Quartz Beloit One Network |
$6,226.92
|
| Rate for Payer: Quartz Commercial |
$7,624.80
|
| Rate for Payer: WEA Trust Commercial |
$6,989.40
|
| Rate for Payer: WPS Commercial |
$9,412.82
|
|
|
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 |
$3,558.24 |
| Max. Negotiated Rate |
$50,832.00 |
| Rate for Payer: Aetna Commercial |
$11,437.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,928.88
|
| Rate for Payer: Aetna Managed Medicare |
$3,558.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,260.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,354.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,099.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,735.24
|
| Rate for Payer: Cash Price |
$3,812.40
|
| Rate for Payer: Cigna Commercial |
$11,691.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,111.40
|
| Rate for Payer: Health EOS Commercial |
$11,310.12
|
| Rate for Payer: HFN Commercial |
$11,691.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,531.00
|
| Rate for Payer: Multiplan Commercial |
$10,166.40
|
| Rate for Payer: NAPHCARE Commercial |
$7,624.80
|
| Rate for Payer: Preferred Network Access Commercial |
$11,691.36
|
| Rate for Payer: Quartz Beloit One Network |
$6,226.92
|
| Rate for Payer: Quartz Commercial |
$8,260.20
|
| Rate for Payer: Quartz Medicare Advantage |
$7,624.80
|
| Rate for Payer: The Alliance Commercial |
$50,832.00
|
| Rate for Payer: WEA Trust Commercial |
$6,989.40
|
| Rate for Payer: WPS Commercial |
$9,412.82
|
|
|
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 |
$10,149.86 |
| Max. Negotiated Rate |
$19,056.88 |
| Rate for Payer: Aetna Commercial |
$18,642.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,814.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,978.42
|
| Rate for Payer: Cash Price |
$6,214.20
|
| Rate for Payer: Cigna Commercial |
$19,056.88
|
| Rate for Payer: Health EOS Commercial |
$18,435.46
|
| Rate for Payer: HFN Commercial |
$19,056.88
|
| Rate for Payer: Multiplan Commercial |
$16,571.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,428.40
|
| Rate for Payer: Preferred Network Access Commercial |
$19,056.88
|
| Rate for Payer: Quartz Beloit One Network |
$10,149.86
|
| Rate for Payer: Quartz Commercial |
$12,428.40
|
| Rate for Payer: WEA Trust Commercial |
$11,392.70
|
| Rate for Payer: WPS Commercial |
$15,342.86
|
|
|
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 |
$5,799.92 |
| Max. Negotiated Rate |
$82,856.00 |
| Rate for Payer: Aetna Commercial |
$18,642.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,814.04
|
| Rate for Payer: Aetna Managed Medicare |
$5,799.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,464.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,357.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,942.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,978.42
|
| Rate for Payer: Cash Price |
$6,214.20
|
| Rate for Payer: Cigna Commercial |
$19,056.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,591.55
|
| Rate for Payer: Health EOS Commercial |
$18,435.46
|
| Rate for Payer: HFN Commercial |
$19,056.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,535.50
|
| Rate for Payer: Multiplan Commercial |
$16,571.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,428.40
|
| Rate for Payer: Preferred Network Access Commercial |
$19,056.88
|
| Rate for Payer: Quartz Beloit One Network |
$10,149.86
|
| Rate for Payer: Quartz Commercial |
$13,464.10
|
| Rate for Payer: Quartz Medicare Advantage |
$12,428.40
|
| Rate for Payer: The Alliance Commercial |
$82,856.00
|
| Rate for Payer: WEA Trust Commercial |
$11,392.70
|
| Rate for Payer: WPS Commercial |
$15,342.86
|
|
|
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 |
$9,585.38 |
| Max. Negotiated Rate |
$17,997.04 |
| Rate for Payer: Aetna Commercial |
$17,605.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,823.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,367.86
|
| Rate for Payer: Cash Price |
$5,868.60
|
| Rate for Payer: Cigna Commercial |
$17,997.04
|
| Rate for Payer: Health EOS Commercial |
$17,410.18
|
| Rate for Payer: HFN Commercial |
$17,997.04
|
| Rate for Payer: Multiplan Commercial |
$15,649.60
|
| Rate for Payer: NAPHCARE Commercial |
$11,737.20
|
| Rate for Payer: Preferred Network Access Commercial |
$17,997.04
|
| Rate for Payer: Quartz Beloit One Network |
$9,585.38
|
| Rate for Payer: Quartz Commercial |
$11,737.20
|
| Rate for Payer: WEA Trust Commercial |
$10,759.10
|
| Rate for Payer: WPS Commercial |
$14,489.57
|
|
|
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 |
$5,477.36 |
| Max. Negotiated Rate |
$78,248.00 |
| Rate for Payer: Aetna Commercial |
$17,605.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,823.32
|
| Rate for Payer: Aetna Managed Medicare |
$5,477.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,715.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,781.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,389.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,367.86
|
| Rate for Payer: Cash Price |
$5,868.60
|
| Rate for Payer: Cigna Commercial |
$17,997.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,946.90
|
| Rate for Payer: Health EOS Commercial |
$17,410.18
|
| Rate for Payer: HFN Commercial |
$17,997.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,671.50
|
| Rate for Payer: Multiplan Commercial |
$15,649.60
|
| Rate for Payer: NAPHCARE Commercial |
$11,737.20
|
| Rate for Payer: Preferred Network Access Commercial |
$17,997.04
|
| Rate for Payer: Quartz Beloit One Network |
$9,585.38
|
| Rate for Payer: Quartz Commercial |
$12,715.30
|
| Rate for Payer: Quartz Medicare Advantage |
$11,737.20
|
| Rate for Payer: The Alliance Commercial |
$78,248.00
|
| Rate for Payer: WEA Trust Commercial |
$10,759.10
|
| Rate for Payer: WPS Commercial |
$14,489.57
|
|
|
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 |
$3,602.48 |
| Max. Negotiated Rate |
$6,763.84 |
| Rate for Payer: Aetna Commercial |
$6,616.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,322.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,896.56
|
| Rate for Payer: Cash Price |
$2,205.60
|
| Rate for Payer: Cigna Commercial |
$6,763.84
|
| Rate for Payer: Health EOS Commercial |
$6,543.28
|
| Rate for Payer: HFN Commercial |
$6,763.84
|
| Rate for Payer: Multiplan Commercial |
$5,881.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,411.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,763.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,602.48
|
| Rate for Payer: Quartz Commercial |
$4,411.20
|
| Rate for Payer: WEA Trust Commercial |
$4,043.60
|
| Rate for Payer: WPS Commercial |
$5,445.63
|
|
|
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 |
$2,058.56 |
| Max. Negotiated Rate |
$29,408.00 |
| Rate for Payer: Aetna Commercial |
$6,616.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,322.72
|
| Rate for Payer: Aetna Managed Medicare |
$2,058.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,778.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,676.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,528.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,896.56
|
| Rate for Payer: Cash Price |
$2,205.60
|
| Rate for Payer: Cigna Commercial |
$6,763.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,114.18
|
| Rate for Payer: Health EOS Commercial |
$6,543.28
|
| Rate for Payer: HFN Commercial |
$6,763.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,514.00
|
| Rate for Payer: Multiplan Commercial |
$5,881.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,411.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,763.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,602.48
|
| Rate for Payer: Quartz Commercial |
$4,778.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,411.20
|
| Rate for Payer: The Alliance Commercial |
$29,408.00
|
| Rate for Payer: WEA Trust Commercial |
$4,043.60
|
| Rate for Payer: WPS Commercial |
$5,445.63
|
|
|
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 |
$2,033.08 |
| Max. Negotiated Rate |
$29,044.00 |
| Rate for Payer: Aetna Commercial |
$6,534.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,244.46
|
| Rate for Payer: Aetna Managed Medicare |
$2,033.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,719.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,630.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,485.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,848.33
|
| Rate for Payer: Cash Price |
$2,178.30
|
| Rate for Payer: Cigna Commercial |
$6,680.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,063.26
|
| Rate for Payer: Health EOS Commercial |
$6,462.29
|
| Rate for Payer: HFN Commercial |
$6,680.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,445.75
|
| Rate for Payer: Multiplan Commercial |
$5,808.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,356.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,680.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,557.89
|
| Rate for Payer: Quartz Commercial |
$4,719.65
|
| Rate for Payer: Quartz Medicare Advantage |
$4,356.60
|
| Rate for Payer: The Alliance Commercial |
$29,044.00
|
| Rate for Payer: WEA Trust Commercial |
$3,993.55
|
| Rate for Payer: WPS Commercial |
$5,378.22
|
|
|
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 |
$3,557.89 |
| Max. Negotiated Rate |
$6,680.12 |
| Rate for Payer: Aetna Commercial |
$6,534.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,244.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,848.33
|
| Rate for Payer: Cash Price |
$2,178.30
|
| Rate for Payer: Cigna Commercial |
$6,680.12
|
| Rate for Payer: Health EOS Commercial |
$6,462.29
|
| Rate for Payer: HFN Commercial |
$6,680.12
|
| Rate for Payer: Multiplan Commercial |
$5,808.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,356.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,680.12
|
| Rate for Payer: Quartz Beloit One Network |
$3,557.89
|
| Rate for Payer: Quartz Commercial |
$4,356.60
|
| Rate for Payer: WEA Trust Commercial |
$3,993.55
|
| Rate for Payer: WPS Commercial |
$5,378.22
|
|
|
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 |
$1,523.76 |
| Max. Negotiated Rate |
$21,768.00 |
| Rate for Payer: Aetna Commercial |
$4,897.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,680.12
|
| Rate for Payer: Aetna Managed Medicare |
$1,523.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,537.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,721.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,612.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,884.26
|
| Rate for Payer: Cash Price |
$1,632.60
|
| Rate for Payer: Cigna Commercial |
$5,006.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,045.34
|
| Rate for Payer: Health EOS Commercial |
$4,843.38
|
| Rate for Payer: HFN Commercial |
$5,006.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,081.50
|
| Rate for Payer: Multiplan Commercial |
$4,353.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,265.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,006.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,666.58
|
| Rate for Payer: Quartz Commercial |
$3,537.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,265.20
|
| Rate for Payer: The Alliance Commercial |
$21,768.00
|
| Rate for Payer: WEA Trust Commercial |
$2,993.10
|
| Rate for Payer: WPS Commercial |
$4,030.89
|
|
|
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 |
$2,666.58 |
| Max. Negotiated Rate |
$5,006.64 |
| Rate for Payer: Aetna Commercial |
$4,897.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,680.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,884.26
|
| Rate for Payer: Cash Price |
$1,632.60
|
| Rate for Payer: Cigna Commercial |
$5,006.64
|
| Rate for Payer: Health EOS Commercial |
$4,843.38
|
| Rate for Payer: HFN Commercial |
$5,006.64
|
| Rate for Payer: Multiplan Commercial |
$4,353.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,265.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,006.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,666.58
|
| Rate for Payer: Quartz Commercial |
$3,265.20
|
| Rate for Payer: WEA Trust Commercial |
$2,993.10
|
| Rate for Payer: WPS Commercial |
$4,030.89
|
|
|
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 |
$1,582.28 |
| Max. Negotiated Rate |
$22,604.00 |
| Rate for Payer: Aetna Commercial |
$5,085.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,859.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,582.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,673.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,825.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,712.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,995.03
|
| Rate for Payer: Cash Price |
$1,695.30
|
| Rate for Payer: Cigna Commercial |
$5,198.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,162.30
|
| Rate for Payer: Health EOS Commercial |
$5,029.39
|
| Rate for Payer: HFN Commercial |
$5,198.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,238.25
|
| Rate for Payer: Multiplan Commercial |
$4,520.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,390.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,198.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,768.99
|
| Rate for Payer: Quartz Commercial |
$3,673.15
|
| Rate for Payer: Quartz Medicare Advantage |
$3,390.60
|
| Rate for Payer: The Alliance Commercial |
$22,604.00
|
| Rate for Payer: WEA Trust Commercial |
$3,108.05
|
| Rate for Payer: WPS Commercial |
$4,185.70
|
|
|
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 |
$2,768.99 |
| Max. Negotiated Rate |
$5,198.92 |
| Rate for Payer: Aetna Commercial |
$5,085.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,859.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,995.03
|
| Rate for Payer: Cash Price |
$1,695.30
|
| Rate for Payer: Cigna Commercial |
$5,198.92
|
| Rate for Payer: Health EOS Commercial |
$5,029.39
|
| Rate for Payer: HFN Commercial |
$5,198.92
|
| Rate for Payer: Multiplan Commercial |
$4,520.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,390.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,198.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,768.99
|
| Rate for Payer: Quartz Commercial |
$3,390.60
|
| Rate for Payer: WEA Trust Commercial |
$3,108.05
|
| Rate for Payer: WPS Commercial |
$4,185.70
|
|
|
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 |
$5,028.87 |
| Max. Negotiated Rate |
$9,441.96 |
| Rate for Payer: Aetna Commercial |
$9,236.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,826.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,439.39
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cigna Commercial |
$9,441.96
|
| Rate for Payer: Health EOS Commercial |
$9,134.07
|
| Rate for Payer: HFN Commercial |
$9,441.96
|
| Rate for Payer: Multiplan Commercial |
$8,210.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,157.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,441.96
|
| Rate for Payer: Quartz Beloit One Network |
$5,028.87
|
| Rate for Payer: Quartz Commercial |
$6,157.80
|
| Rate for Payer: WEA Trust Commercial |
$5,644.65
|
| Rate for Payer: WPS Commercial |
$7,601.80
|
|
|
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 |
$2,873.64 |
| Max. Negotiated Rate |
$41,052.00 |
| Rate for Payer: Aetna Commercial |
$9,236.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,826.18
|
| Rate for Payer: Aetna Managed Medicare |
$2,873.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,670.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,131.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,926.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,439.39
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cigna Commercial |
$9,441.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,743.17
|
| Rate for Payer: Health EOS Commercial |
$9,134.07
|
| Rate for Payer: HFN Commercial |
$9,441.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,697.25
|
| Rate for Payer: Multiplan Commercial |
$8,210.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,157.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,441.96
|
| Rate for Payer: Quartz Beloit One Network |
$5,028.87
|
| Rate for Payer: Quartz Commercial |
$6,670.95
|
| Rate for Payer: Quartz Medicare Advantage |
$6,157.80
|
| Rate for Payer: The Alliance Commercial |
$41,052.00
|
| Rate for Payer: WEA Trust Commercial |
$5,644.65
|
| Rate for Payer: WPS Commercial |
$7,601.80
|
|
|
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 |
$5,028.87 |
| Max. Negotiated Rate |
$9,441.96 |
| Rate for Payer: Aetna Commercial |
$9,236.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,826.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,439.39
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cigna Commercial |
$9,441.96
|
| Rate for Payer: Health EOS Commercial |
$9,134.07
|
| Rate for Payer: HFN Commercial |
$9,441.96
|
| Rate for Payer: Multiplan Commercial |
$8,210.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,157.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,441.96
|
| Rate for Payer: Quartz Beloit One Network |
$5,028.87
|
| Rate for Payer: Quartz Commercial |
$6,157.80
|
| Rate for Payer: WEA Trust Commercial |
$5,644.65
|
| Rate for Payer: WPS Commercial |
$7,601.80
|
|
|
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 |
$2,873.64 |
| Max. Negotiated Rate |
$41,052.00 |
| Rate for Payer: Aetna Commercial |
$9,236.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,826.18
|
| Rate for Payer: Aetna Managed Medicare |
$2,873.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,670.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,131.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,926.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,439.39
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cigna Commercial |
$9,441.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,743.17
|
| Rate for Payer: Health EOS Commercial |
$9,134.07
|
| Rate for Payer: HFN Commercial |
$9,441.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,697.25
|
| Rate for Payer: Multiplan Commercial |
$8,210.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,157.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,441.96
|
| Rate for Payer: Quartz Beloit One Network |
$5,028.87
|
| Rate for Payer: Quartz Commercial |
$6,670.95
|
| Rate for Payer: Quartz Medicare Advantage |
$6,157.80
|
| Rate for Payer: The Alliance Commercial |
$41,052.00
|
| Rate for Payer: WEA Trust Commercial |
$5,644.65
|
| Rate for Payer: WPS Commercial |
$7,601.80
|
|
|
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 |
$5,028.87 |
| Max. Negotiated Rate |
$9,441.96 |
| Rate for Payer: Aetna Commercial |
$9,236.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,826.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,439.39
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cigna Commercial |
$9,441.96
|
| Rate for Payer: Health EOS Commercial |
$9,134.07
|
| Rate for Payer: HFN Commercial |
$9,441.96
|
| Rate for Payer: Multiplan Commercial |
$8,210.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,157.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,441.96
|
| Rate for Payer: Quartz Beloit One Network |
$5,028.87
|
| Rate for Payer: Quartz Commercial |
$6,157.80
|
| Rate for Payer: WEA Trust Commercial |
$5,644.65
|
| Rate for Payer: WPS Commercial |
$7,601.80
|
|
|
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 |
$2,873.64 |
| Max. Negotiated Rate |
$41,052.00 |
| Rate for Payer: Aetna Commercial |
$9,236.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,826.18
|
| Rate for Payer: Aetna Managed Medicare |
$2,873.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,670.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,131.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,926.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,439.39
|
| Rate for Payer: Cash Price |
$3,078.90
|
| Rate for Payer: Cigna Commercial |
$9,441.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,743.17
|
| Rate for Payer: Health EOS Commercial |
$9,134.07
|
| Rate for Payer: HFN Commercial |
$9,441.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,697.25
|
| Rate for Payer: Multiplan Commercial |
$8,210.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,157.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,441.96
|
| Rate for Payer: Quartz Beloit One Network |
$5,028.87
|
| Rate for Payer: Quartz Commercial |
$6,670.95
|
| Rate for Payer: Quartz Medicare Advantage |
$6,157.80
|
| Rate for Payer: The Alliance Commercial |
$41,052.00
|
| Rate for Payer: WEA Trust Commercial |
$5,644.65
|
| Rate for Payer: WPS Commercial |
$7,601.80
|
|
