|
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 |
$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 SE020
|
Facility
|
IP
|
$10,263.00
|
|
|
Service Code
|
HCPCS L8641
|
| Hospital Charge Code |
6021633
|
|
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 SE030
|
Facility
|
IP
|
$10,263.00
|
|
|
Service Code
|
HCPCS L8641
|
| Hospital Charge Code |
6021634
|
|
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 SE030
|
Facility
|
OP
|
$10,263.00
|
|
|
Service Code
|
HCPCS L8641
|
| Hospital Charge Code |
6021634
|
|
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 SIZER RTS SZ 1-4 M03 S0001
|
Facility
|
OP
|
$1,846.00
|
|
| Hospital Charge Code |
6131657
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$516.88 |
| Max. Negotiated Rate |
$7,384.00 |
| Rate for Payer: Aetna Commercial |
$1,661.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,587.56
|
| Rate for Payer: Aetna Managed Medicare |
$516.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,199.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$923.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$886.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$978.38
|
| Rate for Payer: Cash Price |
$553.80
|
| Rate for Payer: Cigna Commercial |
$1,698.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,033.02
|
| Rate for Payer: Health EOS Commercial |
$1,642.94
|
| Rate for Payer: HFN Commercial |
$1,698.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,384.50
|
| Rate for Payer: Multiplan Commercial |
$1,476.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,107.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,698.32
|
| Rate for Payer: Quartz Beloit One Network |
$904.54
|
| Rate for Payer: Quartz Commercial |
$1,199.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,107.60
|
| Rate for Payer: The Alliance Commercial |
$7,384.00
|
| Rate for Payer: WEA Trust Commercial |
$1,015.30
|
| Rate for Payer: WPS Commercial |
$1,367.33
|
|
|
IMPLANT SIZER RTS SZ 1-4 M03 S0001
|
Facility
|
IP
|
$1,846.00
|
|
| Hospital Charge Code |
6131657
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$904.54 |
| Max. Negotiated Rate |
$1,698.32 |
| Rate for Payer: Aetna Commercial |
$1,661.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,587.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$978.38
|
| Rate for Payer: Cash Price |
$553.80
|
| Rate for Payer: Cigna Commercial |
$1,698.32
|
| Rate for Payer: Health EOS Commercial |
$1,642.94
|
| Rate for Payer: HFN Commercial |
$1,698.32
|
| Rate for Payer: Multiplan Commercial |
$1,476.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,107.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,698.32
|
| Rate for Payer: Quartz Beloit One Network |
$904.54
|
| Rate for Payer: Quartz Commercial |
$1,107.60
|
| Rate for Payer: WEA Trust Commercial |
$1,015.30
|
| Rate for Payer: WPS Commercial |
$1,367.33
|
|
|
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 |
$1,781.36 |
| Max. Negotiated Rate |
$25,448.00 |
| Rate for Payer: Aetna Commercial |
$5,725.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,471.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,781.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,135.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,181.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,053.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,371.86
|
| Rate for Payer: Cash Price |
$1,908.60
|
| Rate for Payer: Cigna Commercial |
$5,853.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,560.18
|
| Rate for Payer: Health EOS Commercial |
$5,662.18
|
| Rate for Payer: HFN Commercial |
$5,853.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,771.50
|
| Rate for Payer: Multiplan Commercial |
$5,089.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,817.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,853.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,117.38
|
| Rate for Payer: Quartz Commercial |
$4,135.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,817.20
|
| Rate for Payer: The Alliance Commercial |
$25,448.00
|
| Rate for Payer: WEA Trust Commercial |
$3,499.10
|
| Rate for Payer: WPS Commercial |
$4,712.33
|
|
|
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 |
$3,117.38 |
| Max. Negotiated Rate |
$5,853.04 |
| Rate for Payer: Aetna Commercial |
$5,725.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,471.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,371.86
|
| Rate for Payer: Cash Price |
$1,908.60
|
| Rate for Payer: Cigna Commercial |
$5,853.04
|
| Rate for Payer: Health EOS Commercial |
$5,662.18
|
| Rate for Payer: HFN Commercial |
$5,853.04
|
| Rate for Payer: Multiplan Commercial |
$5,089.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,817.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,853.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,117.38
|
| Rate for Payer: Quartz Commercial |
$3,817.20
|
| Rate for Payer: WEA Trust Commercial |
$3,499.10
|
| Rate for Payer: WPS Commercial |
$4,712.33
|
|
|
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 |
$3,569.65 |
| Max. Negotiated Rate |
$6,702.20 |
| Rate for Payer: Aetna Commercial |
$6,556.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,265.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.05
|
| Rate for Payer: Cash Price |
$2,185.50
|
| Rate for Payer: Cigna Commercial |
$6,702.20
|
| Rate for Payer: Health EOS Commercial |
$6,483.65
|
| Rate for Payer: HFN Commercial |
$6,702.20
|
| Rate for Payer: Multiplan Commercial |
$5,828.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,371.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,702.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,569.65
|
| Rate for Payer: Quartz Commercial |
$4,371.00
|
| Rate for Payer: WEA Trust Commercial |
$4,006.75
|
| Rate for Payer: WPS Commercial |
$5,396.00
|
|
|
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 |
$2,039.80 |
| Max. Negotiated Rate |
$29,140.00 |
| Rate for Payer: Aetna Commercial |
$6,556.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,265.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,039.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,735.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,642.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,496.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,861.05
|
| Rate for Payer: Cash Price |
$2,185.50
|
| Rate for Payer: Cigna Commercial |
$6,702.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,076.69
|
| Rate for Payer: Health EOS Commercial |
$6,483.65
|
| Rate for Payer: HFN Commercial |
$6,702.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,463.75
|
| Rate for Payer: Multiplan Commercial |
$5,828.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,371.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,702.20
|
| Rate for Payer: Quartz Beloit One Network |
$3,569.65
|
| Rate for Payer: Quartz Commercial |
$4,735.25
|
| Rate for Payer: Quartz Medicare Advantage |
$4,371.00
|
| Rate for Payer: The Alliance Commercial |
$29,140.00
|
| Rate for Payer: WEA Trust Commercial |
$4,006.75
|
| Rate for Payer: WPS Commercial |
$5,396.00
|
|
|
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 |
$2,416.19 |
| Max. Negotiated Rate |
$4,536.52 |
| Rate for Payer: Aetna Commercial |
$4,437.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,240.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,613.43
|
| Rate for Payer: Cash Price |
$1,479.30
|
| Rate for Payer: Cigna Commercial |
$4,536.52
|
| Rate for Payer: Health EOS Commercial |
$4,388.59
|
| Rate for Payer: HFN Commercial |
$4,536.52
|
| Rate for Payer: Multiplan Commercial |
$3,944.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,958.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,536.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,416.19
|
| Rate for Payer: Quartz Commercial |
$2,958.60
|
| Rate for Payer: WEA Trust Commercial |
$2,712.05
|
| Rate for Payer: WPS Commercial |
$3,652.39
|
|
|
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 |
$1,380.68 |
| Max. Negotiated Rate |
$19,724.00 |
| Rate for Payer: Aetna Commercial |
$4,437.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,240.66
|
| Rate for Payer: Aetna Managed Medicare |
$1,380.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,465.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,366.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,613.43
|
| Rate for Payer: Cash Price |
$1,479.30
|
| Rate for Payer: Cigna Commercial |
$4,536.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,759.39
|
| Rate for Payer: Health EOS Commercial |
$4,388.59
|
| Rate for Payer: HFN Commercial |
$4,536.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,698.25
|
| Rate for Payer: Multiplan Commercial |
$3,944.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,958.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,536.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,416.19
|
| Rate for Payer: Quartz Commercial |
$3,205.15
|
| Rate for Payer: Quartz Medicare Advantage |
$2,958.60
|
| Rate for Payer: The Alliance Commercial |
$19,724.00
|
| Rate for Payer: WEA Trust Commercial |
$2,712.05
|
| Rate for Payer: WPS Commercial |
$3,652.39
|
|
|
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 |
$1,380.40 |
| Max. Negotiated Rate |
$19,720.00 |
| Rate for Payer: Aetna Commercial |
$4,437.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,239.80
|
| Rate for Payer: Aetna Managed Medicare |
$1,380.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,204.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,465.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,366.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,612.90
|
| Rate for Payer: Cash Price |
$1,479.00
|
| Rate for Payer: Cigna Commercial |
$4,535.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,758.83
|
| Rate for Payer: Health EOS Commercial |
$4,387.70
|
| Rate for Payer: HFN Commercial |
$4,535.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,697.50
|
| Rate for Payer: Multiplan Commercial |
$3,944.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,958.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,535.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,415.70
|
| Rate for Payer: Quartz Commercial |
$3,204.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,958.00
|
| Rate for Payer: The Alliance Commercial |
$19,720.00
|
| Rate for Payer: WEA Trust Commercial |
$2,711.50
|
| Rate for Payer: WPS Commercial |
$3,651.65
|
|
|
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 |
$2,415.70 |
| Max. Negotiated Rate |
$4,535.60 |
| Rate for Payer: Aetna Commercial |
$4,437.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,239.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,612.90
|
| Rate for Payer: Cash Price |
$1,479.00
|
| Rate for Payer: Cigna Commercial |
$4,535.60
|
| Rate for Payer: Health EOS Commercial |
$4,387.70
|
| Rate for Payer: HFN Commercial |
$4,535.60
|
| Rate for Payer: Multiplan Commercial |
$3,944.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,958.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,535.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,415.70
|
| Rate for Payer: Quartz Commercial |
$2,958.00
|
| Rate for Payer: WEA Trust Commercial |
$2,711.50
|
| Rate for Payer: WPS Commercial |
$3,651.65
|
|
|
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 |
$1,380.68 |
| Max. Negotiated Rate |
$19,724.00 |
| Rate for Payer: Aetna Commercial |
$4,437.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,240.66
|
| Rate for Payer: Aetna Managed Medicare |
$1,380.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,465.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,366.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,613.43
|
| Rate for Payer: Cash Price |
$1,479.30
|
| Rate for Payer: Cigna Commercial |
$4,536.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,759.39
|
| Rate for Payer: Health EOS Commercial |
$4,388.59
|
| Rate for Payer: HFN Commercial |
$4,536.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,698.25
|
| Rate for Payer: Multiplan Commercial |
$3,944.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,958.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,536.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,416.19
|
| Rate for Payer: Quartz Commercial |
$3,205.15
|
| Rate for Payer: Quartz Medicare Advantage |
$2,958.60
|
| Rate for Payer: The Alliance Commercial |
$19,724.00
|
| Rate for Payer: WEA Trust Commercial |
$2,712.05
|
| Rate for Payer: WPS Commercial |
$3,652.39
|
|
|
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 |
$2,416.19 |
| Max. Negotiated Rate |
$4,536.52 |
| Rate for Payer: Aetna Commercial |
$4,437.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,240.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,613.43
|
| Rate for Payer: Cash Price |
$1,479.30
|
| Rate for Payer: Cigna Commercial |
$4,536.52
|
| Rate for Payer: Health EOS Commercial |
$4,388.59
|
| Rate for Payer: HFN Commercial |
$4,536.52
|
| Rate for Payer: Multiplan Commercial |
$3,944.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,958.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,536.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,416.19
|
| Rate for Payer: Quartz Commercial |
$2,958.60
|
| Rate for Payer: WEA Trust Commercial |
$2,712.05
|
| Rate for Payer: WPS Commercial |
$3,652.39
|
|
|
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 |
$1,380.68 |
| Max. Negotiated Rate |
$19,724.00 |
| Rate for Payer: Aetna Commercial |
$4,437.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,240.66
|
| Rate for Payer: Aetna Managed Medicare |
$1,380.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,465.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,366.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,613.43
|
| Rate for Payer: Cash Price |
$1,479.30
|
| Rate for Payer: Cigna Commercial |
$4,536.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,759.39
|
| Rate for Payer: Health EOS Commercial |
$4,388.59
|
| Rate for Payer: HFN Commercial |
$4,536.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,698.25
|
| Rate for Payer: Multiplan Commercial |
$3,944.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,958.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,536.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,416.19
|
| Rate for Payer: Quartz Commercial |
$3,205.15
|
| Rate for Payer: Quartz Medicare Advantage |
$2,958.60
|
| Rate for Payer: The Alliance Commercial |
$19,724.00
|
| Rate for Payer: WEA Trust Commercial |
$2,712.05
|
| Rate for Payer: WPS Commercial |
$3,652.39
|
|
|
IMPLANT SMART TOE 19MM STO-19P
|
Facility
|
IP
|
$4,931.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2966084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,416.19 |
| Max. Negotiated Rate |
$4,536.52 |
| Rate for Payer: Aetna Commercial |
$4,437.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,240.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,613.43
|
| Rate for Payer: Cash Price |
$1,479.30
|
| Rate for Payer: Cigna Commercial |
$4,536.52
|
| Rate for Payer: Health EOS Commercial |
$4,388.59
|
| Rate for Payer: HFN Commercial |
$4,536.52
|
| Rate for Payer: Multiplan Commercial |
$3,944.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,958.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,536.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,416.19
|
| Rate for Payer: Quartz Commercial |
$2,958.60
|
| Rate for Payer: WEA Trust Commercial |
$2,712.05
|
| Rate for Payer: WPS Commercial |
$3,652.39
|
|
|
IMPLANT SPACEOAR SYSTEM 10ML SO-2101
|
Facility
|
OP
|
$15,309.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
6165872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,286.52 |
| Max. Negotiated Rate |
$61,236.00 |
| Rate for Payer: Aetna Commercial |
$13,778.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,165.74
|
| Rate for Payer: Aetna Managed Medicare |
$4,286.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,950.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,654.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,348.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,113.77
|
| Rate for Payer: Cash Price |
$4,592.70
|
| Rate for Payer: Cigna Commercial |
$14,084.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,566.92
|
| Rate for Payer: Health EOS Commercial |
$13,625.01
|
| Rate for Payer: HFN Commercial |
$14,084.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,481.75
|
| Rate for Payer: Multiplan Commercial |
$12,247.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,185.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,084.28
|
| Rate for Payer: Quartz Beloit One Network |
$7,501.41
|
| Rate for Payer: Quartz Commercial |
$9,950.85
|
| Rate for Payer: Quartz Medicare Advantage |
$9,185.40
|
| Rate for Payer: The Alliance Commercial |
$61,236.00
|
| Rate for Payer: WEA Trust Commercial |
$8,419.95
|
| Rate for Payer: WPS Commercial |
$11,339.38
|
|
|
IMPLANT SPACEOAR SYSTEM 10ML SO-2101
|
Facility
|
IP
|
$15,309.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
6165872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,501.41 |
| Max. Negotiated Rate |
$14,084.28 |
| Rate for Payer: Aetna Commercial |
$13,778.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,165.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,113.77
|
| Rate for Payer: Cash Price |
$4,592.70
|
| Rate for Payer: Cigna Commercial |
$14,084.28
|
| Rate for Payer: Health EOS Commercial |
$13,625.01
|
| Rate for Payer: HFN Commercial |
$14,084.28
|
| Rate for Payer: Multiplan Commercial |
$12,247.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,185.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,084.28
|
| Rate for Payer: Quartz Beloit One Network |
$7,501.41
|
| Rate for Payer: Quartz Commercial |
$9,185.40
|
| Rate for Payer: WEA Trust Commercial |
$8,419.95
|
| Rate for Payer: WPS Commercial |
$11,339.38
|
|
|
IMPLANT SPACEOAR VUE SYSTEM 10ML SV-2101
|
Facility
|
OP
|
$17,033.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
5456736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,769.24 |
| Max. Negotiated Rate |
$68,132.00 |
| Rate for Payer: Aetna Commercial |
$15,329.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,648.38
|
| Rate for Payer: Aetna Managed Medicare |
$4,769.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,071.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,516.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,175.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,027.49
|
| Rate for Payer: Cash Price |
$5,109.90
|
| Rate for Payer: Cigna Commercial |
$15,670.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,531.67
|
| Rate for Payer: Health EOS Commercial |
$15,159.37
|
| Rate for Payer: HFN Commercial |
$15,670.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,774.75
|
| Rate for Payer: Multiplan Commercial |
$13,626.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,219.80
|
| Rate for Payer: Preferred Network Access Commercial |
$15,670.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,346.17
|
| Rate for Payer: Quartz Commercial |
$11,071.45
|
| Rate for Payer: Quartz Medicare Advantage |
$10,219.80
|
| Rate for Payer: The Alliance Commercial |
$68,132.00
|
| Rate for Payer: WEA Trust Commercial |
$9,368.15
|
| Rate for Payer: WPS Commercial |
$12,616.34
|
|
|
IMPLANT SPACEOAR VUE SYSTEM 10ML SV-2101
|
Facility
|
IP
|
$17,033.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
5456736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,346.17 |
| Max. Negotiated Rate |
$15,670.36 |
| Rate for Payer: Aetna Commercial |
$15,329.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,648.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,027.49
|
| Rate for Payer: Cash Price |
$5,109.90
|
| Rate for Payer: Cigna Commercial |
$15,670.36
|
| Rate for Payer: Health EOS Commercial |
$15,159.37
|
| Rate for Payer: HFN Commercial |
$15,670.36
|
| Rate for Payer: Multiplan Commercial |
$13,626.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,219.80
|
| Rate for Payer: Preferred Network Access Commercial |
$15,670.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,346.17
|
| Rate for Payer: Quartz Commercial |
$10,219.80
|
| Rate for Payer: WEA Trust Commercial |
$9,368.15
|
| Rate for Payer: WPS Commercial |
$12,616.34
|
|
|
IMPLANT SPECTRUM 475CC SALINE 354-2480M
|
Facility
|
IP
|
$6,103.00
|
|
| Hospital Charge Code |
2965397
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,990.47 |
| Max. Negotiated Rate |
$5,614.76 |
| Rate for Payer: Aetna Commercial |
$5,492.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,248.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,234.59
|
| Rate for Payer: Cash Price |
$1,830.90
|
| Rate for Payer: Cigna Commercial |
$5,614.76
|
| Rate for Payer: Health EOS Commercial |
$5,431.67
|
| Rate for Payer: HFN Commercial |
$5,614.76
|
| Rate for Payer: Multiplan Commercial |
$4,882.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,661.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,614.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,990.47
|
| Rate for Payer: Quartz Commercial |
$3,661.80
|
| Rate for Payer: WEA Trust Commercial |
$3,356.65
|
| Rate for Payer: WPS Commercial |
$4,520.49
|
|
|
IMPLANT SPECTRUM 475CC SALINE 354-2480M
|
Facility
|
OP
|
$6,103.00
|
|
| Hospital Charge Code |
2965397
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,708.84 |
| Max. Negotiated Rate |
$24,412.00 |
| Rate for Payer: Aetna Commercial |
$5,492.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,248.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,708.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,966.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,051.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,929.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,234.59
|
| Rate for Payer: Cash Price |
$1,830.90
|
| Rate for Payer: Cigna Commercial |
$5,614.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,415.24
|
| Rate for Payer: Health EOS Commercial |
$5,431.67
|
| Rate for Payer: HFN Commercial |
$5,614.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,577.25
|
| Rate for Payer: Multiplan Commercial |
$4,882.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,661.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,614.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,990.47
|
| Rate for Payer: Quartz Commercial |
$3,966.95
|
| Rate for Payer: Quartz Medicare Advantage |
$3,661.80
|
| Rate for Payer: The Alliance Commercial |
$24,412.00
|
| Rate for Payer: WEA Trust Commercial |
$3,356.65
|
| Rate for Payer: WPS Commercial |
$4,520.49
|
|
|
IMPLANT SUBTALAR 9MM
|
Facility
|
OP
|
$6,407.00
|
|
| Hospital Charge Code |
2965166
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,793.96 |
| Max. Negotiated Rate |
$25,628.00 |
| Rate for Payer: Aetna Commercial |
$5,766.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,510.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,793.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,164.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,203.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,075.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,395.71
|
| Rate for Payer: Cash Price |
$1,922.10
|
| Rate for Payer: Cigna Commercial |
$5,894.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,585.36
|
| Rate for Payer: Health EOS Commercial |
$5,702.23
|
| Rate for Payer: HFN Commercial |
$5,894.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,805.25
|
| Rate for Payer: Multiplan Commercial |
$5,125.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,844.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,894.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,139.43
|
| Rate for Payer: Quartz Commercial |
$4,164.55
|
| Rate for Payer: Quartz Medicare Advantage |
$3,844.20
|
| Rate for Payer: The Alliance Commercial |
$25,628.00
|
| Rate for Payer: WEA Trust Commercial |
$3,523.85
|
| Rate for Payer: WPS Commercial |
$4,745.66
|
|
