|
PIN BALL X-SERIES 4MM X004
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2965220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
PIN BALL X-SERIES 5MM X005
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2965222
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
PIN BALL X-SERIES 5MM X005
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
2965222
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.17
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$42.00
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
PIN BALL X-SERIES 6MM X006
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
2965223
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.17
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$42.00
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
PIN BALL X-SERIES 6MM X006
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2965223
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
PIN BAYONETTE 18 WITH EYELET 219382"
|
Facility
|
IP
|
$3,005.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2973126
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,472.45 |
| Max. Negotiated Rate |
$2,764.60 |
| Rate for Payer: Aetna Commercial |
$2,704.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,584.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,592.65
|
| Rate for Payer: Cash Price |
$901.50
|
| Rate for Payer: Cigna Commercial |
$2,764.60
|
| Rate for Payer: Health EOS Commercial |
$2,674.45
|
| Rate for Payer: HFN Commercial |
$2,764.60
|
| Rate for Payer: Multiplan Commercial |
$2,404.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,803.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,764.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,472.45
|
| Rate for Payer: Quartz Commercial |
$1,803.00
|
| Rate for Payer: WEA Trust Commercial |
$1,652.75
|
| Rate for Payer: WPS Commercial |
$2,225.80
|
|
|
PIN BAYONETTE 18 WITH EYELET 219382"
|
Facility
|
OP
|
$3,005.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2973126
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$841.40 |
| Max. Negotiated Rate |
$12,020.00 |
| Rate for Payer: Aetna Commercial |
$2,704.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,584.30
|
| Rate for Payer: Aetna Managed Medicare |
$841.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,953.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,502.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,442.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,592.65
|
| Rate for Payer: Cash Price |
$901.50
|
| Rate for Payer: Cigna Commercial |
$2,764.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,681.60
|
| Rate for Payer: Health EOS Commercial |
$2,674.45
|
| Rate for Payer: HFN Commercial |
$2,764.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,253.75
|
| Rate for Payer: Multiplan Commercial |
$2,404.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,803.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,764.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,472.45
|
| Rate for Payer: Quartz Commercial |
$1,953.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,803.00
|
| Rate for Payer: The Alliance Commercial |
$12,020.00
|
| Rate for Payer: WEA Trust Commercial |
$1,652.75
|
| Rate for Payer: WPS Commercial |
$2,225.80
|
|
|
PIN BUTRESS 1.8 X 12 200.190
|
Facility
|
OP
|
$1,838.00
|
|
| Hospital Charge Code |
2966307
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$514.64 |
| Max. Negotiated Rate |
$7,352.00 |
| Rate for Payer: Aetna Commercial |
$1,654.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,580.68
|
| Rate for Payer: Aetna Managed Medicare |
$514.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,194.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$919.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$882.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$974.14
|
| Rate for Payer: Cash Price |
$551.40
|
| Rate for Payer: Cigna Commercial |
$1,690.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,028.54
|
| Rate for Payer: Health EOS Commercial |
$1,635.82
|
| Rate for Payer: HFN Commercial |
$1,690.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,378.50
|
| Rate for Payer: Multiplan Commercial |
$1,470.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,102.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,690.96
|
| Rate for Payer: Quartz Beloit One Network |
$900.62
|
| Rate for Payer: Quartz Commercial |
$1,194.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,102.80
|
| Rate for Payer: The Alliance Commercial |
$7,352.00
|
| Rate for Payer: WEA Trust Commercial |
$1,010.90
|
| Rate for Payer: WPS Commercial |
$1,361.41
|
|
|
PIN BUTRESS 1.8 X 12 200.190
|
Facility
|
IP
|
$1,838.00
|
|
| Hospital Charge Code |
2966307
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$900.62 |
| Max. Negotiated Rate |
$1,690.96 |
| Rate for Payer: Aetna Commercial |
$1,654.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,580.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$974.14
|
| Rate for Payer: Cash Price |
$551.40
|
| Rate for Payer: Cigna Commercial |
$1,690.96
|
| Rate for Payer: Health EOS Commercial |
$1,635.82
|
| Rate for Payer: HFN Commercial |
$1,690.96
|
| Rate for Payer: Multiplan Commercial |
$1,470.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,102.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,690.96
|
| Rate for Payer: Quartz Beloit One Network |
$900.62
|
| Rate for Payer: Quartz Commercial |
$1,102.80
|
| Rate for Payer: WEA Trust Commercial |
$1,010.90
|
| Rate for Payer: WPS Commercial |
$1,361.41
|
|
|
PIN BUTRESS 1.8 X 20 200.194
|
Facility
|
OP
|
$1,750.00
|
|
| Hospital Charge Code |
2966308
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$490.00 |
| Max. Negotiated Rate |
$7,000.00 |
| Rate for Payer: Aetna Commercial |
$1,575.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.00
|
| Rate for Payer: Aetna Managed Medicare |
$490.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,137.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$875.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$840.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$927.50
|
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Cigna Commercial |
$1,610.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$979.30
|
| Rate for Payer: Health EOS Commercial |
$1,557.50
|
| Rate for Payer: HFN Commercial |
$1,610.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,312.50
|
| Rate for Payer: Multiplan Commercial |
$1,400.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.00
|
| Rate for Payer: Quartz Beloit One Network |
$857.50
|
| Rate for Payer: Quartz Commercial |
$1,137.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,050.00
|
| Rate for Payer: The Alliance Commercial |
$7,000.00
|
| Rate for Payer: WEA Trust Commercial |
$962.50
|
| Rate for Payer: WPS Commercial |
$1,296.22
|
|
|
PIN BUTRESS 1.8 X 20 200.194
|
Facility
|
IP
|
$1,750.00
|
|
| Hospital Charge Code |
2966308
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$857.50 |
| Max. Negotiated Rate |
$1,610.00 |
| Rate for Payer: Aetna Commercial |
$1,575.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,505.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$927.50
|
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Cigna Commercial |
$1,610.00
|
| Rate for Payer: Health EOS Commercial |
$1,557.50
|
| Rate for Payer: HFN Commercial |
$1,610.00
|
| Rate for Payer: Multiplan Commercial |
$1,400.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,050.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,610.00
|
| Rate for Payer: Quartz Beloit One Network |
$857.50
|
| Rate for Payer: Quartz Commercial |
$1,050.00
|
| Rate for Payer: WEA Trust Commercial |
$962.50
|
| Rate for Payer: WPS Commercial |
$1,296.22
|
|
|
PIN CLAMP 6-POSITION 390.010
|
Facility
|
IP
|
$4,262.00
|
|
| Hospital Charge Code |
4632639
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,088.38 |
| Max. Negotiated Rate |
$3,921.04 |
| Rate for Payer: Aetna Commercial |
$3,835.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,665.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,258.86
|
| Rate for Payer: Cash Price |
$1,278.60
|
| Rate for Payer: Cigna Commercial |
$3,921.04
|
| Rate for Payer: Health EOS Commercial |
$3,793.18
|
| Rate for Payer: HFN Commercial |
$3,921.04
|
| Rate for Payer: Multiplan Commercial |
$3,409.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,557.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,921.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,088.38
|
| Rate for Payer: Quartz Commercial |
$2,557.20
|
| Rate for Payer: WEA Trust Commercial |
$2,344.10
|
| Rate for Payer: WPS Commercial |
$3,156.86
|
|
|
PIN CLAMP 6-POSITION 390.010
|
Facility
|
OP
|
$4,262.00
|
|
| Hospital Charge Code |
4632639
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,193.36 |
| Max. Negotiated Rate |
$17,048.00 |
| Rate for Payer: Aetna Commercial |
$3,835.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,665.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,193.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,770.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,131.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,045.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,258.86
|
| Rate for Payer: Cash Price |
$1,278.60
|
| Rate for Payer: Cigna Commercial |
$3,921.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,385.02
|
| Rate for Payer: Health EOS Commercial |
$3,793.18
|
| Rate for Payer: HFN Commercial |
$3,921.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,196.50
|
| Rate for Payer: Multiplan Commercial |
$3,409.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,557.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,921.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,088.38
|
| Rate for Payer: Quartz Commercial |
$2,770.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,557.20
|
| Rate for Payer: The Alliance Commercial |
$17,048.00
|
| Rate for Payer: WEA Trust Commercial |
$2,344.10
|
| Rate for Payer: WPS Commercial |
$3,156.86
|
|
|
PIN CLAMP SINGLE MONOTUBE TRIAX BLUE 20MM 5150-3-170
|
Facility
|
IP
|
$5,000.00
|
|
| Hospital Charge Code |
5685882
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,450.00 |
| Max. Negotiated Rate |
$4,600.00 |
| Rate for Payer: Aetna Commercial |
$4,500.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,300.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,650.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$4,600.00
|
| Rate for Payer: Health EOS Commercial |
$4,450.00
|
| Rate for Payer: HFN Commercial |
$4,600.00
|
| Rate for Payer: Multiplan Commercial |
$4,000.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,000.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,600.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,450.00
|
| Rate for Payer: Quartz Commercial |
$3,000.00
|
| Rate for Payer: WEA Trust Commercial |
$2,750.00
|
| Rate for Payer: WPS Commercial |
$3,703.50
|
|
|
PIN CLAMP SINGLE MONOTUBE TRIAX BLUE 20MM 5150-3-170
|
Facility
|
OP
|
$5,000.00
|
|
| Hospital Charge Code |
5685882
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,400.00 |
| Max. Negotiated Rate |
$20,000.00 |
| Rate for Payer: Aetna Commercial |
$4,500.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,300.00
|
| Rate for Payer: Aetna Managed Medicare |
$1,400.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,250.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,500.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,400.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,650.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$4,600.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,798.00
|
| Rate for Payer: Health EOS Commercial |
$4,450.00
|
| Rate for Payer: HFN Commercial |
$4,600.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,750.00
|
| Rate for Payer: Multiplan Commercial |
$4,000.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,000.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,600.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,450.00
|
| Rate for Payer: Quartz Commercial |
$3,250.00
|
| Rate for Payer: Quartz Medicare Advantage |
$3,000.00
|
| Rate for Payer: The Alliance Commercial |
$20,000.00
|
| Rate for Payer: WEA Trust Commercial |
$2,750.00
|
| Rate for Payer: WPS Commercial |
$3,703.50
|
|
|
PIN DYNANITE VIP GLENOID 2.8MM NITINOL AR-5400-400NS
|
Facility
|
IP
|
$4,091.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5685679
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,004.59 |
| Max. Negotiated Rate |
$3,763.72 |
| Rate for Payer: Aetna Commercial |
$3,681.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,518.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.23
|
| Rate for Payer: Cash Price |
$1,227.30
|
| Rate for Payer: Cigna Commercial |
$3,763.72
|
| Rate for Payer: Health EOS Commercial |
$3,640.99
|
| Rate for Payer: HFN Commercial |
$3,763.72
|
| Rate for Payer: Multiplan Commercial |
$3,272.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,454.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,763.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,004.59
|
| Rate for Payer: Quartz Commercial |
$2,454.60
|
| Rate for Payer: WEA Trust Commercial |
$2,250.05
|
| Rate for Payer: WPS Commercial |
$3,030.20
|
|
|
PIN DYNANITE VIP GLENOID 2.8MM NITINOL AR-5400-400NS
|
Facility
|
OP
|
$4,091.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5685679
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,145.48 |
| Max. Negotiated Rate |
$16,364.00 |
| Rate for Payer: Aetna Commercial |
$3,681.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,518.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,659.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,045.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,963.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.23
|
| Rate for Payer: Cash Price |
$1,227.30
|
| Rate for Payer: Cigna Commercial |
$3,763.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,289.32
|
| Rate for Payer: Health EOS Commercial |
$3,640.99
|
| Rate for Payer: HFN Commercial |
$3,763.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,068.25
|
| Rate for Payer: Multiplan Commercial |
$3,272.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,454.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,763.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,004.59
|
| Rate for Payer: Quartz Commercial |
$2,659.15
|
| Rate for Payer: Quartz Medicare Advantage |
$2,454.60
|
| Rate for Payer: The Alliance Commercial |
$16,364.00
|
| Rate for Payer: WEA Trust Commercial |
$2,250.05
|
| Rate for Payer: WPS Commercial |
$3,030.20
|
|
|
PIN FLUTED HEADLESS DISPOSABLE 7650-2038A
|
Facility
|
IP
|
$4,982.00
|
|
| Hospital Charge Code |
5106886
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,441.18 |
| Max. Negotiated Rate |
$4,583.44 |
| Rate for Payer: Aetna Commercial |
$4,483.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,284.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,640.46
|
| Rate for Payer: Cash Price |
$1,494.60
|
| Rate for Payer: Cigna Commercial |
$4,583.44
|
| Rate for Payer: Health EOS Commercial |
$4,433.98
|
| Rate for Payer: HFN Commercial |
$4,583.44
|
| Rate for Payer: Multiplan Commercial |
$3,985.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,989.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,583.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,441.18
|
| Rate for Payer: Quartz Commercial |
$2,989.20
|
| Rate for Payer: WEA Trust Commercial |
$2,740.10
|
| Rate for Payer: WPS Commercial |
$3,690.17
|
|
|
PIN FLUTED HEADLESS DISPOSABLE 7650-2038A
|
Facility
|
OP
|
$4,982.00
|
|
| Hospital Charge Code |
5106886
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,394.96 |
| Max. Negotiated Rate |
$19,928.00 |
| Rate for Payer: Aetna Commercial |
$4,483.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,284.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,394.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,238.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,491.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,391.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,640.46
|
| Rate for Payer: Cash Price |
$1,494.60
|
| Rate for Payer: Cigna Commercial |
$4,583.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,787.93
|
| Rate for Payer: Health EOS Commercial |
$4,433.98
|
| Rate for Payer: HFN Commercial |
$4,583.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,736.50
|
| Rate for Payer: Multiplan Commercial |
$3,985.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,989.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,583.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,441.18
|
| Rate for Payer: Quartz Commercial |
$3,238.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,989.20
|
| Rate for Payer: The Alliance Commercial |
$19,928.00
|
| Rate for Payer: WEA Trust Commercial |
$2,740.10
|
| Rate for Payer: WPS Commercial |
$3,690.17
|
|
|
PIN GUIDE PSI PERSONA CS FEMORAL-TIBIAL 00-5970-000-25
|
Facility
|
IP
|
$5,403.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
3491507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,647.47 |
| Max. Negotiated Rate |
$4,970.76 |
| Rate for Payer: Aetna Commercial |
$4,862.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,646.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,863.59
|
| Rate for Payer: Cash Price |
$1,620.90
|
| Rate for Payer: Cigna Commercial |
$4,970.76
|
| Rate for Payer: Health EOS Commercial |
$4,808.67
|
| Rate for Payer: HFN Commercial |
$4,970.76
|
| Rate for Payer: Multiplan Commercial |
$4,322.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,241.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,970.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,647.47
|
| Rate for Payer: Quartz Commercial |
$3,241.80
|
| Rate for Payer: WEA Trust Commercial |
$2,971.65
|
| Rate for Payer: WPS Commercial |
$4,002.00
|
|
|
PIN GUIDE PSI PERSONA CS FEMORAL-TIBIAL 00-5970-000-25
|
Facility
|
OP
|
$5,403.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
3491507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,512.84 |
| Max. Negotiated Rate |
$21,612.00 |
| Rate for Payer: Aetna Commercial |
$4,862.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,646.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,512.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,511.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,701.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,593.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,863.59
|
| Rate for Payer: Cash Price |
$1,620.90
|
| Rate for Payer: Cigna Commercial |
$4,970.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,023.52
|
| Rate for Payer: Health EOS Commercial |
$4,808.67
|
| Rate for Payer: HFN Commercial |
$4,970.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,052.25
|
| Rate for Payer: Multiplan Commercial |
$4,322.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,241.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,970.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,647.47
|
| Rate for Payer: Quartz Commercial |
$3,511.95
|
| Rate for Payer: Quartz Medicare Advantage |
$3,241.80
|
| Rate for Payer: The Alliance Commercial |
$21,612.00
|
| Rate for Payer: WEA Trust Commercial |
$2,971.65
|
| Rate for Payer: WPS Commercial |
$4,002.00
|
|
|
PIN GUIDE PSI PERSONA PS FEMORAL-TIBIAL 00-5970-000-29
|
Facility
|
OP
|
$5,403.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
4594702
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,512.84 |
| Max. Negotiated Rate |
$21,612.00 |
| Rate for Payer: Aetna Commercial |
$4,862.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,646.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,512.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,511.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,701.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,593.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,863.59
|
| Rate for Payer: Cash Price |
$1,620.90
|
| Rate for Payer: Cigna Commercial |
$4,970.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,023.52
|
| Rate for Payer: Health EOS Commercial |
$4,808.67
|
| Rate for Payer: HFN Commercial |
$4,970.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,052.25
|
| Rate for Payer: Multiplan Commercial |
$4,322.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,241.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,970.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,647.47
|
| Rate for Payer: Quartz Commercial |
$3,511.95
|
| Rate for Payer: Quartz Medicare Advantage |
$3,241.80
|
| Rate for Payer: The Alliance Commercial |
$21,612.00
|
| Rate for Payer: WEA Trust Commercial |
$2,971.65
|
| Rate for Payer: WPS Commercial |
$4,002.00
|
|
|
PIN GUIDE PSI PERSONA PS FEMORAL-TIBIAL 00-5970-000-29
|
Facility
|
IP
|
$5,403.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
4594702
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,647.47 |
| Max. Negotiated Rate |
$4,970.76 |
| Rate for Payer: Aetna Commercial |
$4,862.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,646.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,863.59
|
| Rate for Payer: Cash Price |
$1,620.90
|
| Rate for Payer: Cigna Commercial |
$4,970.76
|
| Rate for Payer: Health EOS Commercial |
$4,808.67
|
| Rate for Payer: HFN Commercial |
$4,970.76
|
| Rate for Payer: Multiplan Commercial |
$4,322.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,241.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,970.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,647.47
|
| Rate for Payer: Quartz Commercial |
$3,241.80
|
| Rate for Payer: WEA Trust Commercial |
$2,971.65
|
| Rate for Payer: WPS Commercial |
$4,002.00
|
|
|
PIN SERVICE 60M PER MONTH G0023
|
Professional
|
Both
|
$245.00
|
|
|
Service Code
|
HCPCS G0023
|
| Hospital Charge Code |
6242279
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$107.80 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Aetna Commercial |
$232.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.70
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$232.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$122.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$147.00
|
| Rate for Payer: Health EOS Commercial |
$222.95
|
| Rate for Payer: HFN Commercial |
$232.75
|
| Rate for Payer: Multiplan Commercial |
$196.00
|
| Rate for Payer: Preferred Network Access Commercial |
$232.75
|
| Rate for Payer: Quartz Beloit One Network |
$107.80
|
| Rate for Payer: Quartz Commercial |
$139.65
|
| Rate for Payer: The Alliance Commercial |
$122.50
|
| Rate for Payer: WEA Trust Commercial |
$134.75
|
| Rate for Payer: WPS Commercial |
$181.47
|
|
|
PIN SERVICE ADD 30 MIN PER MONTH G0024
|
Professional
|
Both
|
$123.00
|
|
|
Service Code
|
HCPCS G0024
|
| Hospital Charge Code |
6242280
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$54.12 |
| Max. Negotiated Rate |
$116.85 |
| Rate for Payer: Aetna Commercial |
$116.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$116.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$61.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$73.80
|
| Rate for Payer: Health EOS Commercial |
$111.93
|
| Rate for Payer: HFN Commercial |
$116.85
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: Preferred Network Access Commercial |
$116.85
|
| Rate for Payer: Quartz Beloit One Network |
$54.12
|
| Rate for Payer: Quartz Commercial |
$70.11
|
| Rate for Payer: The Alliance Commercial |
$61.50
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
