|
ProtÈgÈ 8mm x 20mm 120cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548946
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 20mm 80cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548882
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 20mm 80cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548882
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 20mm 80cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548882
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 40mm 120cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548948
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 40mm 120cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548948
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 40mm 120cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548948
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 40mm 80cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548884
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 40mm 80cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548884
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 40mm 80cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548884
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 60mm 120cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548950
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 60mm 120cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548950
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 60mm 120cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548950
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 60mm 80cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 60mm 80cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 60mm 80cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 80mm 120cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548952
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 80mm 120cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548952
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 80mm 120cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548952
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 80mm 80cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548888
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 80mm 80cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548888
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 8mm x 80mm 80cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548888
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 9mm x 20mm 120cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548954
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 9mm x 20mm 120cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548954
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
ProtÈgÈ 9mm x 20mm 120cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548954
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
