|
Rigid EO wo joints L3762
|
Facility
|
OP
|
$308.00
|
|
|
Service Code
|
HCPCS L3762
|
| Hospital Charge Code |
4590638
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$43.85 |
| Max. Negotiated Rate |
$1,232.00 |
| Rate for Payer: Aetna Commercial |
$277.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$264.88
|
| Rate for Payer: Aetna Managed Medicare |
$86.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$163.24
|
| Rate for Payer: Cash Price |
$92.40
|
| Rate for Payer: Cash Price |
$92.40
|
| Rate for Payer: Cigna Commercial |
$283.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$172.36
|
| Rate for Payer: Health EOS Commercial |
$274.12
|
| Rate for Payer: HFN Commercial |
$283.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$231.00
|
| Rate for Payer: Multiplan Commercial |
$246.40
|
| Rate for Payer: NAPHCARE Commercial |
$184.80
|
| Rate for Payer: Preferred Network Access Commercial |
$283.36
|
| Rate for Payer: Quartz Beloit One Network |
$150.92
|
| Rate for Payer: Quartz Commercial |
$200.20
|
| Rate for Payer: Quartz Medicare Advantage |
$184.80
|
| Rate for Payer: The Alliance Commercial |
$1,232.00
|
| Rate for Payer: WEA Trust Commercial |
$169.40
|
| Rate for Payer: WPS Commercial |
$228.14
|
|
|
Rigid EO wo joints L3762
|
Professional
|
Both
|
$308.00
|
|
|
Service Code
|
HCPCS L3762
|
| Hospital Charge Code |
4590638
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$135.52 |
| Max. Negotiated Rate |
$346.72 |
| Rate for Payer: Aetna Commercial |
$292.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$264.88
|
| Rate for Payer: Cash Price |
$92.40
|
| Rate for Payer: Cash Price |
$92.40
|
| Rate for Payer: Cigna Commercial |
$292.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$154.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$184.80
|
| Rate for Payer: Health EOS Commercial |
$280.28
|
| Rate for Payer: HFN Commercial |
$292.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$346.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$346.72
|
| Rate for Payer: Multiplan Commercial |
$246.40
|
| Rate for Payer: Preferred Network Access Commercial |
$292.60
|
| Rate for Payer: Quartz Beloit One Network |
$135.52
|
| Rate for Payer: Quartz Commercial |
$175.56
|
| Rate for Payer: The Alliance Commercial |
$154.00
|
| Rate for Payer: WEA Trust Commercial |
$169.40
|
| Rate for Payer: WPS Commercial |
$228.14
|
|
|
RIMPLATE MATRIX MIDFACE ORBITAL 12HL 0.5MM THICK TI 04.503.343
|
Facility
|
IP
|
$2,502.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5264665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,225.98 |
| Max. Negotiated Rate |
$2,301.84 |
| Rate for Payer: Aetna Commercial |
$2,251.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,151.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,326.06
|
| Rate for Payer: Cash Price |
$750.60
|
| Rate for Payer: Cigna Commercial |
$2,301.84
|
| Rate for Payer: Health EOS Commercial |
$2,226.78
|
| Rate for Payer: HFN Commercial |
$2,301.84
|
| Rate for Payer: Multiplan Commercial |
$2,001.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,501.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,301.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,225.98
|
| Rate for Payer: Quartz Commercial |
$1,501.20
|
| Rate for Payer: WEA Trust Commercial |
$1,376.10
|
| Rate for Payer: WPS Commercial |
$1,853.23
|
|
|
RIMPLATE MATRIX MIDFACE ORBITAL 12HL 0.5MM THICK TI 04.503.343
|
Facility
|
OP
|
$2,502.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5264665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$700.56 |
| Max. Negotiated Rate |
$10,008.00 |
| Rate for Payer: Aetna Commercial |
$2,251.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,151.72
|
| Rate for Payer: Aetna Managed Medicare |
$700.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,626.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,251.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,200.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,326.06
|
| Rate for Payer: Cash Price |
$750.60
|
| Rate for Payer: Cigna Commercial |
$2,301.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,400.12
|
| Rate for Payer: Health EOS Commercial |
$2,226.78
|
| Rate for Payer: HFN Commercial |
$2,301.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,876.50
|
| Rate for Payer: Multiplan Commercial |
$2,001.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,501.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,301.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,225.98
|
| Rate for Payer: Quartz Commercial |
$1,626.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,501.20
|
| Rate for Payer: The Alliance Commercial |
$10,008.00
|
| Rate for Payer: WEA Trust Commercial |
$1,376.10
|
| Rate for Payer: WPS Commercial |
$1,853.23
|
|
|
RIMPLATE MATRIX MIDFACE ORBITAL 12HL 0.7MM THICK TI 04.503.373
|
Facility
|
IP
|
$2,465.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5384732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,207.85 |
| Max. Negotiated Rate |
$2,267.80 |
| Rate for Payer: Aetna Commercial |
$2,218.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,119.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,306.45
|
| Rate for Payer: Cash Price |
$739.50
|
| Rate for Payer: Cigna Commercial |
$2,267.80
|
| Rate for Payer: Health EOS Commercial |
$2,193.85
|
| Rate for Payer: HFN Commercial |
$2,267.80
|
| Rate for Payer: Multiplan Commercial |
$1,972.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,479.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,267.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,207.85
|
| Rate for Payer: Quartz Commercial |
$1,479.00
|
| Rate for Payer: WEA Trust Commercial |
$1,355.75
|
| Rate for Payer: WPS Commercial |
$1,825.83
|
|
|
RIMPLATE MATRIX MIDFACE ORBITAL 12HL 0.7MM THICK TI 04.503.373
|
Facility
|
OP
|
$2,465.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5384732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$690.20 |
| Max. Negotiated Rate |
$9,860.00 |
| Rate for Payer: Aetna Commercial |
$2,218.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,119.90
|
| Rate for Payer: Aetna Managed Medicare |
$690.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,602.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,232.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,183.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,306.45
|
| Rate for Payer: Cash Price |
$739.50
|
| Rate for Payer: Cigna Commercial |
$2,267.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,379.41
|
| Rate for Payer: Health EOS Commercial |
$2,193.85
|
| Rate for Payer: HFN Commercial |
$2,267.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,848.75
|
| Rate for Payer: Multiplan Commercial |
$1,972.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,479.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,267.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,207.85
|
| Rate for Payer: Quartz Commercial |
$1,602.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,479.00
|
| Rate for Payer: The Alliance Commercial |
$9,860.00
|
| Rate for Payer: WEA Trust Commercial |
$1,355.75
|
| Rate for Payer: WPS Commercial |
$1,825.83
|
|
|
RIMPLATE MATRIX ORBITAL 12HL 0.8MM THICK TI 04.503.397
|
Facility
|
OP
|
$5,270.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,475.60 |
| Max. Negotiated Rate |
$21,080.00 |
| Rate for Payer: Aetna Commercial |
$4,743.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,532.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,475.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,425.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,635.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,529.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,793.10
|
| Rate for Payer: Cash Price |
$1,581.00
|
| Rate for Payer: Cigna Commercial |
$4,848.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,949.09
|
| Rate for Payer: Health EOS Commercial |
$4,690.30
|
| Rate for Payer: HFN Commercial |
$4,848.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,952.50
|
| Rate for Payer: Multiplan Commercial |
$4,216.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,848.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,582.30
|
| Rate for Payer: Quartz Commercial |
$3,425.50
|
| Rate for Payer: Quartz Medicare Advantage |
$3,162.00
|
| Rate for Payer: The Alliance Commercial |
$21,080.00
|
| Rate for Payer: WEA Trust Commercial |
$2,898.50
|
| Rate for Payer: WPS Commercial |
$3,903.49
|
|
|
RIMPLATE MATRIX ORBITAL 12HL 0.8MM THICK TI 04.503.397
|
Facility
|
IP
|
$5,270.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,582.30 |
| Max. Negotiated Rate |
$4,848.40 |
| Rate for Payer: Aetna Commercial |
$4,743.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,532.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,793.10
|
| Rate for Payer: Cash Price |
$1,581.00
|
| Rate for Payer: Cigna Commercial |
$4,848.40
|
| Rate for Payer: Health EOS Commercial |
$4,690.30
|
| Rate for Payer: HFN Commercial |
$4,848.40
|
| Rate for Payer: Multiplan Commercial |
$4,216.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,848.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,582.30
|
| Rate for Payer: Quartz Commercial |
$3,162.00
|
| Rate for Payer: WEA Trust Commercial |
$2,898.50
|
| Rate for Payer: WPS Commercial |
$3,903.49
|
|
|
RING 3/4 EXTERNAL FIXATION
|
Facility
|
IP
|
$4,968.00
|
|
| Hospital Charge Code |
2966387
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,434.32 |
| Max. Negotiated Rate |
$4,570.56 |
| Rate for Payer: Aetna Commercial |
$4,471.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,272.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,633.04
|
| Rate for Payer: Cash Price |
$1,490.40
|
| Rate for Payer: Cigna Commercial |
$4,570.56
|
| Rate for Payer: Health EOS Commercial |
$4,421.52
|
| Rate for Payer: HFN Commercial |
$4,570.56
|
| Rate for Payer: Multiplan Commercial |
$3,974.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,980.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,570.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,434.32
|
| Rate for Payer: Quartz Commercial |
$2,980.80
|
| Rate for Payer: WEA Trust Commercial |
$2,732.40
|
| Rate for Payer: WPS Commercial |
$3,679.80
|
|
|
RING 3/4 EXTERNAL FIXATION
|
Facility
|
OP
|
$4,968.00
|
|
| Hospital Charge Code |
2966387
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,391.04 |
| Max. Negotiated Rate |
$19,872.00 |
| Rate for Payer: Aetna Commercial |
$4,471.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,272.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,391.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,229.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,484.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,384.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,633.04
|
| Rate for Payer: Cash Price |
$1,490.40
|
| Rate for Payer: Cigna Commercial |
$4,570.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,780.09
|
| Rate for Payer: Health EOS Commercial |
$4,421.52
|
| Rate for Payer: HFN Commercial |
$4,570.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,726.00
|
| Rate for Payer: Multiplan Commercial |
$3,974.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,980.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,570.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,434.32
|
| Rate for Payer: Quartz Commercial |
$3,229.20
|
| Rate for Payer: Quartz Medicare Advantage |
$2,980.80
|
| Rate for Payer: The Alliance Commercial |
$19,872.00
|
| Rate for Payer: WEA Trust Commercial |
$2,732.40
|
| Rate for Payer: WPS Commercial |
$3,679.80
|
|
|
RING BARRIER ADAPT FLAT #7806
|
Facility
|
IP
|
$59.00
|
|
| Hospital Charge Code |
2963736
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$28.91 |
| Max. Negotiated Rate |
$54.28 |
| Rate for Payer: Aetna Commercial |
$53.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.27
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: Health EOS Commercial |
$52.51
|
| Rate for Payer: HFN Commercial |
$54.28
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: NAPHCARE Commercial |
$35.40
|
| Rate for Payer: Preferred Network Access Commercial |
$54.28
|
| Rate for Payer: Quartz Beloit One Network |
$28.91
|
| Rate for Payer: Quartz Commercial |
$35.40
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$43.70
|
|
|
RING BARRIER ADAPT FLAT #7806
|
Facility
|
OP
|
$59.00
|
|
| Hospital Charge Code |
2963736
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$16.52 |
| Max. Negotiated Rate |
$236.00 |
| Rate for Payer: Aetna Commercial |
$53.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Aetna Managed Medicare |
$16.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.27
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.02
|
| Rate for Payer: Health EOS Commercial |
$52.51
|
| Rate for Payer: HFN Commercial |
$54.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.25
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: NAPHCARE Commercial |
$35.40
|
| Rate for Payer: Preferred Network Access Commercial |
$54.28
|
| Rate for Payer: Quartz Beloit One Network |
$28.91
|
| Rate for Payer: Quartz Commercial |
$38.35
|
| Rate for Payer: Quartz Medicare Advantage |
$35.40
|
| Rate for Payer: The Alliance Commercial |
$236.00
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$43.70
|
|
|
RING CARBON FIBER F00T LONG 155MM HOFFMANN LIMB 4934-4-155
|
Facility
|
IP
|
$9,492.00
|
|
| Hospital Charge Code |
5685634
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,651.08 |
| Max. Negotiated Rate |
$8,732.64 |
| Rate for Payer: Aetna Commercial |
$8,542.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,163.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,030.76
|
| Rate for Payer: Cash Price |
$2,847.60
|
| Rate for Payer: Cigna Commercial |
$8,732.64
|
| Rate for Payer: Health EOS Commercial |
$8,447.88
|
| Rate for Payer: HFN Commercial |
$8,732.64
|
| Rate for Payer: Multiplan Commercial |
$7,593.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,695.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,732.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,651.08
|
| Rate for Payer: Quartz Commercial |
$5,695.20
|
| Rate for Payer: WEA Trust Commercial |
$5,220.60
|
| Rate for Payer: WPS Commercial |
$7,030.72
|
|
|
RING CARBON FIBER F00T LONG 155MM HOFFMANN LIMB 4934-4-155
|
Facility
|
OP
|
$9,492.00
|
|
| Hospital Charge Code |
5685634
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,657.76 |
| Max. Negotiated Rate |
$37,968.00 |
| Rate for Payer: Aetna Commercial |
$8,542.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,163.12
|
| Rate for Payer: Aetna Managed Medicare |
$2,657.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,169.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,746.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,556.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,030.76
|
| Rate for Payer: Cash Price |
$2,847.60
|
| Rate for Payer: Cigna Commercial |
$8,732.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,311.72
|
| Rate for Payer: Health EOS Commercial |
$8,447.88
|
| Rate for Payer: HFN Commercial |
$8,732.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,119.00
|
| Rate for Payer: Multiplan Commercial |
$7,593.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,695.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,732.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,651.08
|
| Rate for Payer: Quartz Commercial |
$6,169.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,695.20
|
| Rate for Payer: The Alliance Commercial |
$37,968.00
|
| Rate for Payer: WEA Trust Commercial |
$5,220.60
|
| Rate for Payer: WPS Commercial |
$7,030.72
|
|
|
RING CARBON FIBER FULL 155MM HOFFMANN LIMB 4933-5-155
|
Facility
|
IP
|
$7,093.00
|
|
| Hospital Charge Code |
5685629
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,475.57 |
| Max. Negotiated Rate |
$6,525.56 |
| Rate for Payer: Aetna Commercial |
$6,383.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,099.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,759.29
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,525.56
|
| Rate for Payer: Health EOS Commercial |
$6,312.77
|
| Rate for Payer: HFN Commercial |
$6,525.56
|
| Rate for Payer: Multiplan Commercial |
$5,674.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,255.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,525.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,475.57
|
| Rate for Payer: Quartz Commercial |
$4,255.80
|
| Rate for Payer: WEA Trust Commercial |
$3,901.15
|
| Rate for Payer: WPS Commercial |
$5,253.79
|
|
|
RING CARBON FIBER FULL 155MM HOFFMANN LIMB 4933-5-155
|
Facility
|
OP
|
$7,093.00
|
|
| Hospital Charge Code |
5685629
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,986.04 |
| Max. Negotiated Rate |
$28,372.00 |
| Rate for Payer: Aetna Commercial |
$6,383.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,099.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,986.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,610.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,546.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,404.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,759.29
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,525.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,969.24
|
| Rate for Payer: Health EOS Commercial |
$6,312.77
|
| Rate for Payer: HFN Commercial |
$6,525.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,319.75
|
| Rate for Payer: Multiplan Commercial |
$5,674.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,255.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,525.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,475.57
|
| Rate for Payer: Quartz Commercial |
$4,610.45
|
| Rate for Payer: Quartz Medicare Advantage |
$4,255.80
|
| Rate for Payer: The Alliance Commercial |
$28,372.00
|
| Rate for Payer: WEA Trust Commercial |
$3,901.15
|
| Rate for Payer: WPS Commercial |
$5,253.79
|
|
|
RING CARBON FIBER FULL 210MM HOFFMANN LIMB 4933-5-210
|
Facility
|
IP
|
$7,093.00
|
|
| Hospital Charge Code |
5599708
|
| Min. Negotiated Rate |
$3,475.57 |
| Max. Negotiated Rate |
$6,525.56 |
| Rate for Payer: Aetna Commercial |
$6,383.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,099.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,759.29
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,525.56
|
| Rate for Payer: Health EOS Commercial |
$6,312.77
|
| Rate for Payer: HFN Commercial |
$6,525.56
|
| Rate for Payer: Multiplan Commercial |
$5,674.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,255.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,525.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,475.57
|
| Rate for Payer: Quartz Commercial |
$4,255.80
|
| Rate for Payer: WEA Trust Commercial |
$3,901.15
|
| Rate for Payer: WPS Commercial |
$5,253.79
|
|
|
RING CARBON FIBER FULL 210MM HOFFMANN LIMB 4933-5-210
|
Facility
|
OP
|
$7,093.00
|
|
| Hospital Charge Code |
5599708
|
| Min. Negotiated Rate |
$1,986.04 |
| Max. Negotiated Rate |
$28,372.00 |
| Rate for Payer: Aetna Commercial |
$6,383.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,099.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,986.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,610.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,546.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,404.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,759.29
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,525.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,969.24
|
| Rate for Payer: Health EOS Commercial |
$6,312.77
|
| Rate for Payer: HFN Commercial |
$6,525.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,319.75
|
| Rate for Payer: Multiplan Commercial |
$5,674.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,255.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,525.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,475.57
|
| Rate for Payer: Quartz Commercial |
$4,610.45
|
| Rate for Payer: Quartz Medicare Advantage |
$4,255.80
|
| Rate for Payer: The Alliance Commercial |
$28,372.00
|
| Rate for Payer: WEA Trust Commercial |
$3,901.15
|
| Rate for Payer: WPS Commercial |
$5,253.79
|
|
|
RING MALYUGIN 6.25 MAL-1001-1
|
Facility
|
OP
|
$2,131.00
|
|
| Hospital Charge Code |
2969501
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$596.68 |
| Max. Negotiated Rate |
$8,524.00 |
| Rate for Payer: Aetna Commercial |
$1,917.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,832.66
|
| Rate for Payer: Aetna Managed Medicare |
$596.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,385.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,065.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,022.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,129.43
|
| Rate for Payer: Cash Price |
$639.30
|
| Rate for Payer: Cigna Commercial |
$1,960.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,192.51
|
| Rate for Payer: Health EOS Commercial |
$1,896.59
|
| Rate for Payer: HFN Commercial |
$1,960.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,598.25
|
| Rate for Payer: Multiplan Commercial |
$1,704.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,278.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,960.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,044.19
|
| Rate for Payer: Quartz Commercial |
$1,385.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,278.60
|
| Rate for Payer: The Alliance Commercial |
$8,524.00
|
| Rate for Payer: WEA Trust Commercial |
$1,172.05
|
| Rate for Payer: WPS Commercial |
$1,578.43
|
|
|
RING MALYUGIN 6.25 MAL-1001-1
|
Facility
|
IP
|
$2,131.00
|
|
| Hospital Charge Code |
2969501
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,044.19 |
| Max. Negotiated Rate |
$1,960.52 |
| Rate for Payer: Aetna Commercial |
$1,917.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,832.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,129.43
|
| Rate for Payer: Cash Price |
$639.30
|
| Rate for Payer: Cigna Commercial |
$1,960.52
|
| Rate for Payer: Health EOS Commercial |
$1,896.59
|
| Rate for Payer: HFN Commercial |
$1,960.52
|
| Rate for Payer: Multiplan Commercial |
$1,704.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,278.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,960.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,044.19
|
| Rate for Payer: Quartz Commercial |
$1,278.60
|
| Rate for Payer: WEA Trust Commercial |
$1,172.05
|
| Rate for Payer: WPS Commercial |
$1,578.43
|
|
|
RING MALYUGIN 7.0 MAL-0002
|
Facility
|
OP
|
$1,857.00
|
|
| Hospital Charge Code |
5415296
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$519.96 |
| Max. Negotiated Rate |
$7,428.00 |
| Rate for Payer: Aetna Commercial |
$1,671.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,597.02
|
| Rate for Payer: Aetna Managed Medicare |
$519.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,207.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$928.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$891.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$984.21
|
| Rate for Payer: Cash Price |
$557.10
|
| Rate for Payer: Cigna Commercial |
$1,708.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,039.18
|
| Rate for Payer: Health EOS Commercial |
$1,652.73
|
| Rate for Payer: HFN Commercial |
$1,708.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,392.75
|
| Rate for Payer: Multiplan Commercial |
$1,485.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,114.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,708.44
|
| Rate for Payer: Quartz Beloit One Network |
$909.93
|
| Rate for Payer: Quartz Commercial |
$1,207.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,114.20
|
| Rate for Payer: The Alliance Commercial |
$7,428.00
|
| Rate for Payer: WEA Trust Commercial |
$1,021.35
|
| Rate for Payer: WPS Commercial |
$1,375.48
|
|
|
RING MALYUGIN 7.0 MAL-0002
|
Facility
|
IP
|
$1,857.00
|
|
| Hospital Charge Code |
5415296
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$909.93 |
| Max. Negotiated Rate |
$1,708.44 |
| Rate for Payer: Aetna Commercial |
$1,671.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,597.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$984.21
|
| Rate for Payer: Cash Price |
$557.10
|
| Rate for Payer: Cigna Commercial |
$1,708.44
|
| Rate for Payer: Health EOS Commercial |
$1,652.73
|
| Rate for Payer: HFN Commercial |
$1,708.44
|
| Rate for Payer: Multiplan Commercial |
$1,485.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,114.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,708.44
|
| Rate for Payer: Quartz Beloit One Network |
$909.93
|
| Rate for Payer: Quartz Commercial |
$1,114.20
|
| Rate for Payer: WEA Trust Commercial |
$1,021.35
|
| Rate for Payer: WPS Commercial |
$1,375.48
|
|
|
RING OSTOMY ADAPT BARRIER 79520
|
Facility
|
IP
|
$94.00
|
|
| Hospital Charge Code |
2969230
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$46.06 |
| Max. Negotiated Rate |
$86.48 |
| Rate for Payer: Aetna Commercial |
$84.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.82
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$86.48
|
| Rate for Payer: Health EOS Commercial |
$83.66
|
| Rate for Payer: HFN Commercial |
$86.48
|
| Rate for Payer: Multiplan Commercial |
$75.20
|
| Rate for Payer: NAPHCARE Commercial |
$56.40
|
| Rate for Payer: Preferred Network Access Commercial |
$86.48
|
| Rate for Payer: Quartz Beloit One Network |
$46.06
|
| Rate for Payer: Quartz Commercial |
$56.40
|
| Rate for Payer: WEA Trust Commercial |
$51.70
|
| Rate for Payer: WPS Commercial |
$69.63
|
|
|
RING OSTOMY ADAPT BARRIER 79520
|
Facility
|
OP
|
$94.00
|
|
| Hospital Charge Code |
2969230
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$26.32 |
| Max. Negotiated Rate |
$376.00 |
| Rate for Payer: Aetna Commercial |
$84.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.84
|
| Rate for Payer: Aetna Managed Medicare |
$26.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$61.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$47.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$45.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.82
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$86.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.60
|
| Rate for Payer: Health EOS Commercial |
$83.66
|
| Rate for Payer: HFN Commercial |
$86.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.50
|
| Rate for Payer: Multiplan Commercial |
$75.20
|
| Rate for Payer: NAPHCARE Commercial |
$56.40
|
| Rate for Payer: Preferred Network Access Commercial |
$86.48
|
| Rate for Payer: Quartz Beloit One Network |
$46.06
|
| Rate for Payer: Quartz Commercial |
$61.10
|
| Rate for Payer: Quartz Medicare Advantage |
$56.40
|
| Rate for Payer: The Alliance Commercial |
$376.00
|
| Rate for Payer: WEA Trust Commercial |
$51.70
|
| Rate for Payer: WPS Commercial |
$69.63
|
|
|
RING REFORM CAPSULAR TENSION 11MM ACTR11 8065225704
|
Facility
|
OP
|
$2,005.00
|
|
|
Service Code
|
CPT 66982
|
| Hospital Charge Code |
4519976
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$962.40 |
| Max. Negotiated Rate |
$11,874.87 |
| Rate for Payer: Aetna Commercial |
$1,804.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,724.30
|
| Rate for Payer: Aetna Managed Medicare |
$2,303.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,303.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,002.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$962.40
|
| Rate for Payer: Anthem Medicare Advantage |
$2,303.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,062.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,303.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,303.35
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cash Price |
$601.50
|
| Rate for Payer: Cigna Commercial |
$1,844.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,303.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,303.35
|
| Rate for Payer: Health EOS Commercial |
$1,784.45
|
| Rate for Payer: HFN Commercial |
$1,844.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,568.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,303.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,303.35
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,303.35
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,303.35
|
| Rate for Payer: Multiplan Commercial |
$1,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,455.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,844.60
|
| Rate for Payer: Quartz Beloit One Network |
$982.45
|
| Rate for Payer: Quartz Commercial |
$1,303.25
|
| Rate for Payer: Quartz Medicare Advantage |
$2,303.35
|
| Rate for Payer: The Alliance Commercial |
$9,213.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,303.35
|
| Rate for Payer: WEA Trust Commercial |
$1,102.75
|
| Rate for Payer: Wellcare Medicare |
$2,303.35
|
| Rate for Payer: WPS Commercial |
$1,485.10
|
|
