|
ATTACHMENT C2C DISPOSABLE 4607-300-032
|
Facility
IP
|
$3,805.00
|
|
| Hospital Charge Code |
6228125
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,864.45 |
| Max. Negotiated Rate |
$3,500.60 |
| Rate for Payer: Aetna Commercial |
$3,424.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,016.65
|
| Rate for Payer: Cash Price |
$1,141.50
|
| Rate for Payer: Cigna Commercial |
$3,500.60
|
| Rate for Payer: Health EOS Commercial |
$3,386.45
|
| Rate for Payer: HFN Commercial |
$3,500.60
|
| Rate for Payer: Multiplan Commercial |
$3,044.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,283.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,500.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,864.45
|
| Rate for Payer: Quartz Commercial |
$2,283.00
|
| Rate for Payer: WEA Trust Commercial |
$2,092.75
|
| Rate for Payer: WPS Commercial |
$2,818.36
|
|
|
.Atypical P ANCA Titer
|
Facility
OP
|
$65.00
|
|
|
Service Code
|
CPT 86037
|
| Hospital Charge Code |
6209196
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$260.00 |
| Rate for Payer: Aetna Commercial |
$58.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.90
|
| Rate for Payer: Aetna Managed Medicare |
$12.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.00
|
| Rate for Payer: Anthem Medicaid |
$12.05
|
| Rate for Payer: Anthem Medicare Advantage |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.05
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cigna Commercial |
$59.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.05
|
| Rate for Payer: Dean Health Medicaid |
$12.05
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.05
|
| Rate for Payer: Health EOS Commercial |
$57.85
|
| Rate for Payer: HFN Commercial |
$59.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.05
|
| Rate for Payer: Managed Health Services Medicaid |
$12.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.05
|
| Rate for Payer: Multiplan Commercial |
$52.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.08
|
| Rate for Payer: Preferred Network Access Commercial |
$59.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.05
|
| Rate for Payer: Quartz Beloit One Network |
$31.85
|
| Rate for Payer: Quartz Commercial |
$42.25
|
| Rate for Payer: Quartz Medicare Advantage |
$12.05
|
| Rate for Payer: The Alliance Commercial |
$260.00
|
| Rate for Payer: United Healthcare Medicaid |
$12.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.05
|
| Rate for Payer: United Healthcare PPO |
$48.75
|
| Rate for Payer: WEA Trust Commercial |
$35.75
|
| Rate for Payer: Wellcare Medicare |
$12.05
|
| Rate for Payer: WMAP Medicaid |
$12.05
|
| Rate for Payer: WPS Commercial |
$48.15
|
|
|
.Atypical P ANCA Titer
|
Professional
|
$65.00
|
|
|
Service Code
|
CPT 86037
|
| Hospital Charge Code |
6209196
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$61.75 |
| Rate for Payer: Aetna Commercial |
$61.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$55.90
|
| Rate for Payer: Aetna Managed Medicare |
$12.05
|
| Rate for Payer: Anthem Medicare Advantage |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.05
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cigna Commercial |
$61.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$32.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.05
|
| Rate for Payer: Health EOS Commercial |
$59.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.05
|
| Rate for Payer: Multiplan Commercial |
$52.00
|
| Rate for Payer: Preferred Network Access Commercial |
$61.75
|
| Rate for Payer: Quartz Beloit One Network |
$28.60
|
| Rate for Payer: Quartz Commercial |
$37.05
|
| Rate for Payer: Quartz Medicare Advantage |
$12.05
|
| Rate for Payer: The Alliance Commercial |
$47.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.05
|
| Rate for Payer: WEA Trust Commercial |
$35.75
|
| Rate for Payer: WPS Commercial |
$53.02
|
|
|
.Atypical P ANCA Titer
|
Facility
IP
|
$65.00
|
|
|
Service Code
|
CPT 86037
|
| Hospital Charge Code |
6209196
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$31.85 |
| Max. Negotiated Rate |
$59.80 |
| Rate for Payer: Aetna Commercial |
$58.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.45
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cigna Commercial |
$59.80
|
| Rate for Payer: Health EOS Commercial |
$57.85
|
| Rate for Payer: HFN Commercial |
$59.80
|
| Rate for Payer: Multiplan Commercial |
$52.00
|
| Rate for Payer: NAPHCARE Commercial |
$39.00
|
| Rate for Payer: Preferred Network Access Commercial |
$59.80
|
| Rate for Payer: Quartz Beloit One Network |
$31.85
|
| Rate for Payer: Quartz Commercial |
$39.00
|
| Rate for Payer: WEA Trust Commercial |
$35.75
|
| Rate for Payer: WPS Commercial |
$48.15
|
|
|
Audiogram (OSHA)
|
Facility
IP
|
$49.00
|
|
| Hospital Charge Code |
3203482
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$24.01 |
| Max. Negotiated Rate |
$45.08 |
| Rate for Payer: Aetna Commercial |
$44.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.97
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$45.08
|
| Rate for Payer: Health EOS Commercial |
$43.61
|
| Rate for Payer: HFN Commercial |
$45.08
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: NAPHCARE Commercial |
$29.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.08
|
| Rate for Payer: Quartz Beloit One Network |
$24.01
|
| Rate for Payer: Quartz Commercial |
$29.40
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Audiogram (OSHA)
|
Professional
|
$49.00
|
|
| Hospital Charge Code |
3203482
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$46.55 |
| Rate for Payer: Quartz Commercial |
$27.93
|
| Rate for Payer: Aetna Commercial |
$46.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.40
|
| Rate for Payer: Health EOS Commercial |
$44.59
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: Preferred Network Access Commercial |
$46.55
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: The Alliance Commercial |
$24.50
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Audiogram (OSHA)
|
Facility
OP
|
$49.00
|
|
| Hospital Charge Code |
3203482
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: Aetna Commercial |
$44.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Aetna Managed Medicare |
$13.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.97
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$45.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.42
|
| Rate for Payer: Health EOS Commercial |
$43.61
|
| Rate for Payer: HFN Commercial |
$45.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.75
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: NAPHCARE Commercial |
$29.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.08
|
| Rate for Payer: Quartz Beloit One Network |
$24.01
|
| Rate for Payer: Quartz Commercial |
$31.85
|
| Rate for Payer: Quartz Medicare Advantage |
$29.40
|
| Rate for Payer: The Alliance Commercial |
$196.00
|
| Rate for Payer: United Healthcare PPO |
$36.75
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Audiometry Threshold Evaluation; Comprehensive
|
Facility
OP
|
$288.00
|
|
|
Service Code
|
CPT 92557
|
| Hospital Charge Code |
1152819
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$138.24 |
| Max. Negotiated Rate |
$574.33 |
| Rate for Payer: Aetna Commercial |
$259.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.68
|
| Rate for Payer: Aetna Managed Medicare |
$154.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$187.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$144.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$138.24
|
| Rate for Payer: Anthem Medicare Advantage |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$154.39
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$264.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$154.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$161.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$154.39
|
| Rate for Payer: Health EOS Commercial |
$256.32
|
| Rate for Payer: HFN Commercial |
$264.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$574.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$154.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$154.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$154.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$154.39
|
| Rate for Payer: Multiplan Commercial |
$230.40
|
| Rate for Payer: NAPHCARE Commercial |
$231.58
|
| Rate for Payer: Preferred Network Access Commercial |
$264.96
|
| Rate for Payer: Quartz Beloit One Network |
$141.12
|
| Rate for Payer: Quartz Commercial |
$187.20
|
| Rate for Payer: Quartz Medicare Advantage |
$154.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$154.39
|
| Rate for Payer: WEA Trust Commercial |
$158.40
|
| Rate for Payer: Wellcare Medicare |
$154.39
|
| Rate for Payer: WPS Commercial |
$213.32
|
|
|
Audiometry Threshold Evaluation; Comprehensive
|
Facility
IP
|
$288.00
|
|
|
Service Code
|
CPT 92557
|
| Hospital Charge Code |
1152819
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$141.12 |
| Max. Negotiated Rate |
$264.96 |
| Rate for Payer: Aetna Commercial |
$259.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.64
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$264.96
|
| Rate for Payer: Health EOS Commercial |
$256.32
|
| Rate for Payer: HFN Commercial |
$264.96
|
| Rate for Payer: Multiplan Commercial |
$230.40
|
| Rate for Payer: NAPHCARE Commercial |
$172.80
|
| Rate for Payer: Preferred Network Access Commercial |
$264.96
|
| Rate for Payer: Quartz Beloit One Network |
$141.12
|
| Rate for Payer: Quartz Commercial |
$172.80
|
| Rate for Payer: WEA Trust Commercial |
$158.40
|
| Rate for Payer: WPS Commercial |
$213.32
|
|
|
Audiometry Threshold Evaluation; Comprehensive
|
Professional
|
$288.00
|
|
|
Service Code
|
CPT 92557
|
| Hospital Charge Code |
1152819
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.85 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna Commercial |
$273.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.68
|
| Rate for Payer: Aetna Managed Medicare |
$30.85
|
| Rate for Payer: Anthem Medicare Advantage |
$30.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.85
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$273.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$144.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.85
|
| Rate for Payer: Health EOS Commercial |
$262.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$131.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$131.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.85
|
| Rate for Payer: Multiplan Commercial |
$230.40
|
| Rate for Payer: Preferred Network Access Commercial |
$273.60
|
| Rate for Payer: Quartz Beloit One Network |
$126.72
|
| Rate for Payer: Quartz Commercial |
$164.16
|
| Rate for Payer: Quartz Medicare Advantage |
$30.85
|
| Rate for Payer: The Alliance Commercial |
$77.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.85
|
| Rate for Payer: WEA Trust Commercial |
$158.40
|
| Rate for Payer: WPS Commercial |
$123.40
|
|
|
AUGMENT BASEPLATE 24MM 10 FULL +2 LATERAL AR-9580-2410-2
|
Facility
IP
|
$16,365.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5659646
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,018.85 |
| Max. Negotiated Rate |
$15,055.80 |
| Rate for Payer: Aetna Commercial |
$14,728.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,673.45
|
| Rate for Payer: Cash Price |
$4,909.50
|
| Rate for Payer: Cigna Commercial |
$15,055.80
|
| Rate for Payer: Health EOS Commercial |
$14,564.85
|
| Rate for Payer: HFN Commercial |
$15,055.80
|
| Rate for Payer: Multiplan Commercial |
$13,092.00
|
| Rate for Payer: NAPHCARE Commercial |
$9,819.00
|
| Rate for Payer: Preferred Network Access Commercial |
$15,055.80
|
| Rate for Payer: Quartz Beloit One Network |
$8,018.85
|
| Rate for Payer: Quartz Commercial |
$9,819.00
|
| Rate for Payer: WEA Trust Commercial |
$9,000.75
|
| Rate for Payer: WPS Commercial |
$12,121.56
|
|
|
AUGMENT BASEPLATE 24MM 10 FULL +2 LATERAL AR-9580-2410-2
|
Facility
OP
|
$16,365.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5659646
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,582.20 |
| Max. Negotiated Rate |
$15,055.80 |
| Rate for Payer: Aetna Commercial |
$14,728.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,073.90
|
| Rate for Payer: Aetna Managed Medicare |
$4,582.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,637.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,182.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,855.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,673.45
|
| Rate for Payer: Cash Price |
$4,909.50
|
| Rate for Payer: Cigna Commercial |
$15,055.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,157.85
|
| Rate for Payer: Health EOS Commercial |
$14,564.85
|
| Rate for Payer: HFN Commercial |
$15,055.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,273.75
|
| Rate for Payer: Multiplan Commercial |
$13,092.00
|
| Rate for Payer: NAPHCARE Commercial |
$9,819.00
|
| Rate for Payer: Preferred Network Access Commercial |
$15,055.80
|
| Rate for Payer: Quartz Beloit One Network |
$8,018.85
|
| Rate for Payer: Quartz Commercial |
$10,637.25
|
| Rate for Payer: Quartz Medicare Advantage |
$9,819.00
|
| Rate for Payer: WEA Trust Commercial |
$9,000.75
|
| Rate for Payer: WPS Commercial |
$12,121.56
|
|
|
AUGMENT BASEPLATE 24MM 10 FULL +2 LATERAL ST AR-9580-2410-2S
|
Facility
IP
|
$15,131.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6220210
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,414.19 |
| Max. Negotiated Rate |
$13,920.52 |
| Rate for Payer: Aetna Commercial |
$13,617.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,019.43
|
| Rate for Payer: Cash Price |
$4,539.30
|
| Rate for Payer: Cigna Commercial |
$13,920.52
|
| Rate for Payer: Health EOS Commercial |
$13,466.59
|
| Rate for Payer: HFN Commercial |
$13,920.52
|
| Rate for Payer: Multiplan Commercial |
$12,104.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,078.60
|
| Rate for Payer: Preferred Network Access Commercial |
$13,920.52
|
| Rate for Payer: Quartz Beloit One Network |
$7,414.19
|
| Rate for Payer: Quartz Commercial |
$9,078.60
|
| Rate for Payer: WEA Trust Commercial |
$8,322.05
|
| Rate for Payer: WPS Commercial |
$11,207.53
|
|
|
AUGMENT BASEPLATE 24MM 10 FULL +2 LATERAL ST AR-9580-2410-2S
|
Facility
OP
|
$15,131.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6220210
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,236.68 |
| Max. Negotiated Rate |
$13,920.52 |
| Rate for Payer: Aetna Commercial |
$13,617.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,012.66
|
| Rate for Payer: Aetna Managed Medicare |
$4,236.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,835.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,565.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,262.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,019.43
|
| Rate for Payer: Cash Price |
$4,539.30
|
| Rate for Payer: Cigna Commercial |
$13,920.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,467.31
|
| Rate for Payer: Health EOS Commercial |
$13,466.59
|
| Rate for Payer: HFN Commercial |
$13,920.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,348.25
|
| Rate for Payer: Multiplan Commercial |
$12,104.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,078.60
|
| Rate for Payer: Preferred Network Access Commercial |
$13,920.52
|
| Rate for Payer: Quartz Beloit One Network |
$7,414.19
|
| Rate for Payer: Quartz Commercial |
$9,835.15
|
| Rate for Payer: Quartz Medicare Advantage |
$9,078.60
|
| Rate for Payer: WEA Trust Commercial |
$8,322.05
|
| Rate for Payer: WPS Commercial |
$11,207.53
|
|
|
AUGMENT BASEPLATE 24MM 10 FULL AR-9580-2410
|
Facility
IP
|
$16,365.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831634
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,018.85 |
| Max. Negotiated Rate |
$15,055.80 |
| Rate for Payer: Aetna Commercial |
$14,728.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,673.45
|
| Rate for Payer: Cash Price |
$4,909.50
|
| Rate for Payer: Cigna Commercial |
$15,055.80
|
| Rate for Payer: Health EOS Commercial |
$14,564.85
|
| Rate for Payer: HFN Commercial |
$15,055.80
|
| Rate for Payer: Multiplan Commercial |
$13,092.00
|
| Rate for Payer: NAPHCARE Commercial |
$9,819.00
|
| Rate for Payer: Preferred Network Access Commercial |
$15,055.80
|
| Rate for Payer: Quartz Beloit One Network |
$8,018.85
|
| Rate for Payer: Quartz Commercial |
$9,819.00
|
| Rate for Payer: WEA Trust Commercial |
$9,000.75
|
| Rate for Payer: WPS Commercial |
$12,121.56
|
|
|
AUGMENT BASEPLATE 24MM 10 FULL AR-9580-2410
|
Facility
OP
|
$16,365.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831634
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,582.20 |
| Max. Negotiated Rate |
$15,055.80 |
| Rate for Payer: Aetna Commercial |
$14,728.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,073.90
|
| Rate for Payer: Aetna Managed Medicare |
$4,582.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,637.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,182.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,855.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,673.45
|
| Rate for Payer: Cash Price |
$4,909.50
|
| Rate for Payer: Cigna Commercial |
$15,055.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,157.85
|
| Rate for Payer: Health EOS Commercial |
$14,564.85
|
| Rate for Payer: HFN Commercial |
$15,055.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,273.75
|
| Rate for Payer: Multiplan Commercial |
$13,092.00
|
| Rate for Payer: NAPHCARE Commercial |
$9,819.00
|
| Rate for Payer: Preferred Network Access Commercial |
$15,055.80
|
| Rate for Payer: Quartz Beloit One Network |
$8,018.85
|
| Rate for Payer: Quartz Commercial |
$10,637.25
|
| Rate for Payer: Quartz Medicare Advantage |
$9,819.00
|
| Rate for Payer: WEA Trust Commercial |
$9,000.75
|
| Rate for Payer: WPS Commercial |
$12,121.56
|
|
|
AUGMENT BLOCK NEXGEN DISTAL SZ D 10MM 00-5990-034-21
|
Facility
OP
|
$7,075.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192967
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,981.00 |
| Max. Negotiated Rate |
$6,509.00 |
| Rate for Payer: Aetna Commercial |
$6,367.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,084.50
|
| Rate for Payer: Aetna Managed Medicare |
$1,981.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,598.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,537.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,396.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,749.75
|
| Rate for Payer: Cash Price |
$2,122.50
|
| Rate for Payer: Cigna Commercial |
$6,509.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,959.17
|
| Rate for Payer: Health EOS Commercial |
$6,296.75
|
| Rate for Payer: HFN Commercial |
$6,509.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,306.25
|
| Rate for Payer: Multiplan Commercial |
$5,660.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,245.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,509.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,466.75
|
| Rate for Payer: Quartz Commercial |
$4,598.75
|
| Rate for Payer: Quartz Medicare Advantage |
$4,245.00
|
| Rate for Payer: WEA Trust Commercial |
$3,891.25
|
| Rate for Payer: WPS Commercial |
$5,240.45
|
|
|
AUGMENT BLOCK NEXGEN DISTAL SZ D 10MM 00-5990-034-21
|
Facility
IP
|
$7,075.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6192967
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,466.75 |
| Max. Negotiated Rate |
$6,509.00 |
| Rate for Payer: Aetna Commercial |
$6,367.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,749.75
|
| Rate for Payer: Cash Price |
$2,122.50
|
| Rate for Payer: Cigna Commercial |
$6,509.00
|
| Rate for Payer: Health EOS Commercial |
$6,296.75
|
| Rate for Payer: HFN Commercial |
$6,509.00
|
| Rate for Payer: Multiplan Commercial |
$5,660.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,245.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,509.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,466.75
|
| Rate for Payer: Quartz Commercial |
$4,245.00
|
| Rate for Payer: WEA Trust Commercial |
$3,891.25
|
| Rate for Payer: WPS Commercial |
$5,240.45
|
|
|
AUGMENT SHOULDER BASEPLATE 24MM 10 FULL AR-9580-2410S
|
Facility
OP
|
$15,131.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6199018
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,236.68 |
| Max. Negotiated Rate |
$13,920.52 |
| Rate for Payer: Aetna Commercial |
$13,617.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,012.66
|
| Rate for Payer: Aetna Managed Medicare |
$4,236.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,835.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,565.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,262.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,019.43
|
| Rate for Payer: Cash Price |
$4,539.30
|
| Rate for Payer: Cigna Commercial |
$13,920.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,467.31
|
| Rate for Payer: Health EOS Commercial |
$13,466.59
|
| Rate for Payer: HFN Commercial |
$13,920.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,348.25
|
| Rate for Payer: Multiplan Commercial |
$12,104.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,078.60
|
| Rate for Payer: Preferred Network Access Commercial |
$13,920.52
|
| Rate for Payer: Quartz Beloit One Network |
$7,414.19
|
| Rate for Payer: Quartz Commercial |
$9,835.15
|
| Rate for Payer: Quartz Medicare Advantage |
$9,078.60
|
| Rate for Payer: WEA Trust Commercial |
$8,322.05
|
| Rate for Payer: WPS Commercial |
$11,207.53
|
|
|
AUGMENT SHOULDER BASEPLATE 24MM 10 FULL AR-9580-2410S
|
Facility
IP
|
$15,131.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6199018
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,414.19 |
| Max. Negotiated Rate |
$13,920.52 |
| Rate for Payer: Aetna Commercial |
$13,617.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,019.43
|
| Rate for Payer: Cash Price |
$4,539.30
|
| Rate for Payer: Cigna Commercial |
$13,920.52
|
| Rate for Payer: Health EOS Commercial |
$13,466.59
|
| Rate for Payer: HFN Commercial |
$13,920.52
|
| Rate for Payer: Multiplan Commercial |
$12,104.80
|
| Rate for Payer: NAPHCARE Commercial |
$9,078.60
|
| Rate for Payer: Preferred Network Access Commercial |
$13,920.52
|
| Rate for Payer: Quartz Beloit One Network |
$7,414.19
|
| Rate for Payer: Quartz Commercial |
$9,078.60
|
| Rate for Payer: WEA Trust Commercial |
$8,322.05
|
| Rate for Payer: WPS Commercial |
$11,207.53
|
|
|
AUGMENT SYNTHETIC BONE GRAFT 1.5CC (BOVINE COLLOGEN) K30001510
|
Facility
IP
|
$10,932.00
|
|
|
Service Code
|
HCPCS C1734
|
| Hospital Charge Code |
6167718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,356.68 |
| Max. Negotiated Rate |
$10,057.44 |
| Rate for Payer: Aetna Commercial |
$9,838.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,793.96
|
| Rate for Payer: Cash Price |
$3,279.60
|
| Rate for Payer: Cigna Commercial |
$10,057.44
|
| Rate for Payer: Health EOS Commercial |
$9,729.48
|
| Rate for Payer: HFN Commercial |
$10,057.44
|
| Rate for Payer: Multiplan Commercial |
$8,745.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,559.20
|
| Rate for Payer: Preferred Network Access Commercial |
$10,057.44
|
| Rate for Payer: Quartz Beloit One Network |
$5,356.68
|
| Rate for Payer: Quartz Commercial |
$6,559.20
|
| Rate for Payer: WEA Trust Commercial |
$6,012.60
|
| Rate for Payer: WPS Commercial |
$8,097.33
|
|
|
AUGMENT SYNTHETIC BONE GRAFT 1.5CC (BOVINE COLLOGEN) K30001510
|
Facility
OP
|
$10,932.00
|
|
|
Service Code
|
HCPCS C1734
|
| Hospital Charge Code |
6167718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,060.96 |
| Max. Negotiated Rate |
$10,057.44 |
| Rate for Payer: Aetna Commercial |
$9,838.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,401.52
|
| Rate for Payer: Aetna Managed Medicare |
$3,060.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,105.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,466.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,247.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,793.96
|
| Rate for Payer: Cash Price |
$3,279.60
|
| Rate for Payer: Cigna Commercial |
$10,057.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,117.55
|
| Rate for Payer: Health EOS Commercial |
$9,729.48
|
| Rate for Payer: HFN Commercial |
$10,057.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,199.00
|
| Rate for Payer: Multiplan Commercial |
$8,745.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,559.20
|
| Rate for Payer: Preferred Network Access Commercial |
$10,057.44
|
| Rate for Payer: Quartz Beloit One Network |
$5,356.68
|
| Rate for Payer: Quartz Commercial |
$7,105.80
|
| Rate for Payer: Quartz Medicare Advantage |
$6,559.20
|
| Rate for Payer: WEA Trust Commercial |
$6,012.60
|
| Rate for Payer: WPS Commercial |
$8,097.33
|
|
|
AUGMENT TRIATHLON FEMORAL DISTAL SZ 4 10MM 5541-A-402
|
Facility
IP
|
$4,978.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246166
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,439.51 |
| Max. Negotiated Rate |
$4,580.31 |
| Rate for Payer: Aetna Commercial |
$4,480.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.66
|
| Rate for Payer: Cash Price |
$1,493.58
|
| Rate for Payer: Cigna Commercial |
$4,580.31
|
| Rate for Payer: Health EOS Commercial |
$4,430.95
|
| Rate for Payer: HFN Commercial |
$4,580.31
|
| Rate for Payer: Multiplan Commercial |
$3,982.88
|
| Rate for Payer: NAPHCARE Commercial |
$2,987.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4,580.31
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.51
|
| Rate for Payer: Quartz Commercial |
$2,987.16
|
| Rate for Payer: WEA Trust Commercial |
$2,738.23
|
| Rate for Payer: WPS Commercial |
$3,687.65
|
|
|
AUGMENT TRIATHLON FEMORAL DISTAL SZ 4 10MM 5541-A-402
|
Facility
OP
|
$4,978.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246166
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,394.01 |
| Max. Negotiated Rate |
$4,580.31 |
| Rate for Payer: Aetna Commercial |
$4,480.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,394.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,236.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,489.30
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,389.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.66
|
| Rate for Payer: Cash Price |
$1,493.58
|
| Rate for Payer: Cigna Commercial |
$4,580.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,786.02
|
| Rate for Payer: Health EOS Commercial |
$4,430.95
|
| Rate for Payer: HFN Commercial |
$4,580.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,733.95
|
| Rate for Payer: Multiplan Commercial |
$3,982.88
|
| Rate for Payer: NAPHCARE Commercial |
$2,987.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4,580.31
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.51
|
| Rate for Payer: Quartz Commercial |
$3,236.09
|
| Rate for Payer: Quartz Medicare Advantage |
$2,987.16
|
| Rate for Payer: WEA Trust Commercial |
$2,738.23
|
| Rate for Payer: WPS Commercial |
$3,687.65
|
|
|
AUGMENT TRIATHLON FEMORAL DISTAL SZ 4 5MM 5540-A-402
|
Facility
OP
|
$4,737.63
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246165
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,326.54 |
| Max. Negotiated Rate |
$4,358.62 |
| Rate for Payer: Aetna Commercial |
$4,263.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,074.36
|
| Rate for Payer: Aetna Managed Medicare |
$1,326.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,079.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,368.82
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,274.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,510.94
|
| Rate for Payer: Cash Price |
$1,421.29
|
| Rate for Payer: Cigna Commercial |
$4,358.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,651.18
|
| Rate for Payer: Health EOS Commercial |
$4,216.49
|
| Rate for Payer: HFN Commercial |
$4,358.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,553.22
|
| Rate for Payer: Multiplan Commercial |
$3,790.10
|
| Rate for Payer: NAPHCARE Commercial |
$2,842.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,358.62
|
| Rate for Payer: Quartz Beloit One Network |
$2,321.44
|
| Rate for Payer: Quartz Commercial |
$3,079.46
|
| Rate for Payer: Quartz Medicare Advantage |
$2,842.58
|
| Rate for Payer: WEA Trust Commercial |
$2,605.70
|
| Rate for Payer: WPS Commercial |
$3,509.16
|
|
