|
SLEEVE COMPRESSION LARGE
|
Facility
|
IP
|
$465.00
|
|
| Hospital Charge Code |
2963056
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$236.96 |
| Max. Negotiated Rate |
$444.91 |
| Rate for Payer: Aetna Commercial |
$435.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$415.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$256.31
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$444.91
|
| Rate for Payer: Health EOS Commercial |
$430.40
|
| Rate for Payer: HFN Commercial |
$444.91
|
| Rate for Payer: Multiplan Commercial |
$386.88
|
| Rate for Payer: Preferred Network Access Commercial |
$444.91
|
| Rate for Payer: Quartz Beloit One Network |
$236.96
|
| Rate for Payer: Quartz Commercial |
$290.16
|
| Rate for Payer: WEA Trust Commercial |
$265.98
|
| Rate for Payer: WPS Commercial |
$358.19
|
|
|
SLEEVE COMPRESSION MEDIUM
|
Facility
|
OP
|
$285.00
|
|
| Hospital Charge Code |
2963266
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$82.99 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Aetna Managed Medicare |
$82.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$192.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$148.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$142.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$165.87
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$222.30
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: NAPHCARE Commercial |
$177.84
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$192.66
|
| Rate for Payer: Quartz Medicare Advantage |
$177.84
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
SLEEVE COMPRESSION MEDIUM
|
Facility
|
IP
|
$285.00
|
|
| Hospital Charge Code |
2963266
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$145.24 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$177.84
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
SLEEVE COMPRESSION-XL
|
Facility
|
OP
|
$915.00
|
|
| Hospital Charge Code |
2975049
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$266.45 |
| Max. Negotiated Rate |
$875.47 |
| Rate for Payer: Aetna Commercial |
$856.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$818.38
|
| Rate for Payer: Aetna Managed Medicare |
$266.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$618.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$475.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$456.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.35
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$875.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$532.53
|
| Rate for Payer: Health EOS Commercial |
$846.92
|
| Rate for Payer: HFN Commercial |
$875.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$713.70
|
| Rate for Payer: Multiplan Commercial |
$761.28
|
| Rate for Payer: NAPHCARE Commercial |
$570.96
|
| Rate for Payer: Preferred Network Access Commercial |
$875.47
|
| Rate for Payer: Quartz Beloit One Network |
$466.28
|
| Rate for Payer: Quartz Commercial |
$618.54
|
| Rate for Payer: Quartz Medicare Advantage |
$570.96
|
| Rate for Payer: The Alliance Commercial |
$475.80
|
| Rate for Payer: WEA Trust Commercial |
$523.38
|
| Rate for Payer: WPS Commercial |
$704.82
|
|
|
SLEEVE COMPRESSION-XL
|
Facility
|
IP
|
$915.00
|
|
| Hospital Charge Code |
2975049
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$466.28 |
| Max. Negotiated Rate |
$875.47 |
| Rate for Payer: Aetna Commercial |
$856.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$818.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.35
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$875.47
|
| Rate for Payer: Health EOS Commercial |
$846.92
|
| Rate for Payer: HFN Commercial |
$875.47
|
| Rate for Payer: Multiplan Commercial |
$761.28
|
| Rate for Payer: Preferred Network Access Commercial |
$875.47
|
| Rate for Payer: Quartz Beloit One Network |
$466.28
|
| Rate for Payer: Quartz Commercial |
$570.96
|
| Rate for Payer: WEA Trust Commercial |
$523.38
|
| Rate for Payer: WPS Commercial |
$704.82
|
|
|
SLEEVE RESORBABLE FOR 5.0 ANGU
|
Facility
|
OP
|
$2,608.00
|
|
| Hospital Charge Code |
2966584
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$759.45 |
| Max. Negotiated Rate |
$2,495.33 |
| Rate for Payer: Aetna Commercial |
$2,441.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,332.60
|
| Rate for Payer: Aetna Managed Medicare |
$759.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,763.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,356.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,301.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,437.53
|
| Rate for Payer: Cash Price |
$782.40
|
| Rate for Payer: Cigna Commercial |
$2,495.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,517.86
|
| Rate for Payer: Health EOS Commercial |
$2,413.96
|
| Rate for Payer: HFN Commercial |
$2,495.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,034.24
|
| Rate for Payer: Multiplan Commercial |
$2,169.86
|
| Rate for Payer: NAPHCARE Commercial |
$1,627.39
|
| Rate for Payer: Preferred Network Access Commercial |
$2,495.33
|
| Rate for Payer: Quartz Beloit One Network |
$1,329.04
|
| Rate for Payer: Quartz Commercial |
$1,763.01
|
| Rate for Payer: Quartz Medicare Advantage |
$1,627.39
|
| Rate for Payer: The Alliance Commercial |
$1,356.16
|
| Rate for Payer: WEA Trust Commercial |
$1,491.78
|
| Rate for Payer: WPS Commercial |
$2,008.94
|
|
|
SLEEVE RESORBABLE FOR 5.0 ANGU
|
Facility
|
IP
|
$2,608.00
|
|
| Hospital Charge Code |
2966584
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,329.04 |
| Max. Negotiated Rate |
$2,495.33 |
| Rate for Payer: Aetna Commercial |
$2,441.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,332.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,437.53
|
| Rate for Payer: Cash Price |
$782.40
|
| Rate for Payer: Cigna Commercial |
$2,495.33
|
| Rate for Payer: Health EOS Commercial |
$2,413.96
|
| Rate for Payer: HFN Commercial |
$2,495.33
|
| Rate for Payer: Multiplan Commercial |
$2,169.86
|
| Rate for Payer: Preferred Network Access Commercial |
$2,495.33
|
| Rate for Payer: Quartz Beloit One Network |
$1,329.04
|
| Rate for Payer: Quartz Commercial |
$1,627.39
|
| Rate for Payer: WEA Trust Commercial |
$1,491.78
|
| Rate for Payer: WPS Commercial |
$2,008.94
|
|
|
SLEEVE REVISION METAPHYSEAL POROUS M.B.T. 29MM 1294-54-000
|
Facility
|
OP
|
$14,721.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5641694
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,286.76 |
| Max. Negotiated Rate |
$14,085.05 |
| Rate for Payer: Aetna Commercial |
$13,778.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,166.46
|
| Rate for Payer: Aetna Managed Medicare |
$4,286.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,951.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,654.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,348.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,114.22
|
| Rate for Payer: Cash Price |
$4,416.30
|
| Rate for Payer: Cigna Commercial |
$14,085.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,567.62
|
| Rate for Payer: Health EOS Commercial |
$13,625.76
|
| Rate for Payer: HFN Commercial |
$14,085.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,482.38
|
| Rate for Payer: Multiplan Commercial |
$12,247.87
|
| Rate for Payer: NAPHCARE Commercial |
$9,185.90
|
| Rate for Payer: Preferred Network Access Commercial |
$14,085.05
|
| Rate for Payer: Quartz Beloit One Network |
$7,501.82
|
| Rate for Payer: Quartz Commercial |
$9,951.40
|
| Rate for Payer: Quartz Medicare Advantage |
$9,185.90
|
| Rate for Payer: The Alliance Commercial |
$7,654.92
|
| Rate for Payer: WEA Trust Commercial |
$8,420.41
|
| Rate for Payer: WPS Commercial |
$11,339.59
|
|
|
SLEEVE REVISION METAPHYSEAL POROUS M.B.T. 29MM 1294-54-000
|
Facility
|
IP
|
$14,721.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5641694
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,501.82 |
| Max. Negotiated Rate |
$14,085.05 |
| Rate for Payer: Aetna Commercial |
$13,778.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,166.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,114.22
|
| Rate for Payer: Cash Price |
$4,416.30
|
| Rate for Payer: Cigna Commercial |
$14,085.05
|
| Rate for Payer: Health EOS Commercial |
$13,625.76
|
| Rate for Payer: HFN Commercial |
$14,085.05
|
| Rate for Payer: Multiplan Commercial |
$12,247.87
|
| Rate for Payer: Preferred Network Access Commercial |
$14,085.05
|
| Rate for Payer: Quartz Beloit One Network |
$7,501.82
|
| Rate for Payer: Quartz Commercial |
$9,185.90
|
| Rate for Payer: WEA Trust Commercial |
$8,420.41
|
| Rate for Payer: WPS Commercial |
$11,339.59
|
|
|
SLEEVE REVISION METAPHYSEAL POROUS M.B.T. 45MM 1294-54-110
|
Facility
|
OP
|
$20,246.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,895.64 |
| Max. Negotiated Rate |
$19,371.37 |
| Rate for Payer: Aetna Commercial |
$18,950.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,108.02
|
| Rate for Payer: Aetna Managed Medicare |
$5,895.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,686.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,527.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,106.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,159.60
|
| Rate for Payer: Cash Price |
$6,073.80
|
| Rate for Payer: Cigna Commercial |
$19,371.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,783.17
|
| Rate for Payer: Health EOS Commercial |
$18,739.70
|
| Rate for Payer: HFN Commercial |
$19,371.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,791.88
|
| Rate for Payer: Multiplan Commercial |
$16,844.67
|
| Rate for Payer: NAPHCARE Commercial |
$12,633.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19,371.37
|
| Rate for Payer: Quartz Beloit One Network |
$10,317.36
|
| Rate for Payer: Quartz Commercial |
$13,686.30
|
| Rate for Payer: Quartz Medicare Advantage |
$12,633.50
|
| Rate for Payer: The Alliance Commercial |
$10,527.92
|
| Rate for Payer: WEA Trust Commercial |
$11,580.71
|
| Rate for Payer: WPS Commercial |
$15,595.49
|
|
|
SLEEVE REVISION METAPHYSEAL POROUS M.B.T. 45MM 1294-54-110
|
Facility
|
IP
|
$20,246.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5459702
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,317.36 |
| Max. Negotiated Rate |
$19,371.37 |
| Rate for Payer: Aetna Commercial |
$18,950.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,108.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,159.60
|
| Rate for Payer: Cash Price |
$6,073.80
|
| Rate for Payer: Cigna Commercial |
$19,371.37
|
| Rate for Payer: Health EOS Commercial |
$18,739.70
|
| Rate for Payer: HFN Commercial |
$19,371.37
|
| Rate for Payer: Multiplan Commercial |
$16,844.67
|
| Rate for Payer: Preferred Network Access Commercial |
$19,371.37
|
| Rate for Payer: Quartz Beloit One Network |
$10,317.36
|
| Rate for Payer: Quartz Commercial |
$12,633.50
|
| Rate for Payer: WEA Trust Commercial |
$11,580.71
|
| Rate for Payer: WPS Commercial |
$15,595.49
|
|
|
SLEEVE SPEEDGUIDE 70-3932
|
Facility
|
IP
|
$4,241.00
|
|
| Hospital Charge Code |
3791364
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,161.21 |
| Max. Negotiated Rate |
$4,057.79 |
| Rate for Payer: Aetna Commercial |
$3,969.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,793.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,337.64
|
| Rate for Payer: Cash Price |
$1,272.30
|
| Rate for Payer: Cigna Commercial |
$4,057.79
|
| Rate for Payer: Health EOS Commercial |
$3,925.47
|
| Rate for Payer: HFN Commercial |
$4,057.79
|
| Rate for Payer: Multiplan Commercial |
$3,528.51
|
| Rate for Payer: Preferred Network Access Commercial |
$4,057.79
|
| Rate for Payer: Quartz Beloit One Network |
$2,161.21
|
| Rate for Payer: Quartz Commercial |
$2,646.38
|
| Rate for Payer: WEA Trust Commercial |
$2,425.85
|
| Rate for Payer: WPS Commercial |
$3,266.84
|
|
|
SLEEVE SPEEDGUIDE 70-3932
|
Facility
|
OP
|
$4,241.00
|
|
| Hospital Charge Code |
3791364
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,234.98 |
| Max. Negotiated Rate |
$4,057.79 |
| Rate for Payer: Aetna Commercial |
$3,969.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,793.15
|
| Rate for Payer: Aetna Managed Medicare |
$1,234.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,866.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,205.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,117.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,337.64
|
| Rate for Payer: Cash Price |
$1,272.30
|
| Rate for Payer: Cigna Commercial |
$4,057.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,468.26
|
| Rate for Payer: Health EOS Commercial |
$3,925.47
|
| Rate for Payer: HFN Commercial |
$4,057.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,307.98
|
| Rate for Payer: Multiplan Commercial |
$3,528.51
|
| Rate for Payer: NAPHCARE Commercial |
$2,646.38
|
| Rate for Payer: Preferred Network Access Commercial |
$4,057.79
|
| Rate for Payer: Quartz Beloit One Network |
$2,161.21
|
| Rate for Payer: Quartz Commercial |
$2,866.92
|
| Rate for Payer: Quartz Medicare Advantage |
$2,646.38
|
| Rate for Payer: The Alliance Commercial |
$2,205.32
|
| Rate for Payer: WEA Trust Commercial |
$2,425.85
|
| Rate for Payer: WPS Commercial |
$3,266.84
|
|
|
SLEEVES SURGICAL 89791
|
Facility
|
IP
|
$54.00
|
|
| Hospital Charge Code |
2963249
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.52 |
| Max. Negotiated Rate |
$51.67 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$33.70
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
SLEEVES SURGICAL 89791
|
Facility
|
OP
|
$54.00
|
|
| Hospital Charge Code |
2963249
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.72 |
| Max. Negotiated Rate |
$51.67 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.43
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.12
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$33.70
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$36.50
|
| Rate for Payer: Quartz Medicare Advantage |
$33.70
|
| Rate for Payer: The Alliance Commercial |
$28.08
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
SLEEVE STAR AR-1606V
|
Facility
|
IP
|
$1,705.00
|
|
| Hospital Charge Code |
2964666
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$868.87 |
| Max. Negotiated Rate |
$1,631.34 |
| Rate for Payer: Aetna Commercial |
$1,595.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,524.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$939.80
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,631.34
|
| Rate for Payer: Health EOS Commercial |
$1,578.15
|
| Rate for Payer: HFN Commercial |
$1,631.34
|
| Rate for Payer: Multiplan Commercial |
$1,418.56
|
| Rate for Payer: Preferred Network Access Commercial |
$1,631.34
|
| Rate for Payer: Quartz Beloit One Network |
$868.87
|
| Rate for Payer: Quartz Commercial |
$1,063.92
|
| Rate for Payer: WEA Trust Commercial |
$975.26
|
| Rate for Payer: WPS Commercial |
$1,313.36
|
|
|
SLEEVE STAR AR-1606V
|
Facility
|
OP
|
$1,705.00
|
|
| Hospital Charge Code |
2964666
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$496.50 |
| Max. Negotiated Rate |
$1,631.34 |
| Rate for Payer: Aetna Commercial |
$1,595.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,524.95
|
| Rate for Payer: Aetna Managed Medicare |
$496.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,152.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$886.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$851.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$939.80
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,631.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$992.31
|
| Rate for Payer: Health EOS Commercial |
$1,578.15
|
| Rate for Payer: HFN Commercial |
$1,631.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,329.90
|
| Rate for Payer: Multiplan Commercial |
$1,418.56
|
| Rate for Payer: NAPHCARE Commercial |
$1,063.92
|
| Rate for Payer: Preferred Network Access Commercial |
$1,631.34
|
| Rate for Payer: Quartz Beloit One Network |
$868.87
|
| Rate for Payer: Quartz Commercial |
$1,152.58
|
| Rate for Payer: Quartz Medicare Advantage |
$1,063.92
|
| Rate for Payer: The Alliance Commercial |
$886.60
|
| Rate for Payer: WEA Trust Commercial |
$975.26
|
| Rate for Payer: WPS Commercial |
$1,313.36
|
|
|
SLEEVE STERILE
|
Facility
|
OP
|
$367.00
|
|
| Hospital Charge Code |
2972925
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$106.87 |
| Max. Negotiated Rate |
$351.15 |
| Rate for Payer: Aetna Commercial |
$343.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.24
|
| Rate for Payer: Aetna Managed Medicare |
$106.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$248.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$190.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$183.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.29
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$351.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$213.59
|
| Rate for Payer: Health EOS Commercial |
$339.70
|
| Rate for Payer: HFN Commercial |
$351.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$286.26
|
| Rate for Payer: Multiplan Commercial |
$305.34
|
| Rate for Payer: NAPHCARE Commercial |
$229.01
|
| Rate for Payer: Preferred Network Access Commercial |
$351.15
|
| Rate for Payer: Quartz Beloit One Network |
$187.02
|
| Rate for Payer: Quartz Commercial |
$248.09
|
| Rate for Payer: Quartz Medicare Advantage |
$229.01
|
| Rate for Payer: The Alliance Commercial |
$190.84
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: WPS Commercial |
$282.70
|
|
|
SLEEVE STERILE
|
Facility
|
IP
|
$367.00
|
|
| Hospital Charge Code |
2972925
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$187.02 |
| Max. Negotiated Rate |
$351.15 |
| Rate for Payer: Aetna Commercial |
$343.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.29
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$351.15
|
| Rate for Payer: Health EOS Commercial |
$339.70
|
| Rate for Payer: HFN Commercial |
$351.15
|
| Rate for Payer: Multiplan Commercial |
$305.34
|
| Rate for Payer: Preferred Network Access Commercial |
$351.15
|
| Rate for Payer: Quartz Beloit One Network |
$187.02
|
| Rate for Payer: Quartz Commercial |
$229.01
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: WPS Commercial |
$282.70
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT +12MM 6942-6-080
|
Facility
|
OP
|
$916.00
|
|
| Hospital Charge Code |
4518659
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$266.74 |
| Max. Negotiated Rate |
$876.43 |
| Rate for Payer: Aetna Commercial |
$857.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$819.27
|
| Rate for Payer: Aetna Managed Medicare |
$266.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$619.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$476.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$457.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.90
|
| Rate for Payer: Cash Price |
$274.80
|
| Rate for Payer: Cigna Commercial |
$876.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$533.11
|
| Rate for Payer: Health EOS Commercial |
$847.85
|
| Rate for Payer: HFN Commercial |
$876.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$714.48
|
| Rate for Payer: Multiplan Commercial |
$762.11
|
| Rate for Payer: NAPHCARE Commercial |
$571.58
|
| Rate for Payer: Preferred Network Access Commercial |
$876.43
|
| Rate for Payer: Quartz Beloit One Network |
$466.79
|
| Rate for Payer: Quartz Commercial |
$619.22
|
| Rate for Payer: Quartz Medicare Advantage |
$571.58
|
| Rate for Payer: The Alliance Commercial |
$476.32
|
| Rate for Payer: WEA Trust Commercial |
$523.95
|
| Rate for Payer: WPS Commercial |
$705.59
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT +12MM 6942-6-080
|
Facility
|
IP
|
$916.00
|
|
| Hospital Charge Code |
4518659
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$466.79 |
| Max. Negotiated Rate |
$876.43 |
| Rate for Payer: Aetna Commercial |
$857.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$819.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.90
|
| Rate for Payer: Cash Price |
$274.80
|
| Rate for Payer: Cigna Commercial |
$876.43
|
| Rate for Payer: Health EOS Commercial |
$847.85
|
| Rate for Payer: HFN Commercial |
$876.43
|
| Rate for Payer: Multiplan Commercial |
$762.11
|
| Rate for Payer: Preferred Network Access Commercial |
$876.43
|
| Rate for Payer: Quartz Beloit One Network |
$466.79
|
| Rate for Payer: Quartz Commercial |
$571.58
|
| Rate for Payer: WEA Trust Commercial |
$523.95
|
| Rate for Payer: WPS Commercial |
$705.59
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT -4MM 6942-6-060
|
Facility
|
IP
|
$915.00
|
|
| Hospital Charge Code |
3922760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$466.28 |
| Max. Negotiated Rate |
$875.47 |
| Rate for Payer: Aetna Commercial |
$856.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$818.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.35
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$875.47
|
| Rate for Payer: Health EOS Commercial |
$846.92
|
| Rate for Payer: HFN Commercial |
$875.47
|
| Rate for Payer: Multiplan Commercial |
$761.28
|
| Rate for Payer: Preferred Network Access Commercial |
$875.47
|
| Rate for Payer: Quartz Beloit One Network |
$466.28
|
| Rate for Payer: Quartz Commercial |
$570.96
|
| Rate for Payer: WEA Trust Commercial |
$523.38
|
| Rate for Payer: WPS Commercial |
$704.82
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT -4MM 6942-6-060
|
Facility
|
OP
|
$915.00
|
|
| Hospital Charge Code |
3922760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$266.45 |
| Max. Negotiated Rate |
$875.47 |
| Rate for Payer: Aetna Commercial |
$856.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$818.38
|
| Rate for Payer: Aetna Managed Medicare |
$266.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$618.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$475.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$456.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.35
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$875.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$532.53
|
| Rate for Payer: Health EOS Commercial |
$846.92
|
| Rate for Payer: HFN Commercial |
$875.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$713.70
|
| Rate for Payer: Multiplan Commercial |
$761.28
|
| Rate for Payer: NAPHCARE Commercial |
$570.96
|
| Rate for Payer: Preferred Network Access Commercial |
$875.47
|
| Rate for Payer: Quartz Beloit One Network |
$466.28
|
| Rate for Payer: Quartz Commercial |
$618.54
|
| Rate for Payer: Quartz Medicare Advantage |
$570.96
|
| Rate for Payer: The Alliance Commercial |
$475.80
|
| Rate for Payer: WEA Trust Commercial |
$523.38
|
| Rate for Payer: WPS Commercial |
$704.82
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT +4MM 6942-6-070
|
Facility
|
OP
|
$951.00
|
|
| Hospital Charge Code |
4220563
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$276.93 |
| Max. Negotiated Rate |
$909.92 |
| Rate for Payer: Aetna Commercial |
$890.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$850.57
|
| Rate for Payer: Aetna Managed Medicare |
$276.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$642.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$494.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$474.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$524.19
|
| Rate for Payer: Cash Price |
$285.30
|
| Rate for Payer: Cigna Commercial |
$909.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$553.48
|
| Rate for Payer: Health EOS Commercial |
$880.25
|
| Rate for Payer: HFN Commercial |
$909.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$741.78
|
| Rate for Payer: Multiplan Commercial |
$791.23
|
| Rate for Payer: NAPHCARE Commercial |
$593.42
|
| Rate for Payer: Preferred Network Access Commercial |
$909.92
|
| Rate for Payer: Quartz Beloit One Network |
$484.63
|
| Rate for Payer: Quartz Commercial |
$642.88
|
| Rate for Payer: Quartz Medicare Advantage |
$593.42
|
| Rate for Payer: The Alliance Commercial |
$494.52
|
| Rate for Payer: WEA Trust Commercial |
$543.97
|
| Rate for Payer: WPS Commercial |
$732.56
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT +4MM 6942-6-070
|
Facility
|
IP
|
$951.00
|
|
| Hospital Charge Code |
4220563
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$484.63 |
| Max. Negotiated Rate |
$909.92 |
| Rate for Payer: Aetna Commercial |
$890.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$850.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$524.19
|
| Rate for Payer: Cash Price |
$285.30
|
| Rate for Payer: Cigna Commercial |
$909.92
|
| Rate for Payer: Health EOS Commercial |
$880.25
|
| Rate for Payer: HFN Commercial |
$909.92
|
| Rate for Payer: Multiplan Commercial |
$791.23
|
| Rate for Payer: Preferred Network Access Commercial |
$909.92
|
| Rate for Payer: Quartz Beloit One Network |
$484.63
|
| Rate for Payer: Quartz Commercial |
$593.42
|
| Rate for Payer: WEA Trust Commercial |
$543.97
|
| Rate for Payer: WPS Commercial |
$732.56
|
|
