|
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 |
$9,920.54 |
| Max. Negotiated Rate |
$18,626.32 |
| Rate for Payer: Aetna Commercial |
$18,221.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,411.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,730.38
|
| Rate for Payer: Cash Price |
$6,073.80
|
| Rate for Payer: Cigna Commercial |
$18,626.32
|
| Rate for Payer: Health EOS Commercial |
$18,018.94
|
| Rate for Payer: HFN Commercial |
$18,626.32
|
| Rate for Payer: Multiplan Commercial |
$16,196.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,147.60
|
| Rate for Payer: Preferred Network Access Commercial |
$18,626.32
|
| Rate for Payer: Quartz Beloit One Network |
$9,920.54
|
| Rate for Payer: Quartz Commercial |
$12,147.60
|
| Rate for Payer: WEA Trust Commercial |
$11,135.30
|
| Rate for Payer: WPS Commercial |
$14,996.21
|
|
|
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 |
$5,668.88 |
| Max. Negotiated Rate |
$80,984.00 |
| Rate for Payer: Aetna Commercial |
$18,221.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,411.56
|
| Rate for Payer: Aetna Managed Medicare |
$5,668.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,159.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,123.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,718.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,730.38
|
| Rate for Payer: Cash Price |
$6,073.80
|
| Rate for Payer: Cigna Commercial |
$18,626.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,329.66
|
| Rate for Payer: Health EOS Commercial |
$18,018.94
|
| Rate for Payer: HFN Commercial |
$18,626.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,184.50
|
| Rate for Payer: Multiplan Commercial |
$16,196.80
|
| Rate for Payer: NAPHCARE Commercial |
$12,147.60
|
| Rate for Payer: Preferred Network Access Commercial |
$18,626.32
|
| Rate for Payer: Quartz Beloit One Network |
$9,920.54
|
| Rate for Payer: Quartz Commercial |
$13,159.90
|
| Rate for Payer: Quartz Medicare Advantage |
$12,147.60
|
| Rate for Payer: The Alliance Commercial |
$80,984.00
|
| Rate for Payer: WEA Trust Commercial |
$11,135.30
|
| Rate for Payer: WPS Commercial |
$14,996.21
|
|
|
SLEEVE SPEEDGUIDE 70-3932
|
Facility
|
IP
|
$4,241.00
|
|
| Hospital Charge Code |
3791364
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,078.09 |
| Max. Negotiated Rate |
$3,901.72 |
| Rate for Payer: Aetna Commercial |
$3,816.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,647.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,247.73
|
| Rate for Payer: Cash Price |
$1,272.30
|
| Rate for Payer: Cigna Commercial |
$3,901.72
|
| Rate for Payer: Health EOS Commercial |
$3,774.49
|
| Rate for Payer: HFN Commercial |
$3,901.72
|
| Rate for Payer: Multiplan Commercial |
$3,392.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,544.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,901.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,078.09
|
| Rate for Payer: Quartz Commercial |
$2,544.60
|
| Rate for Payer: WEA Trust Commercial |
$2,332.55
|
| Rate for Payer: WPS Commercial |
$3,141.31
|
|
|
SLEEVE SPEEDGUIDE 70-3932
|
Facility
|
OP
|
$4,241.00
|
|
| Hospital Charge Code |
3791364
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,187.48 |
| Max. Negotiated Rate |
$16,964.00 |
| Rate for Payer: Aetna Commercial |
$3,816.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,647.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,187.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,756.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,120.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,035.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,247.73
|
| Rate for Payer: Cash Price |
$1,272.30
|
| Rate for Payer: Cigna Commercial |
$3,901.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,373.26
|
| Rate for Payer: Health EOS Commercial |
$3,774.49
|
| Rate for Payer: HFN Commercial |
$3,901.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,180.75
|
| Rate for Payer: Multiplan Commercial |
$3,392.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,544.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,901.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,078.09
|
| Rate for Payer: Quartz Commercial |
$2,756.65
|
| Rate for Payer: Quartz Medicare Advantage |
$2,544.60
|
| Rate for Payer: The Alliance Commercial |
$16,964.00
|
| Rate for Payer: WEA Trust Commercial |
$2,332.55
|
| Rate for Payer: WPS Commercial |
$3,141.31
|
|
|
SLEEVES SURGICAL 89791
|
Facility
|
IP
|
$54.00
|
|
| Hospital Charge Code |
2963249
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$32.40
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
SLEEVES SURGICAL 89791
|
Facility
|
OP
|
$54.00
|
|
| Hospital Charge Code |
2963249
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$15.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.22
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.50
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$35.10
|
| Rate for Payer: Quartz Medicare Advantage |
$32.40
|
| Rate for Payer: The Alliance Commercial |
$216.00
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
SLEEVE STAR AR-1606V
|
Facility
|
IP
|
$1,705.00
|
|
| Hospital Charge Code |
2964666
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$835.45 |
| Max. Negotiated Rate |
$1,568.60 |
| Rate for Payer: Aetna Commercial |
$1,534.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,466.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$903.65
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,568.60
|
| Rate for Payer: Health EOS Commercial |
$1,517.45
|
| Rate for Payer: HFN Commercial |
$1,568.60
|
| Rate for Payer: Multiplan Commercial |
$1,364.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,023.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,568.60
|
| Rate for Payer: Quartz Beloit One Network |
$835.45
|
| Rate for Payer: Quartz Commercial |
$1,023.00
|
| Rate for Payer: WEA Trust Commercial |
$937.75
|
| Rate for Payer: WPS Commercial |
$1,262.89
|
|
|
SLEEVE STAR AR-1606V
|
Facility
|
OP
|
$1,705.00
|
|
| Hospital Charge Code |
2964666
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$477.40 |
| Max. Negotiated Rate |
$6,820.00 |
| Rate for Payer: Aetna Commercial |
$1,534.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,466.30
|
| Rate for Payer: Aetna Managed Medicare |
$477.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,108.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$852.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$818.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$903.65
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,568.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$954.12
|
| Rate for Payer: Health EOS Commercial |
$1,517.45
|
| Rate for Payer: HFN Commercial |
$1,568.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,278.75
|
| Rate for Payer: Multiplan Commercial |
$1,364.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,023.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,568.60
|
| Rate for Payer: Quartz Beloit One Network |
$835.45
|
| Rate for Payer: Quartz Commercial |
$1,108.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,023.00
|
| Rate for Payer: The Alliance Commercial |
$6,820.00
|
| Rate for Payer: WEA Trust Commercial |
$937.75
|
| Rate for Payer: WPS Commercial |
$1,262.89
|
|
|
SLEEVE STERILE
|
Facility
|
OP
|
$367.00
|
|
| Hospital Charge Code |
2972925
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$102.76 |
| Max. Negotiated Rate |
$1,468.00 |
| Rate for Payer: Aetna Commercial |
$330.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$315.62
|
| Rate for Payer: Aetna Managed Medicare |
$102.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$238.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$183.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$194.51
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$337.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$205.37
|
| Rate for Payer: Health EOS Commercial |
$326.63
|
| Rate for Payer: HFN Commercial |
$337.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$275.25
|
| Rate for Payer: Multiplan Commercial |
$293.60
|
| Rate for Payer: NAPHCARE Commercial |
$220.20
|
| Rate for Payer: Preferred Network Access Commercial |
$337.64
|
| Rate for Payer: Quartz Beloit One Network |
$179.83
|
| Rate for Payer: Quartz Commercial |
$238.55
|
| Rate for Payer: Quartz Medicare Advantage |
$220.20
|
| Rate for Payer: The Alliance Commercial |
$1,468.00
|
| Rate for Payer: WEA Trust Commercial |
$201.85
|
| Rate for Payer: WPS Commercial |
$271.84
|
|
|
SLEEVE STERILE
|
Facility
|
IP
|
$367.00
|
|
| Hospital Charge Code |
2972925
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$179.83 |
| Max. Negotiated Rate |
$337.64 |
| Rate for Payer: Aetna Commercial |
$330.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$315.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$194.51
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$337.64
|
| Rate for Payer: Health EOS Commercial |
$326.63
|
| Rate for Payer: HFN Commercial |
$337.64
|
| Rate for Payer: Multiplan Commercial |
$293.60
|
| Rate for Payer: NAPHCARE Commercial |
$220.20
|
| Rate for Payer: Preferred Network Access Commercial |
$337.64
|
| Rate for Payer: Quartz Beloit One Network |
$179.83
|
| Rate for Payer: Quartz Commercial |
$220.20
|
| Rate for Payer: WEA Trust Commercial |
$201.85
|
| Rate for Payer: WPS Commercial |
$271.84
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT +12MM 6942-6-080
|
Facility
|
OP
|
$916.00
|
|
| Hospital Charge Code |
4518659
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$256.48 |
| Max. Negotiated Rate |
$3,664.00 |
| Rate for Payer: Aetna Commercial |
$824.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$787.76
|
| Rate for Payer: Aetna Managed Medicare |
$256.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$595.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$458.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$439.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$485.48
|
| Rate for Payer: Cash Price |
$274.80
|
| Rate for Payer: Cigna Commercial |
$842.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$512.59
|
| Rate for Payer: Health EOS Commercial |
$815.24
|
| Rate for Payer: HFN Commercial |
$842.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$687.00
|
| Rate for Payer: Multiplan Commercial |
$732.80
|
| Rate for Payer: NAPHCARE Commercial |
$549.60
|
| Rate for Payer: Preferred Network Access Commercial |
$842.72
|
| Rate for Payer: Quartz Beloit One Network |
$448.84
|
| Rate for Payer: Quartz Commercial |
$595.40
|
| Rate for Payer: Quartz Medicare Advantage |
$549.60
|
| Rate for Payer: The Alliance Commercial |
$3,664.00
|
| Rate for Payer: WEA Trust Commercial |
$503.80
|
| Rate for Payer: WPS Commercial |
$678.48
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT +12MM 6942-6-080
|
Facility
|
IP
|
$916.00
|
|
| Hospital Charge Code |
4518659
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$448.84 |
| Max. Negotiated Rate |
$842.72 |
| Rate for Payer: Aetna Commercial |
$824.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$787.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$485.48
|
| Rate for Payer: Cash Price |
$274.80
|
| Rate for Payer: Cigna Commercial |
$842.72
|
| Rate for Payer: Health EOS Commercial |
$815.24
|
| Rate for Payer: HFN Commercial |
$842.72
|
| Rate for Payer: Multiplan Commercial |
$732.80
|
| Rate for Payer: NAPHCARE Commercial |
$549.60
|
| Rate for Payer: Preferred Network Access Commercial |
$842.72
|
| Rate for Payer: Quartz Beloit One Network |
$448.84
|
| Rate for Payer: Quartz Commercial |
$549.60
|
| Rate for Payer: WEA Trust Commercial |
$503.80
|
| Rate for Payer: WPS Commercial |
$678.48
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT -4MM 6942-6-060
|
Facility
|
OP
|
$915.00
|
|
| Hospital Charge Code |
3922760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$256.20 |
| Max. Negotiated Rate |
$3,660.00 |
| Rate for Payer: Aetna Commercial |
$823.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$786.90
|
| Rate for Payer: Aetna Managed Medicare |
$256.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$594.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$457.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$439.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$484.95
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$841.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$512.03
|
| Rate for Payer: Health EOS Commercial |
$814.35
|
| Rate for Payer: HFN Commercial |
$841.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$686.25
|
| Rate for Payer: Multiplan Commercial |
$732.00
|
| Rate for Payer: NAPHCARE Commercial |
$549.00
|
| Rate for Payer: Preferred Network Access Commercial |
$841.80
|
| Rate for Payer: Quartz Beloit One Network |
$448.35
|
| Rate for Payer: Quartz Commercial |
$594.75
|
| Rate for Payer: Quartz Medicare Advantage |
$549.00
|
| Rate for Payer: The Alliance Commercial |
$3,660.00
|
| Rate for Payer: WEA Trust Commercial |
$503.25
|
| Rate for Payer: WPS Commercial |
$677.74
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT -4MM 6942-6-060
|
Facility
|
IP
|
$915.00
|
|
| Hospital Charge Code |
3922760
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$448.35 |
| Max. Negotiated Rate |
$841.80 |
| Rate for Payer: Aetna Commercial |
$823.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$786.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$484.95
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$841.80
|
| Rate for Payer: Health EOS Commercial |
$814.35
|
| Rate for Payer: HFN Commercial |
$841.80
|
| Rate for Payer: Multiplan Commercial |
$732.00
|
| Rate for Payer: NAPHCARE Commercial |
$549.00
|
| Rate for Payer: Preferred Network Access Commercial |
$841.80
|
| Rate for Payer: Quartz Beloit One Network |
$448.35
|
| Rate for Payer: Quartz Commercial |
$549.00
|
| Rate for Payer: WEA Trust Commercial |
$503.25
|
| Rate for Payer: WPS Commercial |
$677.74
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT +4MM 6942-6-070
|
Facility
|
IP
|
$951.00
|
|
| Hospital Charge Code |
4220563
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$465.99 |
| Max. Negotiated Rate |
$874.92 |
| Rate for Payer: Aetna Commercial |
$855.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$817.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.03
|
| Rate for Payer: Cash Price |
$285.30
|
| Rate for Payer: Cigna Commercial |
$874.92
|
| Rate for Payer: Health EOS Commercial |
$846.39
|
| Rate for Payer: HFN Commercial |
$874.92
|
| Rate for Payer: Multiplan Commercial |
$760.80
|
| Rate for Payer: NAPHCARE Commercial |
$570.60
|
| Rate for Payer: Preferred Network Access Commercial |
$874.92
|
| Rate for Payer: Quartz Beloit One Network |
$465.99
|
| Rate for Payer: Quartz Commercial |
$570.60
|
| Rate for Payer: WEA Trust Commercial |
$523.05
|
| Rate for Payer: WPS Commercial |
$704.41
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT +4MM 6942-6-070
|
Facility
|
OP
|
$951.00
|
|
| Hospital Charge Code |
4220563
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$266.28 |
| Max. Negotiated Rate |
$3,804.00 |
| Rate for Payer: Aetna Commercial |
$855.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$817.86
|
| Rate for Payer: Aetna Managed Medicare |
$266.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$618.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$475.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$456.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.03
|
| Rate for Payer: Cash Price |
$285.30
|
| Rate for Payer: Cigna Commercial |
$874.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$532.18
|
| Rate for Payer: Health EOS Commercial |
$846.39
|
| Rate for Payer: HFN Commercial |
$874.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$713.25
|
| Rate for Payer: Multiplan Commercial |
$760.80
|
| Rate for Payer: NAPHCARE Commercial |
$570.60
|
| Rate for Payer: Preferred Network Access Commercial |
$874.92
|
| Rate for Payer: Quartz Beloit One Network |
$465.99
|
| Rate for Payer: Quartz Commercial |
$618.15
|
| Rate for Payer: Quartz Medicare Advantage |
$570.60
|
| Rate for Payer: The Alliance Commercial |
$3,804.00
|
| Rate for Payer: WEA Trust Commercial |
$523.05
|
| Rate for Payer: WPS Commercial |
$704.41
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT 6942-6-065
|
Facility
|
IP
|
$915.00
|
|
| Hospital Charge Code |
4079276
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$448.35 |
| Max. Negotiated Rate |
$841.80 |
| Rate for Payer: Aetna Commercial |
$823.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$786.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$484.95
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$841.80
|
| Rate for Payer: Health EOS Commercial |
$814.35
|
| Rate for Payer: HFN Commercial |
$841.80
|
| Rate for Payer: Multiplan Commercial |
$732.00
|
| Rate for Payer: NAPHCARE Commercial |
$549.00
|
| Rate for Payer: Preferred Network Access Commercial |
$841.80
|
| Rate for Payer: Quartz Beloit One Network |
$448.35
|
| Rate for Payer: Quartz Commercial |
$549.00
|
| Rate for Payer: WEA Trust Commercial |
$503.25
|
| Rate for Payer: WPS Commercial |
$677.74
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT 6942-6-065
|
Facility
|
OP
|
$915.00
|
|
| Hospital Charge Code |
4079276
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$256.20 |
| Max. Negotiated Rate |
$3,660.00 |
| Rate for Payer: Aetna Commercial |
$823.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$786.90
|
| Rate for Payer: Aetna Managed Medicare |
$256.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$594.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$457.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$439.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$484.95
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$841.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$512.03
|
| Rate for Payer: Health EOS Commercial |
$814.35
|
| Rate for Payer: HFN Commercial |
$841.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$686.25
|
| Rate for Payer: Multiplan Commercial |
$732.00
|
| Rate for Payer: NAPHCARE Commercial |
$549.00
|
| Rate for Payer: Preferred Network Access Commercial |
$841.80
|
| Rate for Payer: Quartz Beloit One Network |
$448.35
|
| Rate for Payer: Quartz Commercial |
$594.75
|
| Rate for Payer: Quartz Medicare Advantage |
$549.00
|
| Rate for Payer: The Alliance Commercial |
$3,660.00
|
| Rate for Payer: WEA Trust Commercial |
$503.25
|
| Rate for Payer: WPS Commercial |
$677.74
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT +8MM 6942-6-075
|
Facility
|
IP
|
$915.00
|
|
| Hospital Charge Code |
4518658
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$448.35 |
| Max. Negotiated Rate |
$841.80 |
| Rate for Payer: Aetna Commercial |
$823.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$786.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$484.95
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$841.80
|
| Rate for Payer: Health EOS Commercial |
$814.35
|
| Rate for Payer: HFN Commercial |
$841.80
|
| Rate for Payer: Multiplan Commercial |
$732.00
|
| Rate for Payer: NAPHCARE Commercial |
$549.00
|
| Rate for Payer: Preferred Network Access Commercial |
$841.80
|
| Rate for Payer: Quartz Beloit One Network |
$448.35
|
| Rate for Payer: Quartz Commercial |
$549.00
|
| Rate for Payer: WEA Trust Commercial |
$503.25
|
| Rate for Payer: WPS Commercial |
$677.74
|
|
|
SLEEVE UNITRAX NECK ADJUSTMENT +8MM 6942-6-075
|
Facility
|
OP
|
$915.00
|
|
| Hospital Charge Code |
4518658
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$256.20 |
| Max. Negotiated Rate |
$3,660.00 |
| Rate for Payer: Aetna Commercial |
$823.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$786.90
|
| Rate for Payer: Aetna Managed Medicare |
$256.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$594.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$457.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$439.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$484.95
|
| Rate for Payer: Cash Price |
$274.50
|
| Rate for Payer: Cigna Commercial |
$841.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$512.03
|
| Rate for Payer: Health EOS Commercial |
$814.35
|
| Rate for Payer: HFN Commercial |
$841.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$686.25
|
| Rate for Payer: Multiplan Commercial |
$732.00
|
| Rate for Payer: NAPHCARE Commercial |
$549.00
|
| Rate for Payer: Preferred Network Access Commercial |
$841.80
|
| Rate for Payer: Quartz Beloit One Network |
$448.35
|
| Rate for Payer: Quartz Commercial |
$594.75
|
| Rate for Payer: Quartz Medicare Advantage |
$549.00
|
| Rate for Payer: The Alliance Commercial |
$3,660.00
|
| Rate for Payer: WEA Trust Commercial |
$503.25
|
| Rate for Payer: WPS Commercial |
$677.74
|
|
|
Sling applied - Treatments Done
|
Facility
|
OP
|
$81.00
|
|
| Hospital Charge Code |
3002537
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.68 |
| Max. Negotiated Rate |
$324.00 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Aetna Managed Medicare |
$22.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.33
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.75
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$52.65
|
| Rate for Payer: Quartz Medicare Advantage |
$48.60
|
| Rate for Payer: The Alliance Commercial |
$324.00
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Sling applied - Treatments Done
|
Facility
|
IP
|
$81.00
|
|
| Hospital Charge Code |
3002537
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$48.60
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
SLING ARM ADJUSTABLE ORT11010
|
Facility
|
IP
|
$167.00
|
|
|
Service Code
|
HCPCS A4565
|
| Hospital Charge Code |
2964017
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$81.83 |
| Max. Negotiated Rate |
$153.64 |
| Rate for Payer: Aetna Commercial |
$150.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.51
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$153.64
|
| Rate for Payer: Health EOS Commercial |
$148.63
|
| Rate for Payer: HFN Commercial |
$153.64
|
| Rate for Payer: Multiplan Commercial |
$133.60
|
| Rate for Payer: NAPHCARE Commercial |
$100.20
|
| Rate for Payer: Preferred Network Access Commercial |
$153.64
|
| Rate for Payer: Quartz Beloit One Network |
$81.83
|
| Rate for Payer: Quartz Commercial |
$100.20
|
| Rate for Payer: WEA Trust Commercial |
$91.85
|
| Rate for Payer: WPS Commercial |
$123.70
|
|
|
SLING ARM ADJUSTABLE ORT11010
|
Facility
|
OP
|
$167.00
|
|
|
Service Code
|
HCPCS A4565
|
| Hospital Charge Code |
2964017
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$46.76 |
| Max. Negotiated Rate |
$668.00 |
| Rate for Payer: Aetna Commercial |
$150.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.62
|
| Rate for Payer: Aetna Managed Medicare |
$46.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$108.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$83.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$80.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.51
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$153.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$93.45
|
| Rate for Payer: Health EOS Commercial |
$148.63
|
| Rate for Payer: HFN Commercial |
$153.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$125.25
|
| Rate for Payer: Multiplan Commercial |
$133.60
|
| Rate for Payer: NAPHCARE Commercial |
$100.20
|
| Rate for Payer: Preferred Network Access Commercial |
$153.64
|
| Rate for Payer: Quartz Beloit One Network |
$81.83
|
| Rate for Payer: Quartz Commercial |
$108.55
|
| Rate for Payer: Quartz Medicare Advantage |
$100.20
|
| Rate for Payer: The Alliance Commercial |
$668.00
|
| Rate for Payer: WEA Trust Commercial |
$91.85
|
| Rate for Payer: WPS Commercial |
$123.70
|
|
|
SLING ARM BLUE INFNT 10101
|
Facility
|
OP
|
$102.00
|
|
| Hospital Charge Code |
2974213
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$28.56 |
| Max. Negotiated Rate |
$408.00 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Aetna Managed Medicare |
$28.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.06
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$93.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.08
|
| Rate for Payer: Health EOS Commercial |
$90.78
|
| Rate for Payer: HFN Commercial |
$93.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.50
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: NAPHCARE Commercial |
$61.20
|
| Rate for Payer: Preferred Network Access Commercial |
$93.84
|
| Rate for Payer: Quartz Beloit One Network |
$49.98
|
| Rate for Payer: Quartz Commercial |
$66.30
|
| Rate for Payer: Quartz Medicare Advantage |
$61.20
|
| Rate for Payer: The Alliance Commercial |
$408.00
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
