|
Solution 500 SOD CHL
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
3040285
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna Commercial |
$1.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.79
|
| Rate for Payer: Aetna Managed Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.10
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.16
|
| Rate for Payer: Health EOS Commercial |
$1.85
|
| Rate for Payer: HFN Commercial |
$1.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
| Rate for Payer: NAPHCARE Commercial |
$1.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1.91
|
| Rate for Payer: Quartz Beloit One Network |
$1.02
|
| Rate for Payer: Quartz Commercial |
$1.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1.25
|
| Rate for Payer: The Alliance Commercial |
$1.04
|
| Rate for Payer: WEA Trust Commercial |
$1.14
|
| Rate for Payer: WPS Commercial |
$1.54
|
|
|
Solution 500 SOD CHL
|
Facility
|
IP
|
$2.00
|
|
| Hospital Charge Code |
3040285
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna Commercial |
$1.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.10
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.91
|
| Rate for Payer: Health EOS Commercial |
$1.85
|
| Rate for Payer: HFN Commercial |
$1.91
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1.91
|
| Rate for Payer: Quartz Beloit One Network |
$1.02
|
| Rate for Payer: Quartz Commercial |
$1.25
|
| Rate for Payer: WEA Trust Commercial |
$1.14
|
| Rate for Payer: WPS Commercial |
$1.54
|
|
|
SOLUTION BALANCED SALINE 500ML BAG 0065179504
|
Facility
|
IP
|
$135.00
|
|
| Hospital Charge Code |
5107102
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$68.80 |
| Max. Negotiated Rate |
$129.17 |
| Rate for Payer: Aetna Commercial |
$126.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.41
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$129.17
|
| Rate for Payer: Health EOS Commercial |
$124.96
|
| Rate for Payer: HFN Commercial |
$129.17
|
| Rate for Payer: Multiplan Commercial |
$112.32
|
| Rate for Payer: Preferred Network Access Commercial |
$129.17
|
| Rate for Payer: Quartz Beloit One Network |
$68.80
|
| Rate for Payer: Quartz Commercial |
$84.24
|
| Rate for Payer: WEA Trust Commercial |
$77.22
|
| Rate for Payer: WPS Commercial |
$103.99
|
|
|
SOLUTION BALANCED SALINE 500ML BAG 0065179504
|
Facility
|
OP
|
$135.00
|
|
| Hospital Charge Code |
5107102
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$39.31 |
| Max. Negotiated Rate |
$129.17 |
| Rate for Payer: Aetna Commercial |
$126.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.74
|
| Rate for Payer: Aetna Managed Medicare |
$39.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$91.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$70.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$67.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.41
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$129.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$78.57
|
| Rate for Payer: Health EOS Commercial |
$124.96
|
| Rate for Payer: HFN Commercial |
$129.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$105.30
|
| Rate for Payer: Multiplan Commercial |
$112.32
|
| Rate for Payer: NAPHCARE Commercial |
$84.24
|
| Rate for Payer: Preferred Network Access Commercial |
$129.17
|
| Rate for Payer: Quartz Beloit One Network |
$68.80
|
| Rate for Payer: Quartz Commercial |
$91.26
|
| Rate for Payer: Quartz Medicare Advantage |
$84.24
|
| Rate for Payer: The Alliance Commercial |
$70.20
|
| Rate for Payer: WEA Trust Commercial |
$77.22
|
| Rate for Payer: WPS Commercial |
$103.99
|
|
|
SOLUTION BETADINE 10% 4oz
|
Facility
|
IP
|
$30.00
|
|
| Hospital Charge Code |
2963527
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna Commercial |
$28.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.54
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$28.70
|
| Rate for Payer: Health EOS Commercial |
$27.77
|
| Rate for Payer: HFN Commercial |
$28.70
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: Preferred Network Access Commercial |
$28.70
|
| Rate for Payer: Quartz Beloit One Network |
$15.29
|
| Rate for Payer: Quartz Commercial |
$18.72
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: WPS Commercial |
$23.11
|
|
|
SOLUTION BETADINE 10% 4oz
|
Facility
|
OP
|
$30.00
|
|
| Hospital Charge Code |
2963527
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna Commercial |
$28.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Aetna Managed Medicare |
$8.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.54
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$28.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.46
|
| Rate for Payer: Health EOS Commercial |
$27.77
|
| Rate for Payer: HFN Commercial |
$28.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.40
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$28.70
|
| Rate for Payer: Quartz Beloit One Network |
$15.29
|
| Rate for Payer: Quartz Commercial |
$20.28
|
| Rate for Payer: Quartz Medicare Advantage |
$18.72
|
| Rate for Payer: The Alliance Commercial |
$15.60
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: WPS Commercial |
$23.11
|
|
|
Somatostatin Level
|
Facility
|
OP
|
$491.00
|
|
|
Service Code
|
CPT 84307
|
| Hospital Charge Code |
1043145
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.01 |
| Max. Negotiated Rate |
$469.79 |
| Rate for Payer: Aetna Commercial |
$459.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$439.15
|
| Rate for Payer: Aetna Managed Medicare |
$19.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.27
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.56
|
| Rate for Payer: Anthem Medicare Advantage |
$19.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$270.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.01
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cigna Commercial |
$469.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$285.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.01
|
| Rate for Payer: Health EOS Commercial |
$454.47
|
| Rate for Payer: HFN Commercial |
$469.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.01
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.01
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.01
|
| Rate for Payer: Multiplan Commercial |
$408.51
|
| Rate for Payer: NAPHCARE Commercial |
$28.52
|
| Rate for Payer: Preferred Network Access Commercial |
$469.79
|
| Rate for Payer: Quartz Beloit One Network |
$250.21
|
| Rate for Payer: Quartz Commercial |
$331.92
|
| Rate for Payer: Quartz Medicare Advantage |
$19.01
|
| Rate for Payer: The Alliance Commercial |
$76.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.01
|
| Rate for Payer: United Healthcare PPO |
$382.98
|
| Rate for Payer: WEA Trust Commercial |
$280.85
|
| Rate for Payer: Wellcare Medicare |
$19.01
|
| Rate for Payer: WPS Commercial |
$378.22
|
|
|
Somatostatin Level
|
Professional
|
Both
|
$491.00
|
|
|
Service Code
|
CPT 84307
|
| Hospital Charge Code |
1043145
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.01 |
| Max. Negotiated Rate |
$485.11 |
| Rate for Payer: Aetna Commercial |
$485.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$439.15
|
| Rate for Payer: Aetna Managed Medicare |
$19.01
|
| Rate for Payer: Anthem Medicare Advantage |
$19.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.01
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cigna Commercial |
$485.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$255.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.01
|
| Rate for Payer: Health EOS Commercial |
$464.68
|
| Rate for Payer: HFN Commercial |
$485.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$67.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.01
|
| Rate for Payer: Multiplan Commercial |
$408.51
|
| Rate for Payer: NAPHCARE Commercial |
$28.52
|
| Rate for Payer: Preferred Network Access Commercial |
$485.11
|
| Rate for Payer: Quartz Beloit One Network |
$224.68
|
| Rate for Payer: Quartz Commercial |
$291.06
|
| Rate for Payer: Quartz Medicare Advantage |
$19.01
|
| Rate for Payer: The Alliance Commercial |
$75.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.01
|
| Rate for Payer: WEA Trust Commercial |
$280.85
|
| Rate for Payer: WPS Commercial |
$83.65
|
|
|
Somatostatin Level
|
Facility
|
IP
|
$491.00
|
|
|
Service Code
|
CPT 84307
|
| Hospital Charge Code |
1043145
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$250.21 |
| Max. Negotiated Rate |
$469.79 |
| Rate for Payer: Aetna Commercial |
$459.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$439.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$270.64
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cigna Commercial |
$469.79
|
| Rate for Payer: Health EOS Commercial |
$454.47
|
| Rate for Payer: HFN Commercial |
$469.79
|
| Rate for Payer: Multiplan Commercial |
$408.51
|
| Rate for Payer: Preferred Network Access Commercial |
$469.79
|
| Rate for Payer: Quartz Beloit One Network |
$250.21
|
| Rate for Payer: Quartz Commercial |
$306.38
|
| Rate for Payer: WEA Trust Commercial |
$280.85
|
| Rate for Payer: WPS Commercial |
$378.22
|
|
|
SONIC ANCHOR KIT 2.5 X 10MM 1910-1272S
|
Facility
|
OP
|
$3,609.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5917656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.94 |
| Max. Negotiated Rate |
$3,453.09 |
| Rate for Payer: Aetna Commercial |
$3,378.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,227.89
|
| Rate for Payer: Aetna Managed Medicare |
$1,050.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,439.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,876.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,801.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,989.28
|
| Rate for Payer: Cash Price |
$1,082.70
|
| Rate for Payer: Cigna Commercial |
$3,453.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,100.44
|
| Rate for Payer: Health EOS Commercial |
$3,340.49
|
| Rate for Payer: HFN Commercial |
$3,453.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,815.02
|
| Rate for Payer: Multiplan Commercial |
$3,002.69
|
| Rate for Payer: NAPHCARE Commercial |
$2,252.02
|
| Rate for Payer: Preferred Network Access Commercial |
$3,453.09
|
| Rate for Payer: Quartz Beloit One Network |
$1,839.15
|
| Rate for Payer: Quartz Commercial |
$2,439.68
|
| Rate for Payer: Quartz Medicare Advantage |
$2,252.02
|
| Rate for Payer: The Alliance Commercial |
$1,876.68
|
| Rate for Payer: WEA Trust Commercial |
$2,064.35
|
| Rate for Payer: WPS Commercial |
$2,780.01
|
|
|
SONIC ANCHOR KIT 2.5 X 10MM 1910-1272S
|
Facility
|
IP
|
$3,609.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5917656
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,839.15 |
| Max. Negotiated Rate |
$3,453.09 |
| Rate for Payer: Aetna Commercial |
$3,378.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,227.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,989.28
|
| Rate for Payer: Cash Price |
$1,082.70
|
| Rate for Payer: Cigna Commercial |
$3,453.09
|
| Rate for Payer: Health EOS Commercial |
$3,340.49
|
| Rate for Payer: HFN Commercial |
$3,453.09
|
| Rate for Payer: Multiplan Commercial |
$3,002.69
|
| Rate for Payer: Preferred Network Access Commercial |
$3,453.09
|
| Rate for Payer: Quartz Beloit One Network |
$1,839.15
|
| Rate for Payer: Quartz Commercial |
$2,252.02
|
| Rate for Payer: WEA Trust Commercial |
$2,064.35
|
| Rate for Payer: WPS Commercial |
$2,780.01
|
|
|
SPACER TAPERED +0MM MODULAR CATHCART 1363-10-000
|
Facility
|
IP
|
$2,603.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5520984
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,326.49 |
| Max. Negotiated Rate |
$2,490.55 |
| Rate for Payer: Aetna Commercial |
$2,436.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,328.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,434.77
|
| Rate for Payer: Cash Price |
$780.90
|
| Rate for Payer: Cigna Commercial |
$2,490.55
|
| Rate for Payer: Health EOS Commercial |
$2,409.34
|
| Rate for Payer: HFN Commercial |
$2,490.55
|
| Rate for Payer: Multiplan Commercial |
$2,165.70
|
| Rate for Payer: Preferred Network Access Commercial |
$2,490.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,326.49
|
| Rate for Payer: Quartz Commercial |
$1,624.27
|
| Rate for Payer: WEA Trust Commercial |
$1,488.92
|
| Rate for Payer: WPS Commercial |
$2,005.09
|
|
|
SPACER TAPERED +0MM MODULAR CATHCART 1363-10-000
|
Facility
|
OP
|
$2,603.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5520984
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$757.99 |
| Max. Negotiated Rate |
$2,490.55 |
| Rate for Payer: Aetna Commercial |
$2,436.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,328.12
|
| Rate for Payer: Aetna Managed Medicare |
$757.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,759.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,353.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,299.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,434.77
|
| Rate for Payer: Cash Price |
$780.90
|
| Rate for Payer: Cigna Commercial |
$2,490.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,514.95
|
| Rate for Payer: Health EOS Commercial |
$2,409.34
|
| Rate for Payer: HFN Commercial |
$2,490.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,030.34
|
| Rate for Payer: Multiplan Commercial |
$2,165.70
|
| Rate for Payer: NAPHCARE Commercial |
$1,624.27
|
| Rate for Payer: Preferred Network Access Commercial |
$2,490.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,326.49
|
| Rate for Payer: Quartz Commercial |
$1,759.63
|
| Rate for Payer: Quartz Medicare Advantage |
$1,624.27
|
| Rate for Payer: The Alliance Commercial |
$1,353.56
|
| Rate for Payer: WEA Trust Commercial |
$1,488.92
|
| Rate for Payer: WPS Commercial |
$2,005.09
|
|
|
SPACER TAPERED -3MM MODULAR CATHCART 1363-08-000
|
Facility
|
IP
|
$2,603.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5520925
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,326.49 |
| Max. Negotiated Rate |
$2,490.55 |
| Rate for Payer: Aetna Commercial |
$2,436.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,328.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,434.77
|
| Rate for Payer: Cash Price |
$780.90
|
| Rate for Payer: Cigna Commercial |
$2,490.55
|
| Rate for Payer: Health EOS Commercial |
$2,409.34
|
| Rate for Payer: HFN Commercial |
$2,490.55
|
| Rate for Payer: Multiplan Commercial |
$2,165.70
|
| Rate for Payer: Preferred Network Access Commercial |
$2,490.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,326.49
|
| Rate for Payer: Quartz Commercial |
$1,624.27
|
| Rate for Payer: WEA Trust Commercial |
$1,488.92
|
| Rate for Payer: WPS Commercial |
$2,005.09
|
|
|
SPACER TAPERED -3MM MODULAR CATHCART 1363-08-000
|
Facility
|
OP
|
$2,603.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5520925
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$757.99 |
| Max. Negotiated Rate |
$2,490.55 |
| Rate for Payer: Aetna Commercial |
$2,436.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,328.12
|
| Rate for Payer: Aetna Managed Medicare |
$757.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,759.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,353.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,299.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,434.77
|
| Rate for Payer: Cash Price |
$780.90
|
| Rate for Payer: Cigna Commercial |
$2,490.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,514.95
|
| Rate for Payer: Health EOS Commercial |
$2,409.34
|
| Rate for Payer: HFN Commercial |
$2,490.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,030.34
|
| Rate for Payer: Multiplan Commercial |
$2,165.70
|
| Rate for Payer: NAPHCARE Commercial |
$1,624.27
|
| Rate for Payer: Preferred Network Access Commercial |
$2,490.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,326.49
|
| Rate for Payer: Quartz Commercial |
$1,759.63
|
| Rate for Payer: Quartz Medicare Advantage |
$1,624.27
|
| Rate for Payer: The Alliance Commercial |
$1,353.56
|
| Rate for Payer: WEA Trust Commercial |
$1,488.92
|
| Rate for Payer: WPS Commercial |
$2,005.09
|
|
|
SPACER TAPERED +5MM MODULAR CATHCART 1363-12-000
|
Facility
|
IP
|
$1,731.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6172815
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$882.12 |
| Max. Negotiated Rate |
$1,656.22 |
| Rate for Payer: Aetna Commercial |
$1,620.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,548.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$954.13
|
| Rate for Payer: Cash Price |
$519.30
|
| Rate for Payer: Cigna Commercial |
$1,656.22
|
| Rate for Payer: Health EOS Commercial |
$1,602.21
|
| Rate for Payer: HFN Commercial |
$1,656.22
|
| Rate for Payer: Multiplan Commercial |
$1,440.19
|
| Rate for Payer: Preferred Network Access Commercial |
$1,656.22
|
| Rate for Payer: Quartz Beloit One Network |
$882.12
|
| Rate for Payer: Quartz Commercial |
$1,080.14
|
| Rate for Payer: WEA Trust Commercial |
$990.13
|
| Rate for Payer: WPS Commercial |
$1,333.39
|
|
|
SPACER TAPERED +5MM MODULAR CATHCART 1363-12-000
|
Facility
|
OP
|
$1,731.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6172815
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$504.07 |
| Max. Negotiated Rate |
$1,656.22 |
| Rate for Payer: Aetna Commercial |
$1,620.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,548.21
|
| Rate for Payer: Aetna Managed Medicare |
$504.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,170.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$900.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$864.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$954.13
|
| Rate for Payer: Cash Price |
$519.30
|
| Rate for Payer: Cigna Commercial |
$1,656.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,007.44
|
| Rate for Payer: Health EOS Commercial |
$1,602.21
|
| Rate for Payer: HFN Commercial |
$1,656.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,350.18
|
| Rate for Payer: Multiplan Commercial |
$1,440.19
|
| Rate for Payer: NAPHCARE Commercial |
$1,080.14
|
| Rate for Payer: Preferred Network Access Commercial |
$1,656.22
|
| Rate for Payer: Quartz Beloit One Network |
$882.12
|
| Rate for Payer: Quartz Commercial |
$1,170.16
|
| Rate for Payer: Quartz Medicare Advantage |
$1,080.14
|
| Rate for Payer: The Alliance Commercial |
$900.12
|
| Rate for Payer: WEA Trust Commercial |
$990.13
|
| Rate for Payer: WPS Commercial |
$1,333.39
|
|
|
SPACER UNIVERSAL REVERS 36 +6 AR-9555-06
|
Facility
|
OP
|
$5,212.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4317083
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,517.73 |
| Max. Negotiated Rate |
$4,986.84 |
| Rate for Payer: Aetna Commercial |
$4,878.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,661.61
|
| Rate for Payer: Aetna Managed Medicare |
$1,517.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,523.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,710.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,601.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,872.85
|
| Rate for Payer: Cash Price |
$1,563.60
|
| Rate for Payer: Cigna Commercial |
$4,986.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,033.38
|
| Rate for Payer: Health EOS Commercial |
$4,824.23
|
| Rate for Payer: HFN Commercial |
$4,986.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,065.36
|
| Rate for Payer: Multiplan Commercial |
$4,336.38
|
| Rate for Payer: NAPHCARE Commercial |
$3,252.29
|
| Rate for Payer: Preferred Network Access Commercial |
$4,986.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,656.04
|
| Rate for Payer: Quartz Commercial |
$3,523.31
|
| Rate for Payer: Quartz Medicare Advantage |
$3,252.29
|
| Rate for Payer: The Alliance Commercial |
$2,710.24
|
| Rate for Payer: WEA Trust Commercial |
$2,981.26
|
| Rate for Payer: WPS Commercial |
$4,014.80
|
|
|
SPACER UNIVERSAL REVERS 36 +6 AR-9555-06
|
Facility
|
IP
|
$5,212.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4317083
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,656.04 |
| Max. Negotiated Rate |
$4,986.84 |
| Rate for Payer: Aetna Commercial |
$4,878.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,661.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,872.85
|
| Rate for Payer: Cash Price |
$1,563.60
|
| Rate for Payer: Cigna Commercial |
$4,986.84
|
| Rate for Payer: Health EOS Commercial |
$4,824.23
|
| Rate for Payer: HFN Commercial |
$4,986.84
|
| Rate for Payer: Multiplan Commercial |
$4,336.38
|
| Rate for Payer: Preferred Network Access Commercial |
$4,986.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,656.04
|
| Rate for Payer: Quartz Commercial |
$3,252.29
|
| Rate for Payer: WEA Trust Commercial |
$2,981.26
|
| Rate for Payer: WPS Commercial |
$4,014.80
|
|
|
SPACER UNIVERSAL REVERSE 39 +15MM AR-9505-15
|
Facility
|
IP
|
$51,270.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5349256
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$26,127.19 |
| Max. Negotiated Rate |
$49,055.14 |
| Rate for Payer: Aetna Commercial |
$47,988.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45,855.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28,260.02
|
| Rate for Payer: Cash Price |
$15,381.00
|
| Rate for Payer: Cigna Commercial |
$49,055.14
|
| Rate for Payer: Health EOS Commercial |
$47,455.51
|
| Rate for Payer: HFN Commercial |
$49,055.14
|
| Rate for Payer: Multiplan Commercial |
$42,656.64
|
| Rate for Payer: Preferred Network Access Commercial |
$49,055.14
|
| Rate for Payer: Quartz Beloit One Network |
$26,127.19
|
| Rate for Payer: Quartz Commercial |
$31,992.48
|
| Rate for Payer: WEA Trust Commercial |
$29,326.44
|
| Rate for Payer: WPS Commercial |
$39,493.28
|
|
|
SPACER UNIVERSAL REVERSE 39 +15MM AR-9505-15
|
Facility
|
OP
|
$51,270.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5349256
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$14,929.82 |
| Max. Negotiated Rate |
$49,055.14 |
| Rate for Payer: Aetna Commercial |
$47,988.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45,855.89
|
| Rate for Payer: Aetna Managed Medicare |
$14,929.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34,658.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,660.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,593.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28,260.02
|
| Rate for Payer: Cash Price |
$15,381.00
|
| Rate for Payer: Cigna Commercial |
$49,055.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29,839.14
|
| Rate for Payer: Health EOS Commercial |
$47,455.51
|
| Rate for Payer: HFN Commercial |
$49,055.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39,990.60
|
| Rate for Payer: Multiplan Commercial |
$42,656.64
|
| Rate for Payer: NAPHCARE Commercial |
$31,992.48
|
| Rate for Payer: Preferred Network Access Commercial |
$49,055.14
|
| Rate for Payer: Quartz Beloit One Network |
$26,127.19
|
| Rate for Payer: Quartz Commercial |
$34,658.52
|
| Rate for Payer: Quartz Medicare Advantage |
$31,992.48
|
| Rate for Payer: The Alliance Commercial |
$26,660.40
|
| Rate for Payer: WEA Trust Commercial |
$29,326.44
|
| Rate for Payer: WPS Commercial |
$39,493.28
|
|
|
SPACER UNIVERSAL REVERSE 39 +6MM AR-9505-06
|
Facility
|
IP
|
$5,212.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5264988
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,656.04 |
| Max. Negotiated Rate |
$4,986.84 |
| Rate for Payer: Aetna Commercial |
$4,878.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,661.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,872.85
|
| Rate for Payer: Cash Price |
$1,563.60
|
| Rate for Payer: Cigna Commercial |
$4,986.84
|
| Rate for Payer: Health EOS Commercial |
$4,824.23
|
| Rate for Payer: HFN Commercial |
$4,986.84
|
| Rate for Payer: Multiplan Commercial |
$4,336.38
|
| Rate for Payer: Preferred Network Access Commercial |
$4,986.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,656.04
|
| Rate for Payer: Quartz Commercial |
$3,252.29
|
| Rate for Payer: WEA Trust Commercial |
$2,981.26
|
| Rate for Payer: WPS Commercial |
$4,014.80
|
|
|
SPACER UNIVERSAL REVERSE 39 +6MM AR-9505-06
|
Facility
|
OP
|
$5,212.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5264988
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,517.73 |
| Max. Negotiated Rate |
$4,986.84 |
| Rate for Payer: Aetna Commercial |
$4,878.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,661.61
|
| Rate for Payer: Aetna Managed Medicare |
$1,517.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,523.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,710.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,601.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,872.85
|
| Rate for Payer: Cash Price |
$1,563.60
|
| Rate for Payer: Cigna Commercial |
$4,986.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,033.38
|
| Rate for Payer: Health EOS Commercial |
$4,824.23
|
| Rate for Payer: HFN Commercial |
$4,986.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,065.36
|
| Rate for Payer: Multiplan Commercial |
$4,336.38
|
| Rate for Payer: NAPHCARE Commercial |
$3,252.29
|
| Rate for Payer: Preferred Network Access Commercial |
$4,986.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,656.04
|
| Rate for Payer: Quartz Commercial |
$3,523.31
|
| Rate for Payer: Quartz Medicare Advantage |
$3,252.29
|
| Rate for Payer: The Alliance Commercial |
$2,710.24
|
| Rate for Payer: WEA Trust Commercial |
$2,981.26
|
| Rate for Payer: WPS Commercial |
$4,014.80
|
|
|
SPACER UNIVERSAL REVERSE 39 +9MM AR-9505-09
|
Facility
|
OP
|
$5,012.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5416051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,459.49 |
| Max. Negotiated Rate |
$4,795.48 |
| Rate for Payer: Aetna Commercial |
$4,691.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,482.73
|
| Rate for Payer: Aetna Managed Medicare |
$1,459.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,388.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,606.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,501.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,762.61
|
| Rate for Payer: Cash Price |
$1,503.60
|
| Rate for Payer: Cigna Commercial |
$4,795.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,916.98
|
| Rate for Payer: Health EOS Commercial |
$4,639.11
|
| Rate for Payer: HFN Commercial |
$4,795.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,909.36
|
| Rate for Payer: Multiplan Commercial |
$4,169.98
|
| Rate for Payer: NAPHCARE Commercial |
$3,127.49
|
| Rate for Payer: Preferred Network Access Commercial |
$4,795.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,554.12
|
| Rate for Payer: Quartz Commercial |
$3,388.11
|
| Rate for Payer: Quartz Medicare Advantage |
$3,127.49
|
| Rate for Payer: The Alliance Commercial |
$2,606.24
|
| Rate for Payer: WEA Trust Commercial |
$2,866.86
|
| Rate for Payer: WPS Commercial |
$3,860.74
|
|
|
SPACER UNIVERSAL REVERSE 39 +9MM AR-9505-09
|
Facility
|
IP
|
$5,012.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5416051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,554.12 |
| Max. Negotiated Rate |
$4,795.48 |
| Rate for Payer: Aetna Commercial |
$4,691.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,482.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,762.61
|
| Rate for Payer: Cash Price |
$1,503.60
|
| Rate for Payer: Cigna Commercial |
$4,795.48
|
| Rate for Payer: Health EOS Commercial |
$4,639.11
|
| Rate for Payer: HFN Commercial |
$4,795.48
|
| Rate for Payer: Multiplan Commercial |
$4,169.98
|
| Rate for Payer: Preferred Network Access Commercial |
$4,795.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,554.12
|
| Rate for Payer: Quartz Commercial |
$3,127.49
|
| Rate for Payer: WEA Trust Commercial |
$2,866.86
|
| Rate for Payer: WPS Commercial |
$3,860.74
|
|
