|
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 -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 -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 +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 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 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
|
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 +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 +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
|
|
|
SPACER UNIVERSAL REVERSE 42 +6 AR-9550-06
|
Facility
|
IP
|
$5,012.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5349061
|
|
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
|
|
|
SPACER UNIVERSAL REVERSE 42 +6 AR-9550-06
|
Facility
|
OP
|
$5,012.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5349061
|
|
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
|
|
|
SPATULA PROBE PLUS #EPS02
|
Facility
|
OP
|
$1,453.00
|
|
| Hospital Charge Code |
2962913
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$423.11 |
| Max. Negotiated Rate |
$1,390.23 |
| Rate for Payer: The Alliance Commercial |
$755.56
|
| Rate for Payer: Aetna Commercial |
$1,360.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,299.56
|
| Rate for Payer: Aetna Managed Medicare |
$423.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$982.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$755.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$725.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$800.89
|
| Rate for Payer: Cash Price |
$435.90
|
| Rate for Payer: Cigna Commercial |
$1,390.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$845.65
|
| Rate for Payer: Health EOS Commercial |
$1,344.90
|
| Rate for Payer: HFN Commercial |
$1,390.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,133.34
|
| Rate for Payer: Multiplan Commercial |
$1,208.90
|
| Rate for Payer: NAPHCARE Commercial |
$906.67
|
| Rate for Payer: Preferred Network Access Commercial |
$1,390.23
|
| Rate for Payer: Quartz Beloit One Network |
$740.45
|
| Rate for Payer: Quartz Commercial |
$982.23
|
| Rate for Payer: Quartz Medicare Advantage |
$906.67
|
| Rate for Payer: WEA Trust Commercial |
$831.12
|
| Rate for Payer: WPS Commercial |
$1,119.25
|
|
|
SPATULA PROBE PLUS #EPS02
|
Facility
|
IP
|
$1,453.00
|
|
| Hospital Charge Code |
2962913
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$740.45 |
| Max. Negotiated Rate |
$1,390.23 |
| Rate for Payer: Aetna Commercial |
$1,360.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,299.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$800.89
|
| Rate for Payer: Cash Price |
$435.90
|
| Rate for Payer: Cigna Commercial |
$1,390.23
|
| Rate for Payer: Health EOS Commercial |
$1,344.90
|
| Rate for Payer: HFN Commercial |
$1,390.23
|
| Rate for Payer: Multiplan Commercial |
$1,208.90
|
| Rate for Payer: Preferred Network Access Commercial |
$1,390.23
|
| Rate for Payer: Quartz Beloit One Network |
$740.45
|
| Rate for Payer: Quartz Commercial |
$906.67
|
| Rate for Payer: WEA Trust Commercial |
$831.12
|
| Rate for Payer: WPS Commercial |
$1,119.25
|
|
|
SpCO
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
CPT 88740
|
| Hospital Charge Code |
3006906
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.14 |
| Max. Negotiated Rate |
$64.11 |
| Rate for Payer: Aetna Commercial |
$62.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.93
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$64.11
|
| Rate for Payer: Health EOS Commercial |
$62.02
|
| Rate for Payer: HFN Commercial |
$64.11
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: Preferred Network Access Commercial |
$64.11
|
| Rate for Payer: Quartz Beloit One Network |
$34.14
|
| Rate for Payer: Quartz Commercial |
$41.81
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$51.61
|
|
|
SpCO
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
CPT 88740
|
| Hospital Charge Code |
3006906
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.74 |
| Max. Negotiated Rate |
$64.11 |
| Rate for Payer: Aetna Commercial |
$62.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Aetna Managed Medicare |
$9.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.05
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.18
|
| Rate for Payer: Anthem Medicare Advantage |
$9.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.74
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$64.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9.74
|
| Rate for Payer: Health EOS Commercial |
$62.02
|
| Rate for Payer: HFN Commercial |
$64.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9.74
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: NAPHCARE Commercial |
$14.62
|
| Rate for Payer: Preferred Network Access Commercial |
$64.11
|
| Rate for Payer: Quartz Beloit One Network |
$34.14
|
| Rate for Payer: Quartz Commercial |
$45.29
|
| Rate for Payer: Quartz Medicare Advantage |
$9.74
|
| Rate for Payer: The Alliance Commercial |
$38.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.74
|
| Rate for Payer: United Healthcare PPO |
$52.26
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: Wellcare Medicare |
$9.74
|
| Rate for Payer: WPS Commercial |
$51.61
|
|
|
Special bed
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
CPT 94667
|
| Hospital Charge Code |
2989710
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$69.39 |
| Max. Negotiated Rate |
$560.06 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Aetna Managed Medicare |
$140.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$72.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$69.39
|
| Rate for Payer: Anthem Medicare Advantage |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$140.02
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$140.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$140.02
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$520.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$140.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$140.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$140.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$140.02
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: NAPHCARE Commercial |
$210.02
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$93.96
|
| Rate for Payer: Quartz Medicare Advantage |
$140.02
|
| Rate for Payer: The Alliance Commercial |
$560.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.02
|
| Rate for Payer: United Healthcare PPO |
$108.42
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: Wellcare Medicare |
$140.02
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
Special bed
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
CPT 94667
|
| Hospital Charge Code |
2989710
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$70.83 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$86.74
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
Special Care Observation Per Hour
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
3040437
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$32.03 |
| Max. Negotiated Rate |
$7,271.68 |
| Rate for Payer: Aetna Commercial |
$102.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.38
|
| Rate for Payer: Aetna Managed Medicare |
$32.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,271.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,271.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,958.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.63
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$105.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.02
|
| Rate for Payer: Health EOS Commercial |
$101.82
|
| Rate for Payer: HFN Commercial |
$105.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.80
|
| Rate for Payer: Multiplan Commercial |
$91.52
|
| Rate for Payer: NAPHCARE Commercial |
$68.64
|
| Rate for Payer: Preferred Network Access Commercial |
$105.25
|
| Rate for Payer: Quartz Beloit One Network |
$56.06
|
| Rate for Payer: Quartz Commercial |
$74.36
|
| Rate for Payer: Quartz Medicare Advantage |
$68.64
|
| Rate for Payer: The Alliance Commercial |
$57.20
|
| Rate for Payer: United Healthcare PPO |
$2,701.92
|
| Rate for Payer: WEA Trust Commercial |
$62.92
|
| Rate for Payer: WPS Commercial |
$84.73
|
|
|
Special Care Observation Per Hour
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
3040437
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$56.06 |
| Max. Negotiated Rate |
$105.25 |
| Rate for Payer: Aetna Commercial |
$102.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.63
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$105.25
|
| Rate for Payer: Health EOS Commercial |
$101.82
|
| Rate for Payer: HFN Commercial |
$105.25
|
| Rate for Payer: Multiplan Commercial |
$91.52
|
| Rate for Payer: Preferred Network Access Commercial |
$105.25
|
| Rate for Payer: Quartz Beloit One Network |
$56.06
|
| Rate for Payer: Quartz Commercial |
$68.64
|
| Rate for Payer: WEA Trust Commercial |
$62.92
|
| Rate for Payer: WPS Commercial |
$84.73
|
|
|
Special Dosimetry
|
Facility
|
IP
|
$745.00
|
|
|
Service Code
|
CPT 77331
|
| Hospital Charge Code |
3040385
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$379.65 |
| Max. Negotiated Rate |
$712.82 |
| Rate for Payer: Aetna Commercial |
$697.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$666.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$410.64
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cigna Commercial |
$712.82
|
| Rate for Payer: Health EOS Commercial |
$689.57
|
| Rate for Payer: HFN Commercial |
$712.82
|
| Rate for Payer: Multiplan Commercial |
$619.84
|
| Rate for Payer: Preferred Network Access Commercial |
$712.82
|
| Rate for Payer: Quartz Beloit One Network |
$379.65
|
| Rate for Payer: Quartz Commercial |
$464.88
|
| Rate for Payer: WEA Trust Commercial |
$426.14
|
| Rate for Payer: WPS Commercial |
$573.87
|
|
|
Special Dosimetry
|
Facility
|
OP
|
$745.00
|
|
|
Service Code
|
CPT 77331
|
| Hospital Charge Code |
3040385
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$141.45 |
| Max. Negotiated Rate |
$712.82 |
| Rate for Payer: Aetna Commercial |
$697.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$666.33
|
| Rate for Payer: Aetna Managed Medicare |
$141.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$523.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$418.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$397.50
|
| Rate for Payer: Anthem Medicare Advantage |
$141.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$410.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$141.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$141.45
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cash Price |
$223.50
|
| Rate for Payer: Cigna Commercial |
$712.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$141.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$433.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$141.45
|
| Rate for Payer: Health EOS Commercial |
$689.57
|
| Rate for Payer: HFN Commercial |
$712.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$526.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$141.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$141.45
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$141.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$141.45
|
| Rate for Payer: Multiplan Commercial |
$619.84
|
| Rate for Payer: NAPHCARE Commercial |
$212.18
|
| Rate for Payer: Preferred Network Access Commercial |
$712.82
|
| Rate for Payer: Quartz Beloit One Network |
$379.65
|
| Rate for Payer: Quartz Commercial |
$503.62
|
| Rate for Payer: Quartz Medicare Advantage |
$141.45
|
| Rate for Payer: The Alliance Commercial |
$565.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$141.45
|
| Rate for Payer: United Healthcare PPO |
$581.10
|
| Rate for Payer: WEA Trust Commercial |
$426.14
|
| Rate for Payer: Wellcare Medicare |
$141.45
|
| Rate for Payer: WPS Commercial |
$573.87
|
|
