|
Tiagabine (Gabitril)
|
Professional
|
$234.00
|
|
|
Service Code
|
CPT 80199
|
| Hospital Charge Code |
983425
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.11 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Aetna Commercial |
$222.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$27.11
|
| Rate for Payer: Anthem Medicare Advantage |
$27.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27.11
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$222.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.11
|
| Rate for Payer: Health EOS Commercial |
$212.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$95.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$95.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27.11
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: Preferred Network Access Commercial |
$222.30
|
| Rate for Payer: Quartz Beloit One Network |
$102.96
|
| Rate for Payer: Quartz Commercial |
$133.38
|
| Rate for Payer: Quartz Medicare Advantage |
$27.11
|
| Rate for Payer: The Alliance Commercial |
$107.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.11
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$119.28
|
|
|
Tiagabine (Gabitril)
|
Facility
OP
|
$234.00
|
|
|
Service Code
|
CPT 80199
|
| Hospital Charge Code |
983425
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.70 |
| Max. Negotiated Rate |
$936.00 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$27.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$101.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$47.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$45.00
|
| Rate for Payer: Anthem Medicaid |
$19.70
|
| Rate for Payer: Anthem Medicare Advantage |
$27.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27.11
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$27.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.70
|
| Rate for Payer: Dean Health Medicaid |
$19.70
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$27.11
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$27.11
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27.11
|
| Rate for Payer: Managed Health Services Medicaid |
$20.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$27.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$27.11
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$40.66
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.70
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$27.11
|
| Rate for Payer: The Alliance Commercial |
$936.00
|
| Rate for Payer: United Healthcare Medicaid |
$19.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.11
|
| Rate for Payer: United Healthcare PPO |
$175.50
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: Wellcare Medicare |
$27.11
|
| Rate for Payer: WMAP Medicaid |
$19.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
TIBIAL AUGMENT BLOCK NEXGEN 3MM 10MM 00-5988-003-27
|
Facility
IP
|
$7,147.00
|
|
| Hospital Charge Code |
2967886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,502.03 |
| Max. Negotiated Rate |
$6,575.24 |
| Rate for Payer: Aetna Commercial |
$6,432.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,787.91
|
| Rate for Payer: Cash Price |
$2,144.10
|
| Rate for Payer: Cigna Commercial |
$6,575.24
|
| Rate for Payer: Health EOS Commercial |
$6,360.83
|
| Rate for Payer: HFN Commercial |
$6,575.24
|
| Rate for Payer: Multiplan Commercial |
$5,717.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,288.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,575.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,502.03
|
| Rate for Payer: Quartz Commercial |
$4,288.20
|
| Rate for Payer: WEA Trust Commercial |
$3,930.85
|
| Rate for Payer: WPS Commercial |
$5,293.78
|
|
|
TIBIAL AUGMENT BLOCK NEXGEN 3MM 10MM 00-5988-003-27
|
Facility
OP
|
$7,147.00
|
|
| Hospital Charge Code |
2967886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,001.16 |
| Max. Negotiated Rate |
$28,588.00 |
| Rate for Payer: Aetna Commercial |
$6,432.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,146.42
|
| Rate for Payer: Aetna Managed Medicare |
$2,001.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,645.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,573.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,430.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,787.91
|
| Rate for Payer: Cash Price |
$2,144.10
|
| Rate for Payer: Cigna Commercial |
$6,575.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,999.46
|
| Rate for Payer: Health EOS Commercial |
$6,360.83
|
| Rate for Payer: HFN Commercial |
$6,575.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,360.25
|
| Rate for Payer: Multiplan Commercial |
$5,717.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,288.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,575.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,502.03
|
| Rate for Payer: Quartz Commercial |
$4,645.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4,288.20
|
| Rate for Payer: The Alliance Commercial |
$28,588.00
|
| Rate for Payer: WEA Trust Commercial |
$3,930.85
|
| Rate for Payer: WPS Commercial |
$5,293.78
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 2 5MM LT 5545-A-202
|
Facility
IP
|
$6,222.00
|
|
| Hospital Charge Code |
4518663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,048.78 |
| Max. Negotiated Rate |
$5,724.24 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$3,733.20
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 2 5MM LT 5545-A-202
|
Facility
OP
|
$6,222.00
|
|
| Hospital Charge Code |
4518663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,742.16 |
| Max. Negotiated Rate |
$24,888.00 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,350.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,742.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,044.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,111.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,986.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,481.83
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,666.50
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$4,044.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,733.20
|
| Rate for Payer: The Alliance Commercial |
$24,888.00
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 2 5MM RT 5545-A-201
|
Facility
OP
|
$6,222.00
|
|
| Hospital Charge Code |
4518662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,742.16 |
| Max. Negotiated Rate |
$24,888.00 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,350.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,742.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,044.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,111.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,986.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,481.83
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,666.50
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$4,044.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,733.20
|
| Rate for Payer: The Alliance Commercial |
$24,888.00
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 2 5MM RT 5545-A-201
|
Facility
IP
|
$6,222.00
|
|
| Hospital Charge Code |
4518662
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,048.78 |
| Max. Negotiated Rate |
$5,724.24 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$3,733.20
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 3 5MM LT 5545-A-302
|
Facility
IP
|
$6,222.00
|
|
| Hospital Charge Code |
4493839
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,048.78 |
| Max. Negotiated Rate |
$5,724.24 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$3,733.20
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 3 5MM LT 5545-A-302
|
Facility
OP
|
$6,222.00
|
|
| Hospital Charge Code |
4493839
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,742.16 |
| Max. Negotiated Rate |
$24,888.00 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,350.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,742.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,044.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,111.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,986.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,481.83
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,666.50
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$4,044.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,733.20
|
| Rate for Payer: The Alliance Commercial |
$24,888.00
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 3 5MM RT 5545-A-301
|
Facility
IP
|
$6,222.00
|
|
| Hospital Charge Code |
4518661
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,048.78 |
| Max. Negotiated Rate |
$5,724.24 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$3,733.20
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 3 5MM RT 5545-A-301
|
Facility
OP
|
$6,222.00
|
|
| Hospital Charge Code |
4518661
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,742.16 |
| Max. Negotiated Rate |
$24,888.00 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,350.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,742.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,044.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,111.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,986.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,481.83
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,666.50
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$4,044.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,733.20
|
| Rate for Payer: The Alliance Commercial |
$24,888.00
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 4 5MM LT 5545-A-402
|
Facility
OP
|
$6,222.00
|
|
| Hospital Charge Code |
4518665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,742.16 |
| Max. Negotiated Rate |
$24,888.00 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,350.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,742.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,044.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,111.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,986.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,481.83
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,666.50
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$4,044.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,733.20
|
| Rate for Payer: The Alliance Commercial |
$24,888.00
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 4 5MM LT 5545-A-402
|
Facility
IP
|
$6,222.00
|
|
| Hospital Charge Code |
4518665
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,048.78 |
| Max. Negotiated Rate |
$5,724.24 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$3,733.20
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 4 5MM RT 5545-A-401
|
Facility
IP
|
$6,222.00
|
|
| Hospital Charge Code |
4518664
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,048.78 |
| Max. Negotiated Rate |
$5,724.24 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$3,733.20
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 4 5MM RT 5545-A-401
|
Facility
OP
|
$6,222.00
|
|
| Hospital Charge Code |
4518664
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,742.16 |
| Max. Negotiated Rate |
$24,888.00 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,350.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,742.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,044.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,111.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,986.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,481.83
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,666.50
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$4,044.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,733.20
|
| Rate for Payer: The Alliance Commercial |
$24,888.00
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 5 5MM 5545-A-502
|
Facility
IP
|
$6,222.00
|
|
| Hospital Charge Code |
3263469
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,048.78 |
| Max. Negotiated Rate |
$5,724.24 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$3,733.20
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 5 5MM 5545-A-502
|
Facility
OP
|
$6,222.00
|
|
| Hospital Charge Code |
3263469
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,742.16 |
| Max. Negotiated Rate |
$24,888.00 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,350.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,742.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,044.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,111.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,986.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,481.83
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,666.50
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$4,044.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,733.20
|
| Rate for Payer: The Alliance Commercial |
$24,888.00
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 5 5MM LT 5545-A-502
|
Facility
OP
|
$6,222.00
|
|
| Hospital Charge Code |
4518666
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,742.16 |
| Max. Negotiated Rate |
$24,888.00 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,350.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,742.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,044.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,111.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,986.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,481.83
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,666.50
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$4,044.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,733.20
|
| Rate for Payer: The Alliance Commercial |
$24,888.00
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 5 5MM LT 5545-A-502
|
Facility
IP
|
$6,222.00
|
|
| Hospital Charge Code |
4518666
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,048.78 |
| Max. Negotiated Rate |
$5,724.24 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$3,733.20
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 5 5MM RT 5545-A-501
|
Facility
IP
|
$6,222.00
|
|
| Hospital Charge Code |
4494014
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,048.78 |
| Max. Negotiated Rate |
$5,724.24 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$3,733.20
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 5 5MM RT 5545-A-501
|
Facility
OP
|
$6,222.00
|
|
| Hospital Charge Code |
4494014
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,742.16 |
| Max. Negotiated Rate |
$24,888.00 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,350.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,742.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,044.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,111.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,986.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,481.83
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,666.50
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$4,044.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,733.20
|
| Rate for Payer: The Alliance Commercial |
$24,888.00
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 6 5MM LT 5545-A-602
|
Facility
IP
|
$6,222.00
|
|
| Hospital Charge Code |
4518668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,048.78 |
| Max. Negotiated Rate |
$5,724.24 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$3,733.20
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 6 5MM LT 5545-A-602
|
Facility
OP
|
$6,222.00
|
|
| Hospital Charge Code |
4518668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,742.16 |
| Max. Negotiated Rate |
$24,888.00 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,350.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,742.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,044.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,111.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,986.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,481.83
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,666.50
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$4,044.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,733.20
|
| Rate for Payer: The Alliance Commercial |
$24,888.00
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
|
TIBIAL AUGMENT HALF BLOCK SZ 6 5MM RT 5545-A-601
|
Facility
IP
|
$6,222.00
|
|
| Hospital Charge Code |
4518667
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,048.78 |
| Max. Negotiated Rate |
$5,724.24 |
| Rate for Payer: Aetna Commercial |
$5,599.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,297.66
|
| Rate for Payer: Cash Price |
$1,866.60
|
| Rate for Payer: Cigna Commercial |
$5,724.24
|
| Rate for Payer: Health EOS Commercial |
$5,537.58
|
| Rate for Payer: HFN Commercial |
$5,724.24
|
| Rate for Payer: Multiplan Commercial |
$4,977.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,733.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,724.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,048.78
|
| Rate for Payer: Quartz Commercial |
$3,733.20
|
| Rate for Payer: WEA Trust Commercial |
$3,422.10
|
| Rate for Payer: WPS Commercial |
$4,608.64
|
|
