|
TIBIA PERSONA 5 DEG STEMMED LT SZ H 42-5320-083-01
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3267494
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,739.68 |
| Max. Negotiated Rate |
$7,021.44 |
| Rate for Payer: Aetna Commercial |
$6,868.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,563.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,044.96
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,021.44
|
| Rate for Payer: Health EOS Commercial |
$6,792.48
|
| Rate for Payer: HFN Commercial |
$7,021.44
|
| Rate for Payer: Multiplan Commercial |
$6,105.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,579.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,021.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,739.68
|
| Rate for Payer: Quartz Commercial |
$4,579.20
|
| Rate for Payer: WEA Trust Commercial |
$4,197.60
|
| Rate for Payer: WPS Commercial |
$5,653.02
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ H 42-5320-083-01
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3267494
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,136.96 |
| Max. Negotiated Rate |
$30,528.00 |
| Rate for Payer: Aetna Commercial |
$6,868.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,563.52
|
| Rate for Payer: Aetna Managed Medicare |
$2,136.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,960.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,816.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,663.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,044.96
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,021.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,270.87
|
| Rate for Payer: Health EOS Commercial |
$6,792.48
|
| Rate for Payer: HFN Commercial |
$7,021.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,724.00
|
| Rate for Payer: Multiplan Commercial |
$6,105.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,579.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,021.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,739.68
|
| Rate for Payer: Quartz Commercial |
$4,960.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,579.20
|
| Rate for Payer: The Alliance Commercial |
$30,528.00
|
| Rate for Payer: WEA Trust Commercial |
$4,197.60
|
| Rate for Payer: WPS Commercial |
$5,653.02
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ J 42-5320-088-01
|
Facility
|
IP
|
$6,558.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5415935
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,213.42 |
| Max. Negotiated Rate |
$6,033.36 |
| Rate for Payer: Aetna Commercial |
$5,902.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,639.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,475.74
|
| Rate for Payer: Cash Price |
$1,967.40
|
| Rate for Payer: Cigna Commercial |
$6,033.36
|
| Rate for Payer: Health EOS Commercial |
$5,836.62
|
| Rate for Payer: HFN Commercial |
$6,033.36
|
| Rate for Payer: Multiplan Commercial |
$5,246.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,934.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,033.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,213.42
|
| Rate for Payer: Quartz Commercial |
$3,934.80
|
| Rate for Payer: WEA Trust Commercial |
$3,606.90
|
| Rate for Payer: WPS Commercial |
$4,857.51
|
|
|
TIBIA PERSONA 5 DEG STEMMED LT SZ J 42-5320-088-01
|
Facility
|
OP
|
$6,558.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5415935
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,836.24 |
| Max. Negotiated Rate |
$26,232.00 |
| Rate for Payer: Aetna Commercial |
$5,902.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,639.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,836.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,262.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,279.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,147.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,475.74
|
| Rate for Payer: Cash Price |
$1,967.40
|
| Rate for Payer: Cigna Commercial |
$6,033.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,669.86
|
| Rate for Payer: Health EOS Commercial |
$5,836.62
|
| Rate for Payer: HFN Commercial |
$6,033.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,918.50
|
| Rate for Payer: Multiplan Commercial |
$5,246.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,934.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,033.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,213.42
|
| Rate for Payer: Quartz Commercial |
$4,262.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,934.80
|
| Rate for Payer: The Alliance Commercial |
$26,232.00
|
| Rate for Payer: WEA Trust Commercial |
$3,606.90
|
| Rate for Payer: WPS Commercial |
$4,857.51
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ C 42-5320-064-02
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3333503
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,136.96 |
| Max. Negotiated Rate |
$30,528.00 |
| Rate for Payer: Aetna Commercial |
$6,868.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,563.52
|
| Rate for Payer: Aetna Managed Medicare |
$2,136.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,960.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,816.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,663.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,044.96
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,021.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,270.87
|
| Rate for Payer: Health EOS Commercial |
$6,792.48
|
| Rate for Payer: HFN Commercial |
$7,021.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,724.00
|
| Rate for Payer: Multiplan Commercial |
$6,105.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,579.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,021.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,739.68
|
| Rate for Payer: Quartz Commercial |
$4,960.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,579.20
|
| Rate for Payer: The Alliance Commercial |
$30,528.00
|
| Rate for Payer: WEA Trust Commercial |
$4,197.60
|
| Rate for Payer: WPS Commercial |
$5,653.02
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ C 42-5320-064-02
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3333503
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,739.68 |
| Max. Negotiated Rate |
$7,021.44 |
| Rate for Payer: Aetna Commercial |
$6,868.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,563.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,044.96
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,021.44
|
| Rate for Payer: Health EOS Commercial |
$6,792.48
|
| Rate for Payer: HFN Commercial |
$7,021.44
|
| Rate for Payer: Multiplan Commercial |
$6,105.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,579.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,021.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,739.68
|
| Rate for Payer: Quartz Commercial |
$4,579.20
|
| Rate for Payer: WEA Trust Commercial |
$4,197.60
|
| Rate for Payer: WPS Commercial |
$5,653.02
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ D 42-5320-067-02
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3615499
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,739.68 |
| Max. Negotiated Rate |
$7,021.44 |
| Rate for Payer: Aetna Commercial |
$6,868.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,563.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,044.96
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,021.44
|
| Rate for Payer: Health EOS Commercial |
$6,792.48
|
| Rate for Payer: HFN Commercial |
$7,021.44
|
| Rate for Payer: Multiplan Commercial |
$6,105.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,579.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,021.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,739.68
|
| Rate for Payer: Quartz Commercial |
$4,579.20
|
| Rate for Payer: WEA Trust Commercial |
$4,197.60
|
| Rate for Payer: WPS Commercial |
$5,653.02
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ D 42-5320-067-02
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3615499
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,136.96 |
| Max. Negotiated Rate |
$30,528.00 |
| Rate for Payer: Aetna Commercial |
$6,868.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,563.52
|
| Rate for Payer: Aetna Managed Medicare |
$2,136.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,960.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,816.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,663.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,044.96
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,021.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,270.87
|
| Rate for Payer: Health EOS Commercial |
$6,792.48
|
| Rate for Payer: HFN Commercial |
$7,021.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,724.00
|
| Rate for Payer: Multiplan Commercial |
$6,105.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,579.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,021.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,739.68
|
| Rate for Payer: Quartz Commercial |
$4,960.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,579.20
|
| Rate for Payer: The Alliance Commercial |
$30,528.00
|
| Rate for Payer: WEA Trust Commercial |
$4,197.60
|
| Rate for Payer: WPS Commercial |
$5,653.02
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ E 42-5320-071-02
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3221472
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,136.96 |
| Max. Negotiated Rate |
$30,528.00 |
| Rate for Payer: Aetna Commercial |
$6,868.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,563.52
|
| Rate for Payer: Aetna Managed Medicare |
$2,136.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,960.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,816.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,663.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,044.96
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,021.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,270.87
|
| Rate for Payer: Health EOS Commercial |
$6,792.48
|
| Rate for Payer: HFN Commercial |
$7,021.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,724.00
|
| Rate for Payer: Multiplan Commercial |
$6,105.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,579.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,021.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,739.68
|
| Rate for Payer: Quartz Commercial |
$4,960.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,579.20
|
| Rate for Payer: The Alliance Commercial |
$30,528.00
|
| Rate for Payer: WEA Trust Commercial |
$4,197.60
|
| Rate for Payer: WPS Commercial |
$5,653.02
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ E 42-5320-071-02
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3221472
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,739.68 |
| Max. Negotiated Rate |
$7,021.44 |
| Rate for Payer: Aetna Commercial |
$6,868.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,563.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,044.96
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,021.44
|
| Rate for Payer: Health EOS Commercial |
$6,792.48
|
| Rate for Payer: HFN Commercial |
$7,021.44
|
| Rate for Payer: Multiplan Commercial |
$6,105.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,579.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,021.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,739.68
|
| Rate for Payer: Quartz Commercial |
$4,579.20
|
| Rate for Payer: WEA Trust Commercial |
$4,197.60
|
| Rate for Payer: WPS Commercial |
$5,653.02
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ F 42-5320-075-02
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3381506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,739.68 |
| Max. Negotiated Rate |
$7,021.44 |
| Rate for Payer: Aetna Commercial |
$6,868.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,563.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,044.96
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,021.44
|
| Rate for Payer: Health EOS Commercial |
$6,792.48
|
| Rate for Payer: HFN Commercial |
$7,021.44
|
| Rate for Payer: Multiplan Commercial |
$6,105.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,579.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,021.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,739.68
|
| Rate for Payer: Quartz Commercial |
$4,579.20
|
| Rate for Payer: WEA Trust Commercial |
$4,197.60
|
| Rate for Payer: WPS Commercial |
$5,653.02
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ F 42-5320-075-02
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3381506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,136.96 |
| Max. Negotiated Rate |
$30,528.00 |
| Rate for Payer: Aetna Commercial |
$6,868.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,563.52
|
| Rate for Payer: Aetna Managed Medicare |
$2,136.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,960.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,816.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,663.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,044.96
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,021.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,270.87
|
| Rate for Payer: Health EOS Commercial |
$6,792.48
|
| Rate for Payer: HFN Commercial |
$7,021.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,724.00
|
| Rate for Payer: Multiplan Commercial |
$6,105.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,579.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,021.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,739.68
|
| Rate for Payer: Quartz Commercial |
$4,960.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,579.20
|
| Rate for Payer: The Alliance Commercial |
$30,528.00
|
| Rate for Payer: WEA Trust Commercial |
$4,197.60
|
| Rate for Payer: WPS Commercial |
$5,653.02
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ G 42-5320-079-02
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3116527
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,136.96 |
| Max. Negotiated Rate |
$30,528.00 |
| Rate for Payer: Aetna Commercial |
$6,868.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,563.52
|
| Rate for Payer: Aetna Managed Medicare |
$2,136.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,960.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,816.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,663.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,044.96
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,021.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,270.87
|
| Rate for Payer: Health EOS Commercial |
$6,792.48
|
| Rate for Payer: HFN Commercial |
$7,021.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,724.00
|
| Rate for Payer: Multiplan Commercial |
$6,105.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,579.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,021.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,739.68
|
| Rate for Payer: Quartz Commercial |
$4,960.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,579.20
|
| Rate for Payer: The Alliance Commercial |
$30,528.00
|
| Rate for Payer: WEA Trust Commercial |
$4,197.60
|
| Rate for Payer: WPS Commercial |
$5,653.02
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ G 42-5320-079-02
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3116527
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,739.68 |
| Max. Negotiated Rate |
$7,021.44 |
| Rate for Payer: Aetna Commercial |
$6,868.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,563.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,044.96
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,021.44
|
| Rate for Payer: Health EOS Commercial |
$6,792.48
|
| Rate for Payer: HFN Commercial |
$7,021.44
|
| Rate for Payer: Multiplan Commercial |
$6,105.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,579.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,021.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,739.68
|
| Rate for Payer: Quartz Commercial |
$4,579.20
|
| Rate for Payer: WEA Trust Commercial |
$4,197.60
|
| Rate for Payer: WPS Commercial |
$5,653.02
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ H 42-5320-083-02
|
Facility
|
IP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3739521
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,739.68 |
| Max. Negotiated Rate |
$7,021.44 |
| Rate for Payer: Aetna Commercial |
$6,868.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,563.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,044.96
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,021.44
|
| Rate for Payer: Health EOS Commercial |
$6,792.48
|
| Rate for Payer: HFN Commercial |
$7,021.44
|
| Rate for Payer: Multiplan Commercial |
$6,105.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,579.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,021.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,739.68
|
| Rate for Payer: Quartz Commercial |
$4,579.20
|
| Rate for Payer: WEA Trust Commercial |
$4,197.60
|
| Rate for Payer: WPS Commercial |
$5,653.02
|
|
|
TIBIA PERSONA 5 DEG STEMMED RT SZ H 42-5320-083-02
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3739521
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,136.96 |
| Max. Negotiated Rate |
$30,528.00 |
| Rate for Payer: Aetna Commercial |
$6,868.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,563.52
|
| Rate for Payer: Aetna Managed Medicare |
$2,136.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,960.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,816.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,663.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,044.96
|
| Rate for Payer: Cash Price |
$2,289.60
|
| Rate for Payer: Cigna Commercial |
$7,021.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,270.87
|
| Rate for Payer: Health EOS Commercial |
$6,792.48
|
| Rate for Payer: HFN Commercial |
$7,021.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,724.00
|
| Rate for Payer: Multiplan Commercial |
$6,105.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,579.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,021.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,739.68
|
| Rate for Payer: Quartz Commercial |
$4,960.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,579.20
|
| Rate for Payer: The Alliance Commercial |
$30,528.00
|
| Rate for Payer: WEA Trust Commercial |
$4,197.60
|
| Rate for Payer: WPS Commercial |
$5,653.02
|
|
|
TIBIA TRAY ZUK HIGH FLEX SZ 2 RT MED/LT LAT 5842-02-02
|
Facility
|
IP
|
$6,892.00
|
|
| Hospital Charge Code |
3241465
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,377.08 |
| Max. Negotiated Rate |
$6,340.64 |
| Rate for Payer: Aetna Commercial |
$6,202.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,927.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,652.76
|
| Rate for Payer: Cash Price |
$2,067.60
|
| Rate for Payer: Cigna Commercial |
$6,340.64
|
| Rate for Payer: Health EOS Commercial |
$6,133.88
|
| Rate for Payer: HFN Commercial |
$6,340.64
|
| Rate for Payer: Multiplan Commercial |
$5,513.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,135.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,340.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,377.08
|
| Rate for Payer: Quartz Commercial |
$4,135.20
|
| Rate for Payer: WEA Trust Commercial |
$3,790.60
|
| Rate for Payer: WPS Commercial |
$5,104.90
|
|
|
TIBIA TRAY ZUK HIGH FLEX SZ 2 RT MED/LT LAT 5842-02-02
|
Facility
|
OP
|
$6,892.00
|
|
| Hospital Charge Code |
3241465
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,929.76 |
| Max. Negotiated Rate |
$27,568.00 |
| Rate for Payer: Aetna Commercial |
$6,202.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,927.12
|
| Rate for Payer: Aetna Managed Medicare |
$1,929.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,479.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,446.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,308.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,652.76
|
| Rate for Payer: Cash Price |
$2,067.60
|
| Rate for Payer: Cigna Commercial |
$6,340.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,856.76
|
| Rate for Payer: Health EOS Commercial |
$6,133.88
|
| Rate for Payer: HFN Commercial |
$6,340.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,169.00
|
| Rate for Payer: Multiplan Commercial |
$5,513.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,135.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,340.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,377.08
|
| Rate for Payer: Quartz Commercial |
$4,479.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,135.20
|
| Rate for Payer: The Alliance Commercial |
$27,568.00
|
| Rate for Payer: WEA Trust Commercial |
$3,790.60
|
| Rate for Payer: WPS Commercial |
$5,104.90
|
|
|
Tick and Arthropods ID
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
CPT 87168
|
| Hospital Charge Code |
4716606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$48.60
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Tick and Arthropods ID
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
CPT 87168
|
| Hospital Charge Code |
4716606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Aetna Managed Medicare |
$4.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7.47
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7.09
|
| Rate for Payer: Anthem Medicaid |
$4.41
|
| Rate for Payer: Anthem Medicare Advantage |
$4.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.27
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.33
|
| Rate for Payer: Dean Health Medicaid |
$4.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.27
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.27
|
| Rate for Payer: Managed Health Services Medicaid |
$4.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.27
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.27
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$6.40
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4.41
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$52.65
|
| Rate for Payer: Quartz Medicare Advantage |
$4.27
|
| Rate for Payer: The Alliance Commercial |
$17.08
|
| Rate for Payer: United Healthcare Medicaid |
$4.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.27
|
| Rate for Payer: United Healthcare PPO |
$60.75
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: Wellcare Medicare |
$4.27
|
| Rate for Payer: WMAP Medicaid |
$4.41
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Tick and Arthropods ID
|
Professional
|
Both
|
$81.00
|
|
|
Service Code
|
CPT 87168
|
| Hospital Charge Code |
4716606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.07 |
| Max. Negotiated Rate |
$76.95 |
| Rate for Payer: Aetna Commercial |
$76.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$76.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$40.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.60
|
| Rate for Payer: Health EOS Commercial |
$73.71
|
| Rate for Payer: HFN Commercial |
$76.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.07
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: Preferred Network Access Commercial |
$76.95
|
| Rate for Payer: Quartz Beloit One Network |
$35.64
|
| Rate for Payer: Quartz Commercial |
$46.17
|
| Rate for Payer: The Alliance Commercial |
$40.50
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Tick-Borne Disease, Antibody Panel
|
Facility
|
IP
|
$414.00
|
|
|
Service Code
|
CPT 86618
|
| Hospital Charge Code |
5675623
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$202.86 |
| Max. Negotiated Rate |
$380.88 |
| Rate for Payer: Aetna Commercial |
$372.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$356.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$219.42
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cigna Commercial |
$380.88
|
| Rate for Payer: Health EOS Commercial |
$368.46
|
| Rate for Payer: HFN Commercial |
$380.88
|
| Rate for Payer: Multiplan Commercial |
$331.20
|
| Rate for Payer: NAPHCARE Commercial |
$248.40
|
| Rate for Payer: Preferred Network Access Commercial |
$380.88
|
| Rate for Payer: Quartz Beloit One Network |
$202.86
|
| Rate for Payer: Quartz Commercial |
$248.40
|
| Rate for Payer: WEA Trust Commercial |
$227.70
|
| Rate for Payer: WPS Commercial |
$306.65
|
|
|
Tick-Borne Disease, Antibody Panel
|
Facility
|
OP
|
$414.00
|
|
|
Service Code
|
CPT 86618
|
| Hospital Charge Code |
5675623
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.03 |
| Max. Negotiated Rate |
$380.88 |
| Rate for Payer: Aetna Commercial |
$372.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$356.04
|
| Rate for Payer: Aetna Managed Medicare |
$17.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.27
|
| Rate for Payer: Anthem Medicaid |
$17.60
|
| Rate for Payer: Anthem Medicare Advantage |
$17.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$219.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.03
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cigna Commercial |
$380.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$231.67
|
| Rate for Payer: Dean Health Medicaid |
$17.60
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.03
|
| Rate for Payer: Health EOS Commercial |
$368.46
|
| Rate for Payer: HFN Commercial |
$380.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.03
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.03
|
| Rate for Payer: Managed Health Services Medicaid |
$18.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.03
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.03
|
| Rate for Payer: Multiplan Commercial |
$331.20
|
| Rate for Payer: NAPHCARE Commercial |
$25.54
|
| Rate for Payer: Preferred Network Access Commercial |
$380.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.60
|
| Rate for Payer: Quartz Beloit One Network |
$202.86
|
| Rate for Payer: Quartz Commercial |
$269.10
|
| Rate for Payer: Quartz Medicare Advantage |
$17.03
|
| Rate for Payer: The Alliance Commercial |
$68.12
|
| Rate for Payer: United Healthcare Medicaid |
$17.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.03
|
| Rate for Payer: United Healthcare PPO |
$310.50
|
| Rate for Payer: WEA Trust Commercial |
$227.70
|
| Rate for Payer: Wellcare Medicare |
$17.03
|
| Rate for Payer: WMAP Medicaid |
$17.60
|
| Rate for Payer: WPS Commercial |
$306.65
|
|
|
Tick-Borne Disease, Antibody Panel
|
Professional
|
Both
|
$414.00
|
|
|
Service Code
|
CPT 86618
|
| Hospital Charge Code |
5675623
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$60.12 |
| Max. Negotiated Rate |
$393.30 |
| Rate for Payer: Aetna Commercial |
$393.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$356.04
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Cigna Commercial |
$393.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$207.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$248.40
|
| Rate for Payer: Health EOS Commercial |
$376.74
|
| Rate for Payer: HFN Commercial |
$393.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.12
|
| Rate for Payer: Multiplan Commercial |
$331.20
|
| Rate for Payer: Preferred Network Access Commercial |
$393.30
|
| Rate for Payer: Quartz Beloit One Network |
$182.16
|
| Rate for Payer: Quartz Commercial |
$235.98
|
| Rate for Payer: The Alliance Commercial |
$207.00
|
| Rate for Payer: WEA Trust Commercial |
$227.70
|
| Rate for Payer: WPS Commercial |
$306.65
|
|
|
Tick-Borne DNA Panel, PCR, Blood to Mayo
|
Facility
|
IP
|
$405.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
3591523
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$198.45 |
| Max. Negotiated Rate |
$372.60 |
| Rate for Payer: Aetna Commercial |
$364.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.65
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$372.60
|
| Rate for Payer: Health EOS Commercial |
$360.45
|
| Rate for Payer: HFN Commercial |
$372.60
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: NAPHCARE Commercial |
$243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$372.60
|
| Rate for Payer: Quartz Beloit One Network |
$198.45
|
| Rate for Payer: Quartz Commercial |
$243.00
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
