|
BOLT FEMORAL NECK 75MM 04.168.275S
|
Facility
|
OP
|
$3,570.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
6178981
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$999.60 |
| Max. Negotiated Rate |
$14,280.00 |
| Rate for Payer: Aetna Commercial |
$3,213.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,070.20
|
| Rate for Payer: Aetna Managed Medicare |
$999.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,320.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,785.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,713.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,892.10
|
| Rate for Payer: Cash Price |
$1,071.00
|
| Rate for Payer: Cigna Commercial |
$3,284.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,997.77
|
| Rate for Payer: Health EOS Commercial |
$3,177.30
|
| Rate for Payer: HFN Commercial |
$3,284.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,677.50
|
| Rate for Payer: Multiplan Commercial |
$2,856.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,142.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,284.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,749.30
|
| Rate for Payer: Quartz Commercial |
$2,320.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,142.00
|
| Rate for Payer: The Alliance Commercial |
$14,280.00
|
| Rate for Payer: WEA Trust Commercial |
$1,963.50
|
| Rate for Payer: WPS Commercial |
$2,644.30
|
|
|
BOLT FEMORAL NECK 90MM 04.168.290S
|
Facility
|
IP
|
$2,407.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
6178984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,179.43 |
| Max. Negotiated Rate |
$2,214.44 |
| Rate for Payer: Aetna Commercial |
$2,166.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,070.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,275.71
|
| Rate for Payer: Cash Price |
$722.10
|
| Rate for Payer: Cigna Commercial |
$2,214.44
|
| Rate for Payer: Health EOS Commercial |
$2,142.23
|
| Rate for Payer: HFN Commercial |
$2,214.44
|
| Rate for Payer: Multiplan Commercial |
$1,925.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,444.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,214.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,179.43
|
| Rate for Payer: Quartz Commercial |
$1,444.20
|
| Rate for Payer: WEA Trust Commercial |
$1,323.85
|
| Rate for Payer: WPS Commercial |
$1,782.86
|
|
|
BOLT FEMORAL NECK 90MM 04.168.290S
|
Facility
|
OP
|
$2,407.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
6178984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$673.96 |
| Max. Negotiated Rate |
$9,628.00 |
| Rate for Payer: Aetna Commercial |
$2,166.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,070.02
|
| Rate for Payer: Aetna Managed Medicare |
$673.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,564.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,203.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,155.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,275.71
|
| Rate for Payer: Cash Price |
$722.10
|
| Rate for Payer: Cigna Commercial |
$2,214.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,346.96
|
| Rate for Payer: Health EOS Commercial |
$2,142.23
|
| Rate for Payer: HFN Commercial |
$2,214.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,805.25
|
| Rate for Payer: Multiplan Commercial |
$1,925.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,444.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,214.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,179.43
|
| Rate for Payer: Quartz Commercial |
$1,564.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,444.20
|
| Rate for Payer: The Alliance Commercial |
$9,628.00
|
| Rate for Payer: WEA Trust Commercial |
$1,323.85
|
| Rate for Payer: WPS Commercial |
$1,782.86
|
|
|
BONE CEMENT BIOMET R 110035368
|
Facility
|
IP
|
$1,035.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415169
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$507.15 |
| Max. Negotiated Rate |
$952.20 |
| Rate for Payer: Aetna Commercial |
$931.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$890.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$548.55
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cigna Commercial |
$952.20
|
| Rate for Payer: Health EOS Commercial |
$921.15
|
| Rate for Payer: HFN Commercial |
$952.20
|
| Rate for Payer: Multiplan Commercial |
$828.00
|
| Rate for Payer: NAPHCARE Commercial |
$621.00
|
| Rate for Payer: Preferred Network Access Commercial |
$952.20
|
| Rate for Payer: Quartz Beloit One Network |
$507.15
|
| Rate for Payer: Quartz Commercial |
$621.00
|
| Rate for Payer: WEA Trust Commercial |
$569.25
|
| Rate for Payer: WPS Commercial |
$766.62
|
|
|
BONE CEMENT BIOMET R 110035368
|
Facility
|
OP
|
$1,035.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415169
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$289.80 |
| Max. Negotiated Rate |
$4,140.00 |
| Rate for Payer: Aetna Commercial |
$931.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$890.10
|
| Rate for Payer: Aetna Managed Medicare |
$289.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$672.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$517.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$496.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$548.55
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cigna Commercial |
$952.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$579.19
|
| Rate for Payer: Health EOS Commercial |
$921.15
|
| Rate for Payer: HFN Commercial |
$952.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$776.25
|
| Rate for Payer: Multiplan Commercial |
$828.00
|
| Rate for Payer: NAPHCARE Commercial |
$621.00
|
| Rate for Payer: Preferred Network Access Commercial |
$952.20
|
| Rate for Payer: Quartz Beloit One Network |
$507.15
|
| Rate for Payer: Quartz Commercial |
$672.75
|
| Rate for Payer: Quartz Medicare Advantage |
$621.00
|
| Rate for Payer: The Alliance Commercial |
$4,140.00
|
| Rate for Payer: WEA Trust Commercial |
$569.25
|
| Rate for Payer: WPS Commercial |
$766.62
|
|
|
BONE CEMENT CEMENT PALACOS R+G GENTAMICIN 00-1113-140-01
|
Facility
|
OP
|
$3,973.00
|
|
| Hospital Charge Code |
2962971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,112.44 |
| Max. Negotiated Rate |
$15,892.00 |
| Rate for Payer: Aetna Commercial |
$3,575.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,416.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,112.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,582.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,986.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,907.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,105.69
|
| Rate for Payer: Cash Price |
$1,191.90
|
| Rate for Payer: Cigna Commercial |
$3,655.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,223.29
|
| Rate for Payer: Health EOS Commercial |
$3,535.97
|
| Rate for Payer: HFN Commercial |
$3,655.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,979.75
|
| Rate for Payer: Multiplan Commercial |
$3,178.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,383.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,655.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,946.77
|
| Rate for Payer: Quartz Commercial |
$2,582.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,383.80
|
| Rate for Payer: The Alliance Commercial |
$15,892.00
|
| Rate for Payer: WEA Trust Commercial |
$2,185.15
|
| Rate for Payer: WPS Commercial |
$2,942.80
|
|
|
BONE CEMENT CEMENT PALACOS R+G GENTAMICIN 00-1113-140-01
|
Facility
|
IP
|
$3,973.00
|
|
| Hospital Charge Code |
2962971
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,946.77 |
| Max. Negotiated Rate |
$3,655.16 |
| Rate for Payer: Aetna Commercial |
$3,575.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,416.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,105.69
|
| Rate for Payer: Cash Price |
$1,191.90
|
| Rate for Payer: Cigna Commercial |
$3,655.16
|
| Rate for Payer: Health EOS Commercial |
$3,535.97
|
| Rate for Payer: HFN Commercial |
$3,655.16
|
| Rate for Payer: Multiplan Commercial |
$3,178.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,383.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,655.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,946.77
|
| Rate for Payer: Quartz Commercial |
$2,383.80
|
| Rate for Payer: WEA Trust Commercial |
$2,185.15
|
| Rate for Payer: WPS Commercial |
$2,942.80
|
|
|
BONE CEMENT PALACOS R 00-1112-140-01
|
Facility
|
IP
|
$1,579.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2963344
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$773.71 |
| Max. Negotiated Rate |
$1,452.68 |
| Rate for Payer: Aetna Commercial |
$1,421.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,357.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$836.87
|
| Rate for Payer: Cash Price |
$473.70
|
| Rate for Payer: Cigna Commercial |
$1,452.68
|
| Rate for Payer: Health EOS Commercial |
$1,405.31
|
| Rate for Payer: HFN Commercial |
$1,452.68
|
| Rate for Payer: Multiplan Commercial |
$1,263.20
|
| Rate for Payer: NAPHCARE Commercial |
$947.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,452.68
|
| Rate for Payer: Quartz Beloit One Network |
$773.71
|
| Rate for Payer: Quartz Commercial |
$947.40
|
| Rate for Payer: WEA Trust Commercial |
$868.45
|
| Rate for Payer: WPS Commercial |
$1,169.57
|
|
|
BONE CEMENT PALACOS R 00-1112-140-01
|
Facility
|
OP
|
$1,579.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2963344
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$442.12 |
| Max. Negotiated Rate |
$6,316.00 |
| Rate for Payer: Aetna Commercial |
$1,421.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,357.94
|
| Rate for Payer: Aetna Managed Medicare |
$442.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,026.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$789.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$757.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$836.87
|
| Rate for Payer: Cash Price |
$473.70
|
| Rate for Payer: Cigna Commercial |
$1,452.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$883.61
|
| Rate for Payer: Health EOS Commercial |
$1,405.31
|
| Rate for Payer: HFN Commercial |
$1,452.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,184.25
|
| Rate for Payer: Multiplan Commercial |
$1,263.20
|
| Rate for Payer: NAPHCARE Commercial |
$947.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,452.68
|
| Rate for Payer: Quartz Beloit One Network |
$773.71
|
| Rate for Payer: Quartz Commercial |
$1,026.35
|
| Rate for Payer: Quartz Medicare Advantage |
$947.40
|
| Rate for Payer: The Alliance Commercial |
$6,316.00
|
| Rate for Payer: WEA Trust Commercial |
$868.45
|
| Rate for Payer: WPS Commercial |
$1,169.57
|
|
|
BONE CEMENT REFOBACIN R 110034355
|
Facility
|
IP
|
$2,643.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415004
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,295.07 |
| Max. Negotiated Rate |
$2,431.56 |
| Rate for Payer: Aetna Commercial |
$2,378.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,272.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,400.79
|
| Rate for Payer: Cash Price |
$792.90
|
| Rate for Payer: Cigna Commercial |
$2,431.56
|
| Rate for Payer: Health EOS Commercial |
$2,352.27
|
| Rate for Payer: HFN Commercial |
$2,431.56
|
| Rate for Payer: Multiplan Commercial |
$2,114.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,585.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,431.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,295.07
|
| Rate for Payer: Quartz Commercial |
$1,585.80
|
| Rate for Payer: WEA Trust Commercial |
$1,453.65
|
| Rate for Payer: WPS Commercial |
$1,957.67
|
|
|
BONE CEMENT REFOBACIN R 110034355
|
Facility
|
OP
|
$2,643.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5415004
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$740.04 |
| Max. Negotiated Rate |
$10,572.00 |
| Rate for Payer: Aetna Commercial |
$2,378.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,272.98
|
| Rate for Payer: Aetna Managed Medicare |
$740.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,717.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,321.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,268.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,400.79
|
| Rate for Payer: Cash Price |
$792.90
|
| Rate for Payer: Cigna Commercial |
$2,431.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,479.02
|
| Rate for Payer: Health EOS Commercial |
$2,352.27
|
| Rate for Payer: HFN Commercial |
$2,431.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,982.25
|
| Rate for Payer: Multiplan Commercial |
$2,114.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,585.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,431.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,295.07
|
| Rate for Payer: Quartz Commercial |
$1,717.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,585.80
|
| Rate for Payer: The Alliance Commercial |
$10,572.00
|
| Rate for Payer: WEA Trust Commercial |
$1,453.65
|
| Rate for Payer: WPS Commercial |
$1,957.67
|
|
|
BONE CEMENT SIMPLEX HV WITH GENTAMICIN 6195-1-001
|
Facility
|
IP
|
$3,162.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4377231
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,549.38 |
| Max. Negotiated Rate |
$2,909.04 |
| Rate for Payer: Aetna Commercial |
$2,845.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,719.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,675.86
|
| Rate for Payer: Cash Price |
$948.60
|
| Rate for Payer: Cigna Commercial |
$2,909.04
|
| Rate for Payer: Health EOS Commercial |
$2,814.18
|
| Rate for Payer: HFN Commercial |
$2,909.04
|
| Rate for Payer: Multiplan Commercial |
$2,529.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,897.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,909.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,549.38
|
| Rate for Payer: Quartz Commercial |
$1,897.20
|
| Rate for Payer: WEA Trust Commercial |
$1,739.10
|
| Rate for Payer: WPS Commercial |
$2,342.09
|
|
|
BONE CEMENT SIMPLEX HV WITH GENTAMICIN 6195-1-001
|
Facility
|
OP
|
$3,162.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4377231
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.36 |
| Max. Negotiated Rate |
$12,648.00 |
| Rate for Payer: Aetna Commercial |
$2,845.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,719.32
|
| Rate for Payer: Aetna Managed Medicare |
$885.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,055.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,581.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,517.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,675.86
|
| Rate for Payer: Cash Price |
$948.60
|
| Rate for Payer: Cigna Commercial |
$2,909.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,769.46
|
| Rate for Payer: Health EOS Commercial |
$2,814.18
|
| Rate for Payer: HFN Commercial |
$2,909.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,371.50
|
| Rate for Payer: Multiplan Commercial |
$2,529.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,897.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,909.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,549.38
|
| Rate for Payer: Quartz Commercial |
$2,055.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,897.20
|
| Rate for Payer: The Alliance Commercial |
$12,648.00
|
| Rate for Payer: WEA Trust Commercial |
$1,739.10
|
| Rate for Payer: WPS Commercial |
$2,342.09
|
|
|
BONE CEMENT SIMPLEX P 6191-1-001
|
Facility
|
OP
|
$1,047.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2962899
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$293.16 |
| Max. Negotiated Rate |
$4,188.00 |
| Rate for Payer: Aetna Commercial |
$942.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$900.42
|
| Rate for Payer: Aetna Managed Medicare |
$293.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.91
|
| Rate for Payer: Cash Price |
$314.10
|
| Rate for Payer: Cigna Commercial |
$963.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.90
|
| Rate for Payer: Health EOS Commercial |
$931.83
|
| Rate for Payer: HFN Commercial |
$963.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$785.25
|
| Rate for Payer: Multiplan Commercial |
$837.60
|
| Rate for Payer: NAPHCARE Commercial |
$628.20
|
| Rate for Payer: Preferred Network Access Commercial |
$963.24
|
| Rate for Payer: Quartz Beloit One Network |
$513.03
|
| Rate for Payer: Quartz Commercial |
$680.55
|
| Rate for Payer: Quartz Medicare Advantage |
$628.20
|
| Rate for Payer: The Alliance Commercial |
$4,188.00
|
| Rate for Payer: WEA Trust Commercial |
$575.85
|
| Rate for Payer: WPS Commercial |
$775.51
|
|
|
BONE CEMENT SIMPLEX P 6191-1-001
|
Facility
|
IP
|
$1,047.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2962899
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$513.03 |
| Max. Negotiated Rate |
$963.24 |
| Rate for Payer: Aetna Commercial |
$942.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$900.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.91
|
| Rate for Payer: Cash Price |
$314.10
|
| Rate for Payer: Cigna Commercial |
$963.24
|
| Rate for Payer: Health EOS Commercial |
$931.83
|
| Rate for Payer: HFN Commercial |
$963.24
|
| Rate for Payer: Multiplan Commercial |
$837.60
|
| Rate for Payer: NAPHCARE Commercial |
$628.20
|
| Rate for Payer: Preferred Network Access Commercial |
$963.24
|
| Rate for Payer: Quartz Beloit One Network |
$513.03
|
| Rate for Payer: Quartz Commercial |
$628.20
|
| Rate for Payer: WEA Trust Commercial |
$575.85
|
| Rate for Payer: WPS Commercial |
$775.51
|
|
|
BONE CEMENT SIMPLEX P WITH TOBRAMYACIN 6197-9-001
|
Facility
|
OP
|
$2,943.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2962855
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$824.04 |
| Max. Negotiated Rate |
$11,772.00 |
| Rate for Payer: Aetna Commercial |
$2,648.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,530.98
|
| Rate for Payer: Aetna Managed Medicare |
$824.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,912.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,471.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,412.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,559.79
|
| Rate for Payer: Cash Price |
$882.90
|
| Rate for Payer: Cigna Commercial |
$2,707.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,646.90
|
| Rate for Payer: Health EOS Commercial |
$2,619.27
|
| Rate for Payer: HFN Commercial |
$2,707.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,207.25
|
| Rate for Payer: Multiplan Commercial |
$2,354.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,765.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,707.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,442.07
|
| Rate for Payer: Quartz Commercial |
$1,912.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,765.80
|
| Rate for Payer: The Alliance Commercial |
$11,772.00
|
| Rate for Payer: WEA Trust Commercial |
$1,618.65
|
| Rate for Payer: WPS Commercial |
$2,179.88
|
|
|
BONE CEMENT SIMPLEX P WITH TOBRAMYACIN 6197-9-001
|
Facility
|
IP
|
$2,943.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2962855
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,442.07 |
| Max. Negotiated Rate |
$2,707.56 |
| Rate for Payer: Aetna Commercial |
$2,648.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,530.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,559.79
|
| Rate for Payer: Cash Price |
$882.90
|
| Rate for Payer: Cigna Commercial |
$2,707.56
|
| Rate for Payer: Health EOS Commercial |
$2,619.27
|
| Rate for Payer: HFN Commercial |
$2,707.56
|
| Rate for Payer: Multiplan Commercial |
$2,354.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,765.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,707.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,442.07
|
| Rate for Payer: Quartz Commercial |
$1,765.80
|
| Rate for Payer: WEA Trust Commercial |
$1,618.65
|
| Rate for Payer: WPS Commercial |
$2,179.88
|
|
|
BONE CEMENT SMARTSET GMV 5450-50-501
|
Facility
|
IP
|
$3,482.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5528730
|
|
Hospital Revenue Code
|
280
|
| Min. Negotiated Rate |
$1,706.18 |
| Max. Negotiated Rate |
$3,203.44 |
| Rate for Payer: Aetna Commercial |
$3,133.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,994.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,845.46
|
| Rate for Payer: Cash Price |
$1,044.60
|
| Rate for Payer: Cigna Commercial |
$3,203.44
|
| Rate for Payer: Health EOS Commercial |
$3,098.98
|
| Rate for Payer: HFN Commercial |
$3,203.44
|
| Rate for Payer: Multiplan Commercial |
$2,785.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,089.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,203.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,706.18
|
| Rate for Payer: Quartz Commercial |
$2,089.20
|
| Rate for Payer: WEA Trust Commercial |
$1,915.10
|
| Rate for Payer: WPS Commercial |
$2,579.12
|
|
|
BONE CEMENT SMARTSET GMV 5450-50-501
|
Facility
|
OP
|
$3,482.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5528730
|
|
Hospital Revenue Code
|
280
|
| Min. Negotiated Rate |
$974.96 |
| Max. Negotiated Rate |
$13,928.00 |
| Rate for Payer: Aetna Commercial |
$3,133.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,994.52
|
| Rate for Payer: Aetna Managed Medicare |
$974.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,263.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,741.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,671.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,845.46
|
| Rate for Payer: Cash Price |
$1,044.60
|
| Rate for Payer: Cigna Commercial |
$3,203.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,948.53
|
| Rate for Payer: Health EOS Commercial |
$3,098.98
|
| Rate for Payer: HFN Commercial |
$3,203.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,611.50
|
| Rate for Payer: Multiplan Commercial |
$2,785.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,089.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,203.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,706.18
|
| Rate for Payer: Quartz Commercial |
$2,263.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,089.20
|
| Rate for Payer: The Alliance Commercial |
$13,928.00
|
| Rate for Payer: United Healthcare PPO |
$2,611.50
|
| Rate for Payer: WEA Trust Commercial |
$1,915.10
|
| Rate for Payer: WPS Commercial |
$2,579.12
|
|
|
BONE CEMENT SMARTSET MV 3122-040
|
Facility
|
IP
|
$1,488.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5459756
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$729.12 |
| Max. Negotiated Rate |
$1,368.96 |
| Rate for Payer: Aetna Commercial |
$1,339.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,279.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$788.64
|
| Rate for Payer: Cash Price |
$446.40
|
| Rate for Payer: Cigna Commercial |
$1,368.96
|
| Rate for Payer: Health EOS Commercial |
$1,324.32
|
| Rate for Payer: HFN Commercial |
$1,368.96
|
| Rate for Payer: Multiplan Commercial |
$1,190.40
|
| Rate for Payer: NAPHCARE Commercial |
$892.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,368.96
|
| Rate for Payer: Quartz Beloit One Network |
$729.12
|
| Rate for Payer: Quartz Commercial |
$892.80
|
| Rate for Payer: WEA Trust Commercial |
$818.40
|
| Rate for Payer: WPS Commercial |
$1,102.16
|
|
|
BONE CEMENT SMARTSET MV 3122-040
|
Facility
|
OP
|
$1,488.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5459756
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$416.64 |
| Max. Negotiated Rate |
$5,952.00 |
| Rate for Payer: Aetna Commercial |
$1,339.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,279.68
|
| Rate for Payer: Aetna Managed Medicare |
$416.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$967.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$744.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$714.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$788.64
|
| Rate for Payer: Cash Price |
$446.40
|
| Rate for Payer: Cigna Commercial |
$1,368.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$832.68
|
| Rate for Payer: Health EOS Commercial |
$1,324.32
|
| Rate for Payer: HFN Commercial |
$1,368.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,116.00
|
| Rate for Payer: Multiplan Commercial |
$1,190.40
|
| Rate for Payer: NAPHCARE Commercial |
$892.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,368.96
|
| Rate for Payer: Quartz Beloit One Network |
$729.12
|
| Rate for Payer: Quartz Commercial |
$967.20
|
| Rate for Payer: Quartz Medicare Advantage |
$892.80
|
| Rate for Payer: The Alliance Commercial |
$5,952.00
|
| Rate for Payer: WEA Trust Commercial |
$818.40
|
| Rate for Payer: WPS Commercial |
$1,102.16
|
|
|
BONE CHIPS CANCELLOUS 30CC FREEZE DRIED 00600718
|
Facility
|
IP
|
$6,007.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5414970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,943.43 |
| Max. Negotiated Rate |
$5,526.44 |
| Rate for Payer: Aetna Commercial |
$5,406.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,166.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,183.71
|
| Rate for Payer: Cash Price |
$1,802.10
|
| Rate for Payer: Cigna Commercial |
$5,526.44
|
| Rate for Payer: Health EOS Commercial |
$5,346.23
|
| Rate for Payer: HFN Commercial |
$5,526.44
|
| Rate for Payer: Multiplan Commercial |
$4,805.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,604.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,526.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,943.43
|
| Rate for Payer: Quartz Commercial |
$3,604.20
|
| Rate for Payer: WEA Trust Commercial |
$3,303.85
|
| Rate for Payer: WPS Commercial |
$4,449.38
|
|
|
BONE CHIPS CANCELLOUS 30CC FREEZE DRIED 00600718
|
Facility
|
OP
|
$6,007.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5414970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,681.96 |
| Max. Negotiated Rate |
$24,028.00 |
| Rate for Payer: Aetna Commercial |
$5,406.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,166.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,681.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,904.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,003.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,883.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,183.71
|
| Rate for Payer: Cash Price |
$1,802.10
|
| Rate for Payer: Cigna Commercial |
$5,526.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,361.52
|
| Rate for Payer: Health EOS Commercial |
$5,346.23
|
| Rate for Payer: HFN Commercial |
$5,526.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,505.25
|
| Rate for Payer: Multiplan Commercial |
$4,805.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,604.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,526.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,943.43
|
| Rate for Payer: Quartz Commercial |
$3,904.55
|
| Rate for Payer: Quartz Medicare Advantage |
$3,604.20
|
| Rate for Payer: The Alliance Commercial |
$24,028.00
|
| Rate for Payer: WEA Trust Commercial |
$3,303.85
|
| Rate for Payer: WPS Commercial |
$4,449.38
|
|
|
BONE DISEASES AND ARTHROPATHIES WITH MCC
|
Facility
|
IP
|
$36,251.00
|
|
|
Service Code
|
MSDRG 553
|
| Min. Negotiated Rate |
$13,040.06 |
| Max. Negotiated Rate |
$36,251.00 |
| Rate for Payer: Aetna Managed Medicare |
$13,040.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28,323.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21,709.35
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,625.30
|
| Rate for Payer: Anthem Medicare Advantage |
$13,040.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13,040.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13,040.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13,040.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22,895.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13,040.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,354.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13,040.06
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13,040.06
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13,040.06
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13,040.06
|
| Rate for Payer: NAPHCARE Commercial |
$19,560.09
|
| Rate for Payer: Quartz Medicare Advantage |
$13,040.06
|
| Rate for Payer: The Alliance Commercial |
$36,251.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13,040.06
|
| Rate for Payer: United Healthcare PPO |
$20,517.12
|
| Rate for Payer: Wellcare Medicare |
$13,040.06
|
|
|
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC
|
Facility
|
IP
|
$22,169.00
|
|
|
Service Code
|
MSDRG 554
|
| Min. Negotiated Rate |
$7,974.38 |
| Max. Negotiated Rate |
$22,169.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,974.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,203.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,186.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,527.96
|
| Rate for Payer: Anthem Medicare Advantage |
$7,974.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,974.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,974.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,974.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,907.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,974.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,025.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,974.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,974.38
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,974.38
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,974.38
|
| Rate for Payer: NAPHCARE Commercial |
$11,961.57
|
| Rate for Payer: Quartz Medicare Advantage |
$7,974.38
|
| Rate for Payer: The Alliance Commercial |
$22,169.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,974.38
|
| Rate for Payer: United Healthcare PPO |
$12,475.75
|
| Rate for Payer: Wellcare Medicare |
$7,974.38
|
|
