|
BONE MARROW HARVEST TRANSPLANTATION AUTOLOGOUS 38232
|
Professional
|
Both
|
$3,028.00
|
|
|
Service Code
|
CPT 38232
|
| Hospital Charge Code |
6170067
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$136.62 |
| Max. Negotiated Rate |
$2,876.60 |
| Rate for Payer: Aetna Commercial |
$2,876.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,604.08
|
| Rate for Payer: Cash Price |
$908.40
|
| Rate for Payer: Cash Price |
$908.40
|
| Rate for Payer: Cigna Commercial |
$2,876.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$136.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,816.80
|
| Rate for Payer: Health EOS Commercial |
$2,755.48
|
| Rate for Payer: HFN Commercial |
$2,876.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$655.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$655.66
|
| Rate for Payer: Multiplan Commercial |
$2,422.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,876.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,332.32
|
| Rate for Payer: Quartz Commercial |
$1,725.96
|
| Rate for Payer: The Alliance Commercial |
$1,514.00
|
| Rate for Payer: United Healthcare Medicaid |
$136.62
|
| Rate for Payer: WEA Trust Commercial |
$1,665.40
|
| Rate for Payer: WPS Commercial |
$2,242.84
|
|
|
Bone Marrow Peripheral Blood
|
Professional
|
Both
|
$330.00
|
|
|
Service Code
|
CPT 85060
|
| Hospital Charge Code |
5543210
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.51 |
| Max. Negotiated Rate |
$313.50 |
| Rate for Payer: Aetna Commercial |
$313.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.80
|
| Rate for Payer: Anthem Commercial |
$21.51
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$313.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$165.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$198.00
|
| Rate for Payer: Health EOS Commercial |
$300.30
|
| Rate for Payer: HFN Commercial |
$313.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$82.43
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: Preferred Network Access Commercial |
$313.50
|
| Rate for Payer: Quartz Beloit One Network |
$145.20
|
| Rate for Payer: Quartz Commercial |
$188.10
|
| Rate for Payer: The Alliance Commercial |
$165.00
|
| Rate for Payer: WEA Trust Commercial |
$181.50
|
| Rate for Payer: WPS Commercial |
$244.43
|
|
|
Bone Marrow Peripheral Blood
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
CPT 85060
|
| Hospital Charge Code |
5543210
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$92.40 |
| Max. Negotiated Rate |
$1,320.00 |
| Rate for Payer: Aetna Commercial |
$297.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.80
|
| Rate for Payer: Aetna Managed Medicare |
$92.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$214.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$165.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$158.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$174.90
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$303.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$184.67
|
| Rate for Payer: Health EOS Commercial |
$293.70
|
| Rate for Payer: HFN Commercial |
$303.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$247.50
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: NAPHCARE Commercial |
$198.00
|
| Rate for Payer: Preferred Network Access Commercial |
$303.60
|
| Rate for Payer: Quartz Beloit One Network |
$161.70
|
| Rate for Payer: Quartz Commercial |
$214.50
|
| Rate for Payer: Quartz Medicare Advantage |
$198.00
|
| Rate for Payer: The Alliance Commercial |
$1,320.00
|
| Rate for Payer: United Healthcare PPO |
$247.50
|
| Rate for Payer: WEA Trust Commercial |
$181.50
|
| Rate for Payer: WPS Commercial |
$244.43
|
|
|
Bone Marrow Peripheral Blood
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
CPT 85060
|
| Hospital Charge Code |
5543210
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$161.70 |
| Max. Negotiated Rate |
$303.60 |
| Rate for Payer: Aetna Commercial |
$297.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$174.90
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$303.60
|
| Rate for Payer: Health EOS Commercial |
$293.70
|
| Rate for Payer: HFN Commercial |
$303.60
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: NAPHCARE Commercial |
$198.00
|
| Rate for Payer: Preferred Network Access Commercial |
$303.60
|
| Rate for Payer: Quartz Beloit One Network |
$161.70
|
| Rate for Payer: Quartz Commercial |
$198.00
|
| Rate for Payer: WEA Trust Commercial |
$181.50
|
| Rate for Payer: WPS Commercial |
$244.43
|
|
|
Bone Marrow Peripheral Blood, TC
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT 85007
|
| Hospital Charge Code |
5543211
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.05 |
| Max. Negotiated Rate |
$41.40 |
| Rate for Payer: Aetna Commercial |
$40.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$38.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.85
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna Commercial |
$41.40
|
| Rate for Payer: Health EOS Commercial |
$40.05
|
| Rate for Payer: HFN Commercial |
$41.40
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: NAPHCARE Commercial |
$27.00
|
| Rate for Payer: Preferred Network Access Commercial |
$41.40
|
| Rate for Payer: Quartz Beloit One Network |
$22.05
|
| Rate for Payer: Quartz Commercial |
$27.00
|
| Rate for Payer: WEA Trust Commercial |
$24.75
|
| Rate for Payer: WPS Commercial |
$33.33
|
|
|
Bone Marrow Peripheral Blood, TC
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT 85007
|
| Hospital Charge Code |
5543211
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$41.40 |
| Rate for Payer: Aetna Commercial |
$40.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$38.70
|
| Rate for Payer: Aetna Managed Medicare |
$3.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.65
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6.31
|
| Rate for Payer: Anthem Medicaid |
$3.93
|
| Rate for Payer: Anthem Medicare Advantage |
$3.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.80
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna Commercial |
$41.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.18
|
| Rate for Payer: Dean Health Medicaid |
$3.93
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3.80
|
| Rate for Payer: Health EOS Commercial |
$40.05
|
| Rate for Payer: HFN Commercial |
$41.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.80
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.80
|
| Rate for Payer: Managed Health Services Medicaid |
$4.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3.80
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3.80
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: NAPHCARE Commercial |
$5.70
|
| Rate for Payer: Preferred Network Access Commercial |
$41.40
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3.93
|
| Rate for Payer: Quartz Beloit One Network |
$22.05
|
| Rate for Payer: Quartz Commercial |
$29.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3.80
|
| Rate for Payer: The Alliance Commercial |
$15.20
|
| Rate for Payer: United Healthcare Medicaid |
$3.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.80
|
| Rate for Payer: United Healthcare PPO |
$33.75
|
| Rate for Payer: WEA Trust Commercial |
$24.75
|
| Rate for Payer: Wellcare Medicare |
$3.80
|
| Rate for Payer: WMAP Medicaid |
$3.93
|
| Rate for Payer: WPS Commercial |
$33.33
|
|
|
Bone Marrow Peripheral Blood, TC
|
Professional
|
Both
|
$45.00
|
|
|
Service Code
|
CPT 85007
|
| Hospital Charge Code |
5543211
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.41 |
| Max. Negotiated Rate |
$42.75 |
| Rate for Payer: Aetna Commercial |
$42.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$38.70
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna Commercial |
$42.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.00
|
| Rate for Payer: Health EOS Commercial |
$40.95
|
| Rate for Payer: HFN Commercial |
$42.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.41
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: Preferred Network Access Commercial |
$42.75
|
| Rate for Payer: Quartz Beloit One Network |
$19.80
|
| Rate for Payer: Quartz Commercial |
$25.65
|
| Rate for Payer: The Alliance Commercial |
$22.50
|
| Rate for Payer: WEA Trust Commercial |
$24.75
|
| Rate for Payer: WPS Commercial |
$33.33
|
|
|
BONE MATRIX BIO4 10CC 3102-2110
|
Facility
|
OP
|
$26,185.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5685698
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,331.80 |
| Max. Negotiated Rate |
$104,740.00 |
| Rate for Payer: Aetna Commercial |
$23,566.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,519.10
|
| Rate for Payer: Aetna Managed Medicare |
$7,331.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,020.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,092.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,568.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,878.05
|
| Rate for Payer: Cash Price |
$7,855.50
|
| Rate for Payer: Cigna Commercial |
$24,090.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,653.13
|
| Rate for Payer: Health EOS Commercial |
$23,304.65
|
| Rate for Payer: HFN Commercial |
$24,090.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,638.75
|
| Rate for Payer: Multiplan Commercial |
$20,948.00
|
| Rate for Payer: NAPHCARE Commercial |
$15,711.00
|
| Rate for Payer: Preferred Network Access Commercial |
$24,090.20
|
| Rate for Payer: Quartz Beloit One Network |
$12,830.65
|
| Rate for Payer: Quartz Commercial |
$17,020.25
|
| Rate for Payer: Quartz Medicare Advantage |
$15,711.00
|
| Rate for Payer: The Alliance Commercial |
$104,740.00
|
| Rate for Payer: WEA Trust Commercial |
$14,401.75
|
| Rate for Payer: WPS Commercial |
$19,395.23
|
|
|
BONE MATRIX BIO4 10CC 3102-2110
|
Facility
|
IP
|
$26,185.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5685698
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,830.65 |
| Max. Negotiated Rate |
$24,090.20 |
| Rate for Payer: Aetna Commercial |
$23,566.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,519.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,878.05
|
| Rate for Payer: Cash Price |
$7,855.50
|
| Rate for Payer: Cigna Commercial |
$24,090.20
|
| Rate for Payer: Health EOS Commercial |
$23,304.65
|
| Rate for Payer: HFN Commercial |
$24,090.20
|
| Rate for Payer: Multiplan Commercial |
$20,948.00
|
| Rate for Payer: NAPHCARE Commercial |
$15,711.00
|
| Rate for Payer: Preferred Network Access Commercial |
$24,090.20
|
| Rate for Payer: Quartz Beloit One Network |
$12,830.65
|
| Rate for Payer: Quartz Commercial |
$15,711.00
|
| Rate for Payer: WEA Trust Commercial |
$14,401.75
|
| Rate for Payer: WPS Commercial |
$19,395.23
|
|
|
BONE MATRIX BIO4 1CC 3102-2101
|
Facility
|
OP
|
$5,983.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5685695
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,675.24 |
| Max. Negotiated Rate |
$23,932.00 |
| Rate for Payer: Aetna Commercial |
$5,384.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,145.38
|
| Rate for Payer: Aetna Managed Medicare |
$1,675.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,888.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,991.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,871.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,170.99
|
| Rate for Payer: Cash Price |
$1,794.90
|
| Rate for Payer: Cigna Commercial |
$5,504.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,348.09
|
| Rate for Payer: Health EOS Commercial |
$5,324.87
|
| Rate for Payer: HFN Commercial |
$5,504.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,487.25
|
| Rate for Payer: Multiplan Commercial |
$4,786.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,589.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,504.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,931.67
|
| Rate for Payer: Quartz Commercial |
$3,888.95
|
| Rate for Payer: Quartz Medicare Advantage |
$3,589.80
|
| Rate for Payer: The Alliance Commercial |
$23,932.00
|
| Rate for Payer: WEA Trust Commercial |
$3,290.65
|
| Rate for Payer: WPS Commercial |
$4,431.61
|
|
|
BONE MATRIX BIO4 1CC 3102-2101
|
Facility
|
IP
|
$5,983.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5685695
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,931.67 |
| Max. Negotiated Rate |
$5,504.36 |
| Rate for Payer: Aetna Commercial |
$5,384.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,145.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,170.99
|
| Rate for Payer: Cash Price |
$1,794.90
|
| Rate for Payer: Cigna Commercial |
$5,504.36
|
| Rate for Payer: Health EOS Commercial |
$5,324.87
|
| Rate for Payer: HFN Commercial |
$5,504.36
|
| Rate for Payer: Multiplan Commercial |
$4,786.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,589.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,504.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,931.67
|
| Rate for Payer: Quartz Commercial |
$3,589.80
|
| Rate for Payer: WEA Trust Commercial |
$3,290.65
|
| Rate for Payer: WPS Commercial |
$4,431.61
|
|
|
BONE MATRIX BIO4 2.5CC 3102-2102
|
Facility
|
OP
|
$8,695.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5685696
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,434.60 |
| Max. Negotiated Rate |
$34,780.00 |
| Rate for Payer: Aetna Commercial |
$7,825.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,477.70
|
| Rate for Payer: Aetna Managed Medicare |
$2,434.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,651.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,347.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,173.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,608.35
|
| Rate for Payer: Cash Price |
$2,608.50
|
| Rate for Payer: Cigna Commercial |
$7,999.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,865.72
|
| Rate for Payer: Health EOS Commercial |
$7,738.55
|
| Rate for Payer: HFN Commercial |
$7,999.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,521.25
|
| Rate for Payer: Multiplan Commercial |
$6,956.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,217.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,999.40
|
| Rate for Payer: Quartz Beloit One Network |
$4,260.55
|
| Rate for Payer: Quartz Commercial |
$5,651.75
|
| Rate for Payer: Quartz Medicare Advantage |
$5,217.00
|
| Rate for Payer: The Alliance Commercial |
$34,780.00
|
| Rate for Payer: WEA Trust Commercial |
$4,782.25
|
| Rate for Payer: WPS Commercial |
$6,440.39
|
|
|
BONE MATRIX BIO4 2.5CC 3102-2102
|
Facility
|
IP
|
$8,695.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5685696
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,260.55 |
| Max. Negotiated Rate |
$7,999.40 |
| Rate for Payer: Aetna Commercial |
$7,825.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,477.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,608.35
|
| Rate for Payer: Cash Price |
$2,608.50
|
| Rate for Payer: Cigna Commercial |
$7,999.40
|
| Rate for Payer: Health EOS Commercial |
$7,738.55
|
| Rate for Payer: HFN Commercial |
$7,999.40
|
| Rate for Payer: Multiplan Commercial |
$6,956.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,217.00
|
| Rate for Payer: Preferred Network Access Commercial |
$7,999.40
|
| Rate for Payer: Quartz Beloit One Network |
$4,260.55
|
| Rate for Payer: Quartz Commercial |
$5,217.00
|
| Rate for Payer: WEA Trust Commercial |
$4,782.25
|
| Rate for Payer: WPS Commercial |
$6,440.39
|
|
|
BONE MATRIX BIO4 5CC 3102-2105
|
Facility
|
OP
|
$15,343.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5685697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,296.04 |
| Max. Negotiated Rate |
$61,372.00 |
| Rate for Payer: Aetna Commercial |
$13,808.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,194.98
|
| Rate for Payer: Aetna Managed Medicare |
$4,296.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,972.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,671.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,364.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,131.79
|
| Rate for Payer: Cash Price |
$4,602.90
|
| Rate for Payer: Cigna Commercial |
$14,115.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,585.94
|
| Rate for Payer: Health EOS Commercial |
$13,655.27
|
| Rate for Payer: HFN Commercial |
$14,115.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,507.25
|
| Rate for Payer: Multiplan Commercial |
$12,274.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,205.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,115.56
|
| Rate for Payer: Quartz Beloit One Network |
$7,518.07
|
| Rate for Payer: Quartz Commercial |
$9,972.95
|
| Rate for Payer: Quartz Medicare Advantage |
$9,205.80
|
| Rate for Payer: The Alliance Commercial |
$61,372.00
|
| Rate for Payer: WEA Trust Commercial |
$8,438.65
|
| Rate for Payer: WPS Commercial |
$11,364.56
|
|
|
BONE MATRIX BIO4 5CC 3102-2105
|
Facility
|
IP
|
$15,343.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5685697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,518.07 |
| Max. Negotiated Rate |
$14,115.56 |
| Rate for Payer: Aetna Commercial |
$13,808.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,194.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,131.79
|
| Rate for Payer: Cash Price |
$4,602.90
|
| Rate for Payer: Cigna Commercial |
$14,115.56
|
| Rate for Payer: Health EOS Commercial |
$13,655.27
|
| Rate for Payer: HFN Commercial |
$14,115.56
|
| Rate for Payer: Multiplan Commercial |
$12,274.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,205.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,115.56
|
| Rate for Payer: Quartz Beloit One Network |
$7,518.07
|
| Rate for Payer: Quartz Commercial |
$9,205.80
|
| Rate for Payer: WEA Trust Commercial |
$8,438.65
|
| Rate for Payer: WPS Commercial |
$11,364.56
|
|
|
BONE MATRIX DBX DEMINERALIZED MIX 5CC 058050
|
Facility
|
IP
|
$7,500.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
3153468
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,675.00 |
| Max. Negotiated Rate |
$6,900.00 |
| Rate for Payer: Aetna Commercial |
$6,750.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,450.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,975.00
|
| Rate for Payer: Cash Price |
$2,250.00
|
| Rate for Payer: Cigna Commercial |
$6,900.00
|
| Rate for Payer: Health EOS Commercial |
$6,675.00
|
| Rate for Payer: HFN Commercial |
$6,900.00
|
| Rate for Payer: Multiplan Commercial |
$6,000.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,500.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,900.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,675.00
|
| Rate for Payer: Quartz Commercial |
$4,500.00
|
| Rate for Payer: WEA Trust Commercial |
$4,125.00
|
| Rate for Payer: WPS Commercial |
$5,555.25
|
|
|
BONE MATRIX DBX DEMINERALIZED MIX 5CC 058050
|
Facility
|
OP
|
$7,500.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
3153468
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,100.00 |
| Max. Negotiated Rate |
$30,000.00 |
| Rate for Payer: Aetna Commercial |
$6,750.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,450.00
|
| Rate for Payer: Aetna Managed Medicare |
$2,100.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,875.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,750.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,600.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,975.00
|
| Rate for Payer: Cash Price |
$2,250.00
|
| Rate for Payer: Cigna Commercial |
$6,900.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,197.00
|
| Rate for Payer: Health EOS Commercial |
$6,675.00
|
| Rate for Payer: HFN Commercial |
$6,900.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,625.00
|
| Rate for Payer: Multiplan Commercial |
$6,000.00
|
| Rate for Payer: NAPHCARE Commercial |
$4,500.00
|
| Rate for Payer: Preferred Network Access Commercial |
$6,900.00
|
| Rate for Payer: Quartz Beloit One Network |
$3,675.00
|
| Rate for Payer: Quartz Commercial |
$4,875.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4,500.00
|
| Rate for Payer: The Alliance Commercial |
$30,000.00
|
| Rate for Payer: WEA Trust Commercial |
$4,125.00
|
| Rate for Payer: WPS Commercial |
$5,555.25
|
|
|
BONE PREPARATION KIT BIOPREP 0206-710-000
|
Facility
|
IP
|
$1,973.00
|
|
| Hospital Charge Code |
2962898
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$966.77 |
| Max. Negotiated Rate |
$1,815.16 |
| Rate for Payer: Aetna Commercial |
$1,775.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,696.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,045.69
|
| Rate for Payer: Cash Price |
$591.90
|
| Rate for Payer: Cigna Commercial |
$1,815.16
|
| Rate for Payer: Health EOS Commercial |
$1,755.97
|
| Rate for Payer: HFN Commercial |
$1,815.16
|
| Rate for Payer: Multiplan Commercial |
$1,578.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,183.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,815.16
|
| Rate for Payer: Quartz Beloit One Network |
$966.77
|
| Rate for Payer: Quartz Commercial |
$1,183.80
|
| Rate for Payer: WEA Trust Commercial |
$1,085.15
|
| Rate for Payer: WPS Commercial |
$1,461.40
|
|
|
BONE PREPARATION KIT BIOPREP 0206-710-000
|
Facility
|
OP
|
$1,973.00
|
|
| Hospital Charge Code |
2962898
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$552.44 |
| Max. Negotiated Rate |
$7,892.00 |
| Rate for Payer: Aetna Commercial |
$1,775.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,696.78
|
| Rate for Payer: Aetna Managed Medicare |
$552.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,282.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$986.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$947.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,045.69
|
| Rate for Payer: Cash Price |
$591.90
|
| Rate for Payer: Cigna Commercial |
$1,815.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,104.09
|
| Rate for Payer: Health EOS Commercial |
$1,755.97
|
| Rate for Payer: HFN Commercial |
$1,815.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,479.75
|
| Rate for Payer: Multiplan Commercial |
$1,578.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,183.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,815.16
|
| Rate for Payer: Quartz Beloit One Network |
$966.77
|
| Rate for Payer: Quartz Commercial |
$1,282.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,183.80
|
| Rate for Payer: The Alliance Commercial |
$7,892.00
|
| Rate for Payer: WEA Trust Commercial |
$1,085.15
|
| Rate for Payer: WPS Commercial |
$1,461.40
|
|
|
BONE PUTTY AHBP HBP-2512
|
Facility
|
OP
|
$993.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
4048783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$278.04 |
| Max. Negotiated Rate |
$3,972.00 |
| Rate for Payer: Aetna Commercial |
$893.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$853.98
|
| Rate for Payer: Aetna Managed Medicare |
$278.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$645.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$496.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$476.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$526.29
|
| Rate for Payer: Cash Price |
$297.90
|
| Rate for Payer: Cigna Commercial |
$913.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$555.68
|
| Rate for Payer: Health EOS Commercial |
$883.77
|
| Rate for Payer: HFN Commercial |
$913.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$744.75
|
| Rate for Payer: Multiplan Commercial |
$794.40
|
| Rate for Payer: NAPHCARE Commercial |
$595.80
|
| Rate for Payer: Preferred Network Access Commercial |
$913.56
|
| Rate for Payer: Quartz Beloit One Network |
$486.57
|
| Rate for Payer: Quartz Commercial |
$645.45
|
| Rate for Payer: Quartz Medicare Advantage |
$595.80
|
| Rate for Payer: The Alliance Commercial |
$3,972.00
|
| Rate for Payer: WEA Trust Commercial |
$546.15
|
| Rate for Payer: WPS Commercial |
$735.52
|
|
|
BONE PUTTY AHBP HBP-2512
|
Facility
|
IP
|
$993.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
4048783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$486.57 |
| Max. Negotiated Rate |
$913.56 |
| Rate for Payer: Aetna Commercial |
$893.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$853.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$526.29
|
| Rate for Payer: Cash Price |
$297.90
|
| Rate for Payer: Cigna Commercial |
$913.56
|
| Rate for Payer: Health EOS Commercial |
$883.77
|
| Rate for Payer: HFN Commercial |
$913.56
|
| Rate for Payer: Multiplan Commercial |
$794.40
|
| Rate for Payer: NAPHCARE Commercial |
$595.80
|
| Rate for Payer: Preferred Network Access Commercial |
$913.56
|
| Rate for Payer: Quartz Beloit One Network |
$486.57
|
| Rate for Payer: Quartz Commercial |
$595.80
|
| Rate for Payer: WEA Trust Commercial |
$546.15
|
| Rate for Payer: WPS Commercial |
$735.52
|
|
|
BONE PUTTY ALLOGRAFT 10CC 3102-1010
|
Facility
|
IP
|
$9,308.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5685694
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,560.92 |
| Max. Negotiated Rate |
$8,563.36 |
| Rate for Payer: Aetna Commercial |
$8,377.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,004.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,933.24
|
| Rate for Payer: Cash Price |
$2,792.40
|
| Rate for Payer: Cigna Commercial |
$8,563.36
|
| Rate for Payer: Health EOS Commercial |
$8,284.12
|
| Rate for Payer: HFN Commercial |
$8,563.36
|
| Rate for Payer: Multiplan Commercial |
$7,446.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,584.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,563.36
|
| Rate for Payer: Quartz Beloit One Network |
$4,560.92
|
| Rate for Payer: Quartz Commercial |
$5,584.80
|
| Rate for Payer: WEA Trust Commercial |
$5,119.40
|
| Rate for Payer: WPS Commercial |
$6,894.44
|
|
|
BONE PUTTY ALLOGRAFT 10CC 3102-1010
|
Facility
|
OP
|
$9,308.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5685694
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,606.24 |
| Max. Negotiated Rate |
$37,232.00 |
| Rate for Payer: Aetna Commercial |
$8,377.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,004.88
|
| Rate for Payer: Aetna Managed Medicare |
$2,606.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,050.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,654.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,467.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,933.24
|
| Rate for Payer: Cash Price |
$2,792.40
|
| Rate for Payer: Cigna Commercial |
$8,563.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,208.76
|
| Rate for Payer: Health EOS Commercial |
$8,284.12
|
| Rate for Payer: HFN Commercial |
$8,563.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,981.00
|
| Rate for Payer: Multiplan Commercial |
$7,446.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,584.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,563.36
|
| Rate for Payer: Quartz Beloit One Network |
$4,560.92
|
| Rate for Payer: Quartz Commercial |
$6,050.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5,584.80
|
| Rate for Payer: The Alliance Commercial |
$37,232.00
|
| Rate for Payer: WEA Trust Commercial |
$5,119.40
|
| Rate for Payer: WPS Commercial |
$6,894.44
|
|
|
BONE PUTTY ALLOGRAFT 1CC 3102-1001
|
Facility
|
OP
|
$3,936.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5685691
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,102.08 |
| Max. Negotiated Rate |
$15,744.00 |
| Rate for Payer: Aetna Commercial |
$3,542.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,102.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,558.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,968.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,889.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,086.08
|
| Rate for Payer: Cash Price |
$1,180.80
|
| Rate for Payer: Cigna Commercial |
$3,621.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.59
|
| Rate for Payer: Health EOS Commercial |
$3,503.04
|
| Rate for Payer: HFN Commercial |
$3,621.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,952.00
|
| Rate for Payer: Multiplan Commercial |
$3,148.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,621.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.64
|
| Rate for Payer: Quartz Commercial |
$2,558.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.60
|
| Rate for Payer: The Alliance Commercial |
$15,744.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.80
|
| Rate for Payer: WPS Commercial |
$2,915.40
|
|
|
BONE PUTTY ALLOGRAFT 1CC 3102-1001
|
Facility
|
IP
|
$3,936.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5685691
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,928.64 |
| Max. Negotiated Rate |
$3,621.12 |
| Rate for Payer: Aetna Commercial |
$3,542.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,086.08
|
| Rate for Payer: Cash Price |
$1,180.80
|
| Rate for Payer: Cigna Commercial |
$3,621.12
|
| Rate for Payer: Health EOS Commercial |
$3,503.04
|
| Rate for Payer: HFN Commercial |
$3,621.12
|
| Rate for Payer: Multiplan Commercial |
$3,148.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,621.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.64
|
| Rate for Payer: Quartz Commercial |
$2,361.60
|
| Rate for Payer: WEA Trust Commercial |
$2,164.80
|
| Rate for Payer: WPS Commercial |
$2,915.40
|
|
