|
BO Autologous Handling Fee
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
CPT 86890
|
| Hospital Charge Code |
973791
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$55.04 |
| Max. Negotiated Rate |
$717.18 |
| Rate for Payer: Aetna Commercial |
$101.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.60
|
| Rate for Payer: Aetna Managed Medicare |
$179.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$658.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$307.25
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$291.45
|
| Rate for Payer: Anthem Medicare Advantage |
$179.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$179.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$179.30
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$103.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$179.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$179.30
|
| Rate for Payer: Health EOS Commercial |
$99.96
|
| Rate for Payer: HFN Commercial |
$103.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$666.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$179.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$179.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$179.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$179.30
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: NAPHCARE Commercial |
$268.94
|
| Rate for Payer: Preferred Network Access Commercial |
$103.33
|
| Rate for Payer: Quartz Beloit One Network |
$55.04
|
| Rate for Payer: Quartz Commercial |
$73.01
|
| Rate for Payer: Quartz Medicare Advantage |
$179.30
|
| Rate for Payer: The Alliance Commercial |
$717.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$179.30
|
| Rate for Payer: United Healthcare PPO |
$84.24
|
| Rate for Payer: WEA Trust Commercial |
$61.78
|
| Rate for Payer: Wellcare Medicare |
$179.30
|
| Rate for Payer: WPS Commercial |
$83.19
|
|
|
BO Autologous Handling Fee
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
CPT 86890
|
| Hospital Charge Code |
973791
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$55.04 |
| Max. Negotiated Rate |
$103.33 |
| Rate for Payer: Aetna Commercial |
$101.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.53
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$103.33
|
| Rate for Payer: Health EOS Commercial |
$99.96
|
| Rate for Payer: HFN Commercial |
$103.33
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: Preferred Network Access Commercial |
$103.33
|
| Rate for Payer: Quartz Beloit One Network |
$55.04
|
| Rate for Payer: Quartz Commercial |
$67.39
|
| Rate for Payer: WEA Trust Commercial |
$61.78
|
| Rate for Payer: WPS Commercial |
$83.19
|
|
|
BO Chloroquin Pretreatment
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
CPT 86970
|
| Hospital Charge Code |
975768
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$62.09 |
| Max. Negotiated Rate |
$248.35 |
| Rate for Payer: Aetna Commercial |
$115.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.01
|
| Rate for Payer: Aetna Managed Medicare |
$62.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$235.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$104.38
|
| Rate for Payer: Anthem Medicare Advantage |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.09
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$117.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$62.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$62.09
|
| Rate for Payer: Health EOS Commercial |
$113.85
|
| Rate for Payer: HFN Commercial |
$117.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$230.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$62.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$62.09
|
| Rate for Payer: Multiplan Commercial |
$102.34
|
| Rate for Payer: NAPHCARE Commercial |
$93.13
|
| Rate for Payer: Preferred Network Access Commercial |
$117.69
|
| Rate for Payer: Quartz Beloit One Network |
$62.68
|
| Rate for Payer: Quartz Commercial |
$83.15
|
| Rate for Payer: Quartz Medicare Advantage |
$62.09
|
| Rate for Payer: The Alliance Commercial |
$248.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.09
|
| Rate for Payer: United Healthcare PPO |
$95.94
|
| Rate for Payer: WEA Trust Commercial |
$70.36
|
| Rate for Payer: Wellcare Medicare |
$62.09
|
| Rate for Payer: WPS Commercial |
$94.75
|
|
|
BO Chloroquin Pretreatment
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
CPT 86970
|
| Hospital Charge Code |
975768
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$62.68 |
| Max. Negotiated Rate |
$117.69 |
| Rate for Payer: Aetna Commercial |
$115.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.80
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$117.69
|
| Rate for Payer: Health EOS Commercial |
$113.85
|
| Rate for Payer: HFN Commercial |
$117.69
|
| Rate for Payer: Multiplan Commercial |
$102.34
|
| Rate for Payer: Preferred Network Access Commercial |
$117.69
|
| Rate for Payer: Quartz Beloit One Network |
$62.68
|
| Rate for Payer: Quartz Commercial |
$76.75
|
| Rate for Payer: WEA Trust Commercial |
$70.36
|
| Rate for Payer: WPS Commercial |
$94.75
|
|
|
Body Fluid Culture
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
633883
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Body Fluid Culture
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
633883
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.96 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Aetna Commercial |
$222.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$8.96
|
| Rate for Payer: Anthem Medicare Advantage |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.96
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$222.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.96
|
| Rate for Payer: Health EOS Commercial |
$212.94
|
| Rate for Payer: HFN Commercial |
$222.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.96
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$13.45
|
| Rate for Payer: Preferred Network Access Commercial |
$222.30
|
| Rate for Payer: Quartz Beloit One Network |
$102.96
|
| Rate for Payer: Quartz Commercial |
$133.38
|
| Rate for Payer: Quartz Medicare Advantage |
$8.96
|
| Rate for Payer: The Alliance Commercial |
$35.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.96
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$39.45
|
|
|
Body Fluid Culture
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
633883
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.96 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$8.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.69
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.88
|
| Rate for Payer: Anthem Medicare Advantage |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.96
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.96
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.96
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$13.45
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$8.96
|
| Rate for Payer: The Alliance Commercial |
$35.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.96
|
| Rate for Payer: United Healthcare PPO |
$175.50
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: Wellcare Medicare |
$8.96
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
BO Enzyme Pretreatment
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
CPT 86971
|
| Hospital Charge Code |
973790
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.83 |
| Max. Negotiated Rate |
$717.18 |
| Rate for Payer: Aetna Commercial |
$80.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.92
|
| Rate for Payer: Aetna Managed Medicare |
$179.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$658.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$307.25
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$291.45
|
| Rate for Payer: Anthem Medicare Advantage |
$179.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$179.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$179.30
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$82.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$179.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.05
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$179.30
|
| Rate for Payer: Health EOS Commercial |
$79.60
|
| Rate for Payer: HFN Commercial |
$82.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$666.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$179.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$179.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$179.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$179.30
|
| Rate for Payer: Multiplan Commercial |
$71.55
|
| Rate for Payer: NAPHCARE Commercial |
$268.94
|
| Rate for Payer: Preferred Network Access Commercial |
$82.28
|
| Rate for Payer: Quartz Beloit One Network |
$43.83
|
| Rate for Payer: Quartz Commercial |
$58.14
|
| Rate for Payer: Quartz Medicare Advantage |
$179.30
|
| Rate for Payer: The Alliance Commercial |
$717.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$179.30
|
| Rate for Payer: United Healthcare PPO |
$67.08
|
| Rate for Payer: WEA Trust Commercial |
$49.19
|
| Rate for Payer: Wellcare Medicare |
$179.30
|
| Rate for Payer: WPS Commercial |
$66.25
|
|
|
BO Enzyme Pretreatment
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
CPT 86971
|
| Hospital Charge Code |
973790
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.83 |
| Max. Negotiated Rate |
$82.28 |
| Rate for Payer: Aetna Commercial |
$80.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.40
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$82.28
|
| Rate for Payer: Health EOS Commercial |
$79.60
|
| Rate for Payer: HFN Commercial |
$82.28
|
| Rate for Payer: Multiplan Commercial |
$71.55
|
| Rate for Payer: Preferred Network Access Commercial |
$82.28
|
| Rate for Payer: Quartz Beloit One Network |
$43.83
|
| Rate for Payer: Quartz Commercial |
$53.66
|
| Rate for Payer: WEA Trust Commercial |
$49.19
|
| Rate for Payer: WPS Commercial |
$66.25
|
|
|
BO Hgb S Neg
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
CPT 85660
|
| Hospital Charge Code |
4544606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$88.03 |
| Rate for Payer: Aetna Commercial |
$86.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.28
|
| Rate for Payer: Aetna Managed Medicare |
$5.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.51
|
| Rate for Payer: Anthem Medicare Advantage |
$5.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.73
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$88.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.54
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.73
|
| Rate for Payer: Health EOS Commercial |
$85.16
|
| Rate for Payer: HFN Commercial |
$88.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.73
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.73
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.73
|
| Rate for Payer: Multiplan Commercial |
$76.54
|
| Rate for Payer: NAPHCARE Commercial |
$8.60
|
| Rate for Payer: Preferred Network Access Commercial |
$88.03
|
| Rate for Payer: Quartz Beloit One Network |
$46.88
|
| Rate for Payer: Quartz Commercial |
$62.19
|
| Rate for Payer: Quartz Medicare Advantage |
$5.73
|
| Rate for Payer: The Alliance Commercial |
$22.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.73
|
| Rate for Payer: United Healthcare PPO |
$71.76
|
| Rate for Payer: WEA Trust Commercial |
$52.62
|
| Rate for Payer: Wellcare Medicare |
$5.73
|
| Rate for Payer: WPS Commercial |
$70.87
|
|
|
BO Hgb S Neg
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
CPT 85660
|
| Hospital Charge Code |
4544606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$46.88 |
| Max. Negotiated Rate |
$88.03 |
| Rate for Payer: Aetna Commercial |
$86.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.71
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$88.03
|
| Rate for Payer: Health EOS Commercial |
$85.16
|
| Rate for Payer: HFN Commercial |
$88.03
|
| Rate for Payer: Multiplan Commercial |
$76.54
|
| Rate for Payer: Preferred Network Access Commercial |
$88.03
|
| Rate for Payer: Quartz Beloit One Network |
$46.88
|
| Rate for Payer: Quartz Commercial |
$57.41
|
| Rate for Payer: WEA Trust Commercial |
$52.62
|
| Rate for Payer: WPS Commercial |
$70.87
|
|
|
BOLT FEMORAL NECK 75MM 04.168.275S
|
Facility
|
IP
|
$3,570.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
6178981
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,819.27 |
| Max. Negotiated Rate |
$3,415.78 |
| Rate for Payer: Aetna Commercial |
$3,341.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,193.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,967.78
|
| Rate for Payer: Cash Price |
$1,071.00
|
| Rate for Payer: Cigna Commercial |
$3,415.78
|
| Rate for Payer: Health EOS Commercial |
$3,304.39
|
| Rate for Payer: HFN Commercial |
$3,415.78
|
| Rate for Payer: Multiplan Commercial |
$2,970.24
|
| Rate for Payer: Preferred Network Access Commercial |
$3,415.78
|
| Rate for Payer: Quartz Beloit One Network |
$1,819.27
|
| Rate for Payer: Quartz Commercial |
$2,227.68
|
| Rate for Payer: WEA Trust Commercial |
$2,042.04
|
| Rate for Payer: WPS Commercial |
$2,749.97
|
|
|
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 |
$1,039.58 |
| Max. Negotiated Rate |
$3,415.78 |
| Rate for Payer: Aetna Commercial |
$3,341.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,193.01
|
| Rate for Payer: Aetna Managed Medicare |
$1,039.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,413.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,856.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,782.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,967.78
|
| Rate for Payer: Cash Price |
$1,071.00
|
| Rate for Payer: Cigna Commercial |
$3,415.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,077.74
|
| Rate for Payer: Health EOS Commercial |
$3,304.39
|
| Rate for Payer: HFN Commercial |
$3,415.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,784.60
|
| Rate for Payer: Multiplan Commercial |
$2,970.24
|
| Rate for Payer: NAPHCARE Commercial |
$2,227.68
|
| Rate for Payer: Preferred Network Access Commercial |
$3,415.78
|
| Rate for Payer: Quartz Beloit One Network |
$1,819.27
|
| Rate for Payer: Quartz Commercial |
$2,413.32
|
| Rate for Payer: Quartz Medicare Advantage |
$2,227.68
|
| Rate for Payer: The Alliance Commercial |
$1,856.40
|
| Rate for Payer: WEA Trust Commercial |
$2,042.04
|
| Rate for Payer: WPS Commercial |
$2,749.97
|
|
|
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 |
$700.92 |
| Max. Negotiated Rate |
$2,303.02 |
| Rate for Payer: Aetna Commercial |
$2,252.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,152.82
|
| Rate for Payer: Aetna Managed Medicare |
$700.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,627.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,251.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,201.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,326.74
|
| Rate for Payer: Cash Price |
$722.10
|
| Rate for Payer: Cigna Commercial |
$2,303.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,400.87
|
| Rate for Payer: Health EOS Commercial |
$2,227.92
|
| Rate for Payer: HFN Commercial |
$2,303.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,877.46
|
| Rate for Payer: Multiplan Commercial |
$2,002.62
|
| Rate for Payer: NAPHCARE Commercial |
$1,501.97
|
| Rate for Payer: Preferred Network Access Commercial |
$2,303.02
|
| Rate for Payer: Quartz Beloit One Network |
$1,226.61
|
| Rate for Payer: Quartz Commercial |
$1,627.13
|
| Rate for Payer: Quartz Medicare Advantage |
$1,501.97
|
| Rate for Payer: The Alliance Commercial |
$1,251.64
|
| Rate for Payer: WEA Trust Commercial |
$1,376.80
|
| Rate for Payer: WPS Commercial |
$1,854.11
|
|
|
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 |
$1,226.61 |
| Max. Negotiated Rate |
$2,303.02 |
| Rate for Payer: Aetna Commercial |
$2,252.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,152.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,326.74
|
| Rate for Payer: Cash Price |
$722.10
|
| Rate for Payer: Cigna Commercial |
$2,303.02
|
| Rate for Payer: Health EOS Commercial |
$2,227.92
|
| Rate for Payer: HFN Commercial |
$2,303.02
|
| Rate for Payer: Multiplan Commercial |
$2,002.62
|
| Rate for Payer: Preferred Network Access Commercial |
$2,303.02
|
| Rate for Payer: Quartz Beloit One Network |
$1,226.61
|
| Rate for Payer: Quartz Commercial |
$1,501.97
|
| Rate for Payer: WEA Trust Commercial |
$1,376.80
|
| Rate for Payer: WPS Commercial |
$1,854.11
|
|
|
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 |
$301.39 |
| Max. Negotiated Rate |
$990.29 |
| Rate for Payer: Aetna Commercial |
$968.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$925.70
|
| Rate for Payer: Aetna Managed Medicare |
$301.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$699.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$538.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$516.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$570.49
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cigna Commercial |
$990.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$602.37
|
| Rate for Payer: Health EOS Commercial |
$958.00
|
| Rate for Payer: HFN Commercial |
$990.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$807.30
|
| Rate for Payer: Multiplan Commercial |
$861.12
|
| Rate for Payer: NAPHCARE Commercial |
$645.84
|
| Rate for Payer: Preferred Network Access Commercial |
$990.29
|
| Rate for Payer: Quartz Beloit One Network |
$527.44
|
| Rate for Payer: Quartz Commercial |
$699.66
|
| Rate for Payer: Quartz Medicare Advantage |
$645.84
|
| Rate for Payer: The Alliance Commercial |
$538.20
|
| Rate for Payer: WEA Trust Commercial |
$592.02
|
| Rate for Payer: WPS Commercial |
$797.26
|
|
|
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 |
$527.44 |
| Max. Negotiated Rate |
$990.29 |
| Rate for Payer: Aetna Commercial |
$968.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$925.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$570.49
|
| Rate for Payer: Cash Price |
$310.50
|
| Rate for Payer: Cigna Commercial |
$990.29
|
| Rate for Payer: Health EOS Commercial |
$958.00
|
| Rate for Payer: HFN Commercial |
$990.29
|
| Rate for Payer: Multiplan Commercial |
$861.12
|
| Rate for Payer: Preferred Network Access Commercial |
$990.29
|
| Rate for Payer: Quartz Beloit One Network |
$527.44
|
| Rate for Payer: Quartz Commercial |
$645.84
|
| Rate for Payer: WEA Trust Commercial |
$592.02
|
| Rate for Payer: WPS Commercial |
$797.26
|
|
|
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 |
$2,024.64 |
| Max. Negotiated Rate |
$3,801.37 |
| Rate for Payer: Aetna Commercial |
$3,718.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,553.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,189.92
|
| Rate for Payer: Cash Price |
$1,191.90
|
| Rate for Payer: Cigna Commercial |
$3,801.37
|
| Rate for Payer: Health EOS Commercial |
$3,677.41
|
| Rate for Payer: HFN Commercial |
$3,801.37
|
| Rate for Payer: Multiplan Commercial |
$3,305.54
|
| Rate for Payer: Preferred Network Access Commercial |
$3,801.37
|
| Rate for Payer: Quartz Beloit One Network |
$2,024.64
|
| Rate for Payer: Quartz Commercial |
$2,479.15
|
| Rate for Payer: WEA Trust Commercial |
$2,272.56
|
| Rate for Payer: WPS Commercial |
$3,060.40
|
|
|
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 |
$1,156.94 |
| Max. Negotiated Rate |
$3,801.37 |
| Rate for Payer: Aetna Commercial |
$3,718.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,553.45
|
| Rate for Payer: Aetna Managed Medicare |
$1,156.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,685.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,065.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,983.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,189.92
|
| Rate for Payer: Cash Price |
$1,191.90
|
| Rate for Payer: Cigna Commercial |
$3,801.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,312.29
|
| Rate for Payer: Health EOS Commercial |
$3,677.41
|
| Rate for Payer: HFN Commercial |
$3,801.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,098.94
|
| Rate for Payer: Multiplan Commercial |
$3,305.54
|
| Rate for Payer: NAPHCARE Commercial |
$2,479.15
|
| Rate for Payer: Preferred Network Access Commercial |
$3,801.37
|
| Rate for Payer: Quartz Beloit One Network |
$2,024.64
|
| Rate for Payer: Quartz Commercial |
$2,685.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,479.15
|
| Rate for Payer: The Alliance Commercial |
$2,065.96
|
| Rate for Payer: WEA Trust Commercial |
$2,272.56
|
| Rate for Payer: WPS Commercial |
$3,060.40
|
|
|
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 |
$804.66 |
| Max. Negotiated Rate |
$1,510.79 |
| Rate for Payer: Aetna Commercial |
$1,477.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,412.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$870.34
|
| Rate for Payer: Cash Price |
$473.70
|
| Rate for Payer: Cigna Commercial |
$1,510.79
|
| Rate for Payer: Health EOS Commercial |
$1,461.52
|
| Rate for Payer: HFN Commercial |
$1,510.79
|
| Rate for Payer: Multiplan Commercial |
$1,313.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,510.79
|
| Rate for Payer: Quartz Beloit One Network |
$804.66
|
| Rate for Payer: Quartz Commercial |
$985.30
|
| Rate for Payer: WEA Trust Commercial |
$903.19
|
| Rate for Payer: WPS Commercial |
$1,216.30
|
|
|
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 |
$459.80 |
| Max. Negotiated Rate |
$1,510.79 |
| Rate for Payer: Aetna Commercial |
$1,477.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,412.26
|
| Rate for Payer: Aetna Managed Medicare |
$459.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,067.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$821.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$788.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$870.34
|
| Rate for Payer: Cash Price |
$473.70
|
| Rate for Payer: Cigna Commercial |
$1,510.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$918.98
|
| Rate for Payer: Health EOS Commercial |
$1,461.52
|
| Rate for Payer: HFN Commercial |
$1,510.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,231.62
|
| Rate for Payer: Multiplan Commercial |
$1,313.73
|
| Rate for Payer: NAPHCARE Commercial |
$985.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,510.79
|
| Rate for Payer: Quartz Beloit One Network |
$804.66
|
| Rate for Payer: Quartz Commercial |
$1,067.40
|
| Rate for Payer: Quartz Medicare Advantage |
$985.30
|
| Rate for Payer: The Alliance Commercial |
$821.08
|
| Rate for Payer: WEA Trust Commercial |
$903.19
|
| Rate for Payer: WPS Commercial |
$1,216.30
|
|
|
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 |
$1,346.87 |
| Max. Negotiated Rate |
$2,528.82 |
| Rate for Payer: Aetna Commercial |
$2,473.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,363.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,456.82
|
| Rate for Payer: Cash Price |
$792.90
|
| Rate for Payer: Cigna Commercial |
$2,528.82
|
| Rate for Payer: Health EOS Commercial |
$2,446.36
|
| Rate for Payer: HFN Commercial |
$2,528.82
|
| Rate for Payer: Multiplan Commercial |
$2,198.98
|
| Rate for Payer: Preferred Network Access Commercial |
$2,528.82
|
| Rate for Payer: Quartz Beloit One Network |
$1,346.87
|
| Rate for Payer: Quartz Commercial |
$1,649.23
|
| Rate for Payer: WEA Trust Commercial |
$1,511.80
|
| Rate for Payer: WPS Commercial |
$2,035.90
|
|
|
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 |
$769.64 |
| Max. Negotiated Rate |
$2,528.82 |
| Rate for Payer: Aetna Commercial |
$2,473.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,363.90
|
| Rate for Payer: Aetna Managed Medicare |
$769.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,786.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,374.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,319.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,456.82
|
| Rate for Payer: Cash Price |
$792.90
|
| Rate for Payer: Cigna Commercial |
$2,528.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,538.23
|
| Rate for Payer: Health EOS Commercial |
$2,446.36
|
| Rate for Payer: HFN Commercial |
$2,528.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,061.54
|
| Rate for Payer: Multiplan Commercial |
$2,198.98
|
| Rate for Payer: NAPHCARE Commercial |
$1,649.23
|
| Rate for Payer: Preferred Network Access Commercial |
$2,528.82
|
| Rate for Payer: Quartz Beloit One Network |
$1,346.87
|
| Rate for Payer: Quartz Commercial |
$1,786.67
|
| Rate for Payer: Quartz Medicare Advantage |
$1,649.23
|
| Rate for Payer: The Alliance Commercial |
$1,374.36
|
| Rate for Payer: WEA Trust Commercial |
$1,511.80
|
| Rate for Payer: WPS Commercial |
$2,035.90
|
|
|
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 |
$920.77 |
| Max. Negotiated Rate |
$3,025.40 |
| Rate for Payer: Aetna Commercial |
$2,959.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,828.09
|
| Rate for Payer: Aetna Managed Medicare |
$920.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,137.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,644.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,578.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,742.89
|
| Rate for Payer: Cash Price |
$948.60
|
| Rate for Payer: Cigna Commercial |
$3,025.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,840.28
|
| Rate for Payer: Health EOS Commercial |
$2,926.75
|
| Rate for Payer: HFN Commercial |
$3,025.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,466.36
|
| Rate for Payer: Multiplan Commercial |
$2,630.78
|
| Rate for Payer: NAPHCARE Commercial |
$1,973.09
|
| Rate for Payer: Preferred Network Access Commercial |
$3,025.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,611.36
|
| Rate for Payer: Quartz Commercial |
$2,137.51
|
| Rate for Payer: Quartz Medicare Advantage |
$1,973.09
|
| Rate for Payer: The Alliance Commercial |
$1,644.24
|
| Rate for Payer: WEA Trust Commercial |
$1,808.66
|
| Rate for Payer: WPS Commercial |
$2,435.69
|
|
|
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 |
$1,611.36 |
| Max. Negotiated Rate |
$3,025.40 |
| Rate for Payer: Aetna Commercial |
$2,959.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,828.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,742.89
|
| Rate for Payer: Cash Price |
$948.60
|
| Rate for Payer: Cigna Commercial |
$3,025.40
|
| Rate for Payer: Health EOS Commercial |
$2,926.75
|
| Rate for Payer: HFN Commercial |
$3,025.40
|
| Rate for Payer: Multiplan Commercial |
$2,630.78
|
| Rate for Payer: Preferred Network Access Commercial |
$3,025.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,611.36
|
| Rate for Payer: Quartz Commercial |
$1,973.09
|
| Rate for Payer: WEA Trust Commercial |
$1,808.66
|
| Rate for Payer: WPS Commercial |
$2,435.69
|
|
