|
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 |
$304.89 |
| Max. Negotiated Rate |
$1,001.77 |
| Rate for Payer: Aetna Commercial |
$979.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$936.44
|
| Rate for Payer: Aetna Managed Medicare |
$304.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$707.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$544.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$522.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$577.11
|
| Rate for Payer: Cash Price |
$314.10
|
| Rate for Payer: Cigna Commercial |
$1,001.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$609.35
|
| Rate for Payer: Health EOS Commercial |
$969.10
|
| Rate for Payer: HFN Commercial |
$1,001.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$816.66
|
| Rate for Payer: Multiplan Commercial |
$871.10
|
| Rate for Payer: NAPHCARE Commercial |
$653.33
|
| Rate for Payer: Preferred Network Access Commercial |
$1,001.77
|
| Rate for Payer: Quartz Beloit One Network |
$533.55
|
| Rate for Payer: Quartz Commercial |
$707.77
|
| Rate for Payer: Quartz Medicare Advantage |
$653.33
|
| Rate for Payer: The Alliance Commercial |
$544.44
|
| Rate for Payer: WEA Trust Commercial |
$598.88
|
| Rate for Payer: WPS Commercial |
$806.50
|
|
|
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 |
$533.55 |
| Max. Negotiated Rate |
$1,001.77 |
| Rate for Payer: Aetna Commercial |
$979.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$936.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$577.11
|
| Rate for Payer: Cash Price |
$314.10
|
| Rate for Payer: Cigna Commercial |
$1,001.77
|
| Rate for Payer: Health EOS Commercial |
$969.10
|
| Rate for Payer: HFN Commercial |
$1,001.77
|
| Rate for Payer: Multiplan Commercial |
$871.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,001.77
|
| Rate for Payer: Quartz Beloit One Network |
$533.55
|
| Rate for Payer: Quartz Commercial |
$653.33
|
| Rate for Payer: WEA Trust Commercial |
$598.88
|
| Rate for Payer: WPS Commercial |
$806.50
|
|
|
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 |
$1,499.75 |
| Max. Negotiated Rate |
$2,815.86 |
| Rate for Payer: Aetna Commercial |
$2,754.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,632.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,622.18
|
| Rate for Payer: Cash Price |
$882.90
|
| Rate for Payer: Cigna Commercial |
$2,815.86
|
| Rate for Payer: Health EOS Commercial |
$2,724.04
|
| Rate for Payer: HFN Commercial |
$2,815.86
|
| Rate for Payer: Multiplan Commercial |
$2,448.58
|
| Rate for Payer: Preferred Network Access Commercial |
$2,815.86
|
| Rate for Payer: Quartz Beloit One Network |
$1,499.75
|
| Rate for Payer: Quartz Commercial |
$1,836.43
|
| Rate for Payer: WEA Trust Commercial |
$1,683.40
|
| Rate for Payer: WPS Commercial |
$2,266.99
|
|
|
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 |
$857.00 |
| Max. Negotiated Rate |
$2,815.86 |
| Rate for Payer: Aetna Commercial |
$2,754.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,632.22
|
| Rate for Payer: Aetna Managed Medicare |
$857.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,989.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,530.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,469.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,622.18
|
| Rate for Payer: Cash Price |
$882.90
|
| Rate for Payer: Cigna Commercial |
$2,815.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,712.83
|
| Rate for Payer: Health EOS Commercial |
$2,724.04
|
| Rate for Payer: HFN Commercial |
$2,815.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,295.54
|
| Rate for Payer: Multiplan Commercial |
$2,448.58
|
| Rate for Payer: NAPHCARE Commercial |
$1,836.43
|
| Rate for Payer: Preferred Network Access Commercial |
$2,815.86
|
| Rate for Payer: Quartz Beloit One Network |
$1,499.75
|
| Rate for Payer: Quartz Commercial |
$1,989.47
|
| Rate for Payer: Quartz Medicare Advantage |
$1,836.43
|
| Rate for Payer: The Alliance Commercial |
$1,530.36
|
| Rate for Payer: WEA Trust Commercial |
$1,683.40
|
| Rate for Payer: WPS Commercial |
$2,266.99
|
|
|
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 |
$1,774.43 |
| Max. Negotiated Rate |
$3,331.58 |
| Rate for Payer: Aetna Commercial |
$3,259.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,114.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,919.28
|
| Rate for Payer: Cash Price |
$1,044.60
|
| Rate for Payer: Cigna Commercial |
$3,331.58
|
| Rate for Payer: Health EOS Commercial |
$3,222.94
|
| Rate for Payer: HFN Commercial |
$3,331.58
|
| Rate for Payer: Multiplan Commercial |
$2,897.02
|
| Rate for Payer: Preferred Network Access Commercial |
$3,331.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,774.43
|
| Rate for Payer: Quartz Commercial |
$2,172.77
|
| Rate for Payer: WEA Trust Commercial |
$1,991.70
|
| Rate for Payer: WPS Commercial |
$2,682.18
|
|
|
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 |
$1,013.96 |
| Max. Negotiated Rate |
$3,331.58 |
| Rate for Payer: Aetna Commercial |
$3,259.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,114.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,013.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,353.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,810.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,738.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,919.28
|
| Rate for Payer: Cash Price |
$1,044.60
|
| Rate for Payer: Cigna Commercial |
$3,331.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,026.52
|
| Rate for Payer: Health EOS Commercial |
$3,222.94
|
| Rate for Payer: HFN Commercial |
$3,331.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,715.96
|
| Rate for Payer: Multiplan Commercial |
$2,897.02
|
| Rate for Payer: NAPHCARE Commercial |
$2,172.77
|
| Rate for Payer: Preferred Network Access Commercial |
$3,331.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,774.43
|
| Rate for Payer: Quartz Commercial |
$2,353.83
|
| Rate for Payer: Quartz Medicare Advantage |
$2,172.77
|
| Rate for Payer: The Alliance Commercial |
$1,810.64
|
| Rate for Payer: United Healthcare PPO |
$2,715.96
|
| Rate for Payer: WEA Trust Commercial |
$1,991.70
|
| Rate for Payer: WPS Commercial |
$2,682.18
|
|
|
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 |
$433.31 |
| Max. Negotiated Rate |
$1,423.72 |
| Rate for Payer: Aetna Commercial |
$1,392.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,330.87
|
| Rate for Payer: Aetna Managed Medicare |
$433.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,005.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$773.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$742.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$820.19
|
| Rate for Payer: Cash Price |
$446.40
|
| Rate for Payer: Cigna Commercial |
$1,423.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$866.02
|
| Rate for Payer: Health EOS Commercial |
$1,377.29
|
| Rate for Payer: HFN Commercial |
$1,423.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,160.64
|
| Rate for Payer: Multiplan Commercial |
$1,238.02
|
| Rate for Payer: NAPHCARE Commercial |
$928.51
|
| Rate for Payer: Preferred Network Access Commercial |
$1,423.72
|
| Rate for Payer: Quartz Beloit One Network |
$758.28
|
| Rate for Payer: Quartz Commercial |
$1,005.89
|
| Rate for Payer: Quartz Medicare Advantage |
$928.51
|
| Rate for Payer: The Alliance Commercial |
$773.76
|
| Rate for Payer: WEA Trust Commercial |
$851.14
|
| Rate for Payer: WPS Commercial |
$1,146.21
|
|
|
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 |
$758.28 |
| Max. Negotiated Rate |
$1,423.72 |
| Rate for Payer: Aetna Commercial |
$1,392.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,330.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$820.19
|
| Rate for Payer: Cash Price |
$446.40
|
| Rate for Payer: Cigna Commercial |
$1,423.72
|
| Rate for Payer: Health EOS Commercial |
$1,377.29
|
| Rate for Payer: HFN Commercial |
$1,423.72
|
| Rate for Payer: Multiplan Commercial |
$1,238.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,423.72
|
| Rate for Payer: Quartz Beloit One Network |
$758.28
|
| Rate for Payer: Quartz Commercial |
$928.51
|
| Rate for Payer: WEA Trust Commercial |
$851.14
|
| Rate for Payer: WPS Commercial |
$1,146.21
|
|
|
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 |
$3,061.17 |
| Max. Negotiated Rate |
$5,747.50 |
| Rate for Payer: Aetna Commercial |
$5,622.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,372.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,311.06
|
| Rate for Payer: Cash Price |
$1,802.10
|
| Rate for Payer: Cigna Commercial |
$5,747.50
|
| Rate for Payer: Health EOS Commercial |
$5,560.08
|
| Rate for Payer: HFN Commercial |
$5,747.50
|
| Rate for Payer: Multiplan Commercial |
$4,997.82
|
| Rate for Payer: Preferred Network Access Commercial |
$5,747.50
|
| Rate for Payer: Quartz Beloit One Network |
$3,061.17
|
| Rate for Payer: Quartz Commercial |
$3,748.37
|
| Rate for Payer: WEA Trust Commercial |
$3,436.00
|
| Rate for Payer: WPS Commercial |
$4,627.19
|
|
|
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 |
$1,749.24 |
| Max. Negotiated Rate |
$5,747.50 |
| Rate for Payer: Aetna Commercial |
$5,622.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,372.66
|
| Rate for Payer: Aetna Managed Medicare |
$1,749.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,060.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,123.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,998.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,311.06
|
| Rate for Payer: Cash Price |
$1,802.10
|
| Rate for Payer: Cigna Commercial |
$5,747.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,496.07
|
| Rate for Payer: Health EOS Commercial |
$5,560.08
|
| Rate for Payer: HFN Commercial |
$5,747.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,685.46
|
| Rate for Payer: Multiplan Commercial |
$4,997.82
|
| Rate for Payer: NAPHCARE Commercial |
$3,748.37
|
| Rate for Payer: Preferred Network Access Commercial |
$5,747.50
|
| Rate for Payer: Quartz Beloit One Network |
$3,061.17
|
| Rate for Payer: Quartz Commercial |
$4,060.73
|
| Rate for Payer: Quartz Medicare Advantage |
$3,748.37
|
| Rate for Payer: The Alliance Commercial |
$3,123.64
|
| Rate for Payer: WEA Trust Commercial |
$3,436.00
|
| Rate for Payer: WPS Commercial |
$4,627.19
|
|
|
BONE CONDUCTION HEARING DEVICE IMPLANTATION
|
Facility
|
OP
|
$2,445.02
|
|
|
Service Code
|
EAPG 03011
|
| Min. Negotiated Rate |
$2,350.97 |
| Max. Negotiated Rate |
$2,445.02 |
| Rate for Payer: Anthem Medicaid |
$2,350.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$2,350.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,350.97
|
| Rate for Payer: Dean Health Medicaid |
$2,350.97
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$2,350.97
|
| Rate for Payer: Managed Health Services Medicaid |
$2,445.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,350.97
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$2,350.97
|
| Rate for Payer: United Healthcare Medicaid |
$2,350.97
|
|
|
BONE DENSITY AND RELATED PROCEDURES
|
Facility
|
OP
|
$117.93
|
|
|
Service Code
|
EAPG 00291
|
| Min. Negotiated Rate |
$113.39 |
| Max. Negotiated Rate |
$117.93 |
| Rate for Payer: Anthem Medicaid |
$113.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$113.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$113.39
|
| Rate for Payer: Dean Health Medicaid |
$113.39
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$113.39
|
| Rate for Payer: Managed Health Services Medicaid |
$117.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$113.39
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$113.39
|
| Rate for Payer: United Healthcare Medicaid |
$113.39
|
|
|
BONE DISEASES AND ARTHROPATHIES WITH MCC
|
Facility
|
IP
|
$37,701.04
|
|
|
Service Code
|
MSDRG 553
|
| Min. Negotiated Rate |
$10,434.10 |
| Max. Negotiated Rate |
$37,701.04 |
| Rate for Payer: Aetna Managed Medicare |
$10,434.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28,284.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21,679.63
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,597.07
|
| Rate for Payer: Anthem Medicare Advantage |
$10,434.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,434.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,434.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,434.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22,864.63
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,434.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27,408.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,434.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,434.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,434.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,434.10
|
| Rate for Payer: NAPHCARE Commercial |
$15,651.15
|
| Rate for Payer: Quartz Medicare Advantage |
$10,434.10
|
| Rate for Payer: The Alliance Commercial |
$37,701.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,434.10
|
| Rate for Payer: United Healthcare PPO |
$21,337.80
|
| Rate for Payer: Wellcare Medicare |
$10,434.10
|
|
|
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC
|
Facility
|
IP
|
$23,055.76
|
|
|
Service Code
|
MSDRG 554
|
| Min. Negotiated Rate |
$6,863.84 |
| Max. Negotiated Rate |
$23,055.76 |
| Rate for Payer: Aetna Managed Medicare |
$6,863.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,112.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,882.79
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,189.56
|
| Rate for Payer: Anthem Medicare Advantage |
$6,863.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,863.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,863.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,863.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,641.62
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,863.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,666.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,863.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,863.84
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,863.84
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,863.84
|
| Rate for Payer: NAPHCARE Commercial |
$10,295.77
|
| Rate for Payer: Quartz Medicare Advantage |
$6,863.84
|
| Rate for Payer: The Alliance Commercial |
$23,055.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,863.84
|
| Rate for Payer: United Healthcare PPO |
$12,974.78
|
| Rate for Payer: Wellcare Medicare |
$6,863.84
|
|
|
BONE FILLER OSTEOVATION EX
|
Facility
|
OP
|
$1,212.00
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
2965443
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$352.93 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Aetna Managed Medicare |
$352.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$819.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$630.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$605.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$705.38
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$945.36
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: NAPHCARE Commercial |
$756.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$819.31
|
| Rate for Payer: Quartz Medicare Advantage |
$756.29
|
| Rate for Payer: The Alliance Commercial |
$630.24
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
BONE FILLER OSTEOVATION EX
|
Facility
|
IP
|
$1,212.00
|
|
|
Service Code
|
HCPCS C9359
|
| Hospital Charge Code |
2965443
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$617.64 |
| Max. Negotiated Rate |
$1,159.64 |
| Rate for Payer: Aetna Commercial |
$1,134.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,084.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$668.05
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,159.64
|
| Rate for Payer: Health EOS Commercial |
$1,121.83
|
| Rate for Payer: HFN Commercial |
$1,159.64
|
| Rate for Payer: Multiplan Commercial |
$1,008.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,159.64
|
| Rate for Payer: Quartz Beloit One Network |
$617.64
|
| Rate for Payer: Quartz Commercial |
$756.29
|
| Rate for Payer: WEA Trust Commercial |
$693.26
|
| Rate for Payer: WPS Commercial |
$933.60
|
|
|
BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE
|
Facility
|
OP
|
$30,545.47
|
|
|
Service Code
|
CPT 20902
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,636.37 |
| Max. Negotiated Rate |
$30,545.47 |
| Rate for Payer: Aetna Managed Medicare |
$7,636.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,182.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,724.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,889.12
|
| Rate for Payer: Anthem Medicare Advantage |
$7,636.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,636.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,636.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,636.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,107.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,636.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,407.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,636.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,636.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,636.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,636.37
|
| Rate for Payer: NAPHCARE Commercial |
$11,454.55
|
| Rate for Payer: Quartz Medicare Advantage |
$7,636.37
|
| Rate for Payer: The Alliance Commercial |
$30,545.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,636.37
|
| Rate for Payer: United Healthcare PPO |
$8,790.08
|
| Rate for Payer: Wellcare Medicare |
$7,636.37
|
|
|
BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)
|
Facility
|
OP
|
$30,545.47
|
|
|
Service Code
|
CPT 20900
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,807.99 |
| Max. Negotiated Rate |
$30,545.47 |
| Rate for Payer: Aetna Managed Medicare |
$7,636.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,182.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,724.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,889.12
|
| Rate for Payer: Anthem Medicare Advantage |
$7,636.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,636.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,636.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,636.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,807.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,636.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,407.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,636.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,636.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,636.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,636.37
|
| Rate for Payer: NAPHCARE Commercial |
$11,454.55
|
| Rate for Payer: Quartz Medicare Advantage |
$7,636.37
|
| Rate for Payer: The Alliance Commercial |
$30,545.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,636.37
|
| Rate for Payer: United Healthcare PPO |
$8,790.08
|
| Rate for Payer: Wellcare Medicare |
$7,636.37
|
|
|
BONE GRAFT DRILL 12MM BG-8030-S
|
Facility
|
OP
|
$5,546.00
|
|
| Hospital Charge Code |
5458681
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,615.00 |
| Max. Negotiated Rate |
$5,306.41 |
| Rate for Payer: Aetna Commercial |
$5,191.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,960.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,615.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,749.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,883.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,768.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,056.96
|
| Rate for Payer: Cash Price |
$1,663.80
|
| Rate for Payer: Cigna Commercial |
$5,306.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,227.77
|
| Rate for Payer: Health EOS Commercial |
$5,133.38
|
| Rate for Payer: HFN Commercial |
$5,306.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,325.88
|
| Rate for Payer: Multiplan Commercial |
$4,614.27
|
| Rate for Payer: NAPHCARE Commercial |
$3,460.70
|
| Rate for Payer: Preferred Network Access Commercial |
$5,306.41
|
| Rate for Payer: Quartz Beloit One Network |
$2,826.24
|
| Rate for Payer: Quartz Commercial |
$3,749.10
|
| Rate for Payer: Quartz Medicare Advantage |
$3,460.70
|
| Rate for Payer: The Alliance Commercial |
$2,883.92
|
| Rate for Payer: WEA Trust Commercial |
$3,172.31
|
| Rate for Payer: WPS Commercial |
$4,272.08
|
|
|
BONE GRAFT DRILL 12MM BG-8030-S
|
Facility
|
IP
|
$5,546.00
|
|
| Hospital Charge Code |
5458681
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,826.24 |
| Max. Negotiated Rate |
$5,306.41 |
| Rate for Payer: Aetna Commercial |
$5,191.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,960.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,056.96
|
| Rate for Payer: Cash Price |
$1,663.80
|
| Rate for Payer: Cigna Commercial |
$5,306.41
|
| Rate for Payer: Health EOS Commercial |
$5,133.38
|
| Rate for Payer: HFN Commercial |
$5,306.41
|
| Rate for Payer: Multiplan Commercial |
$4,614.27
|
| Rate for Payer: Preferred Network Access Commercial |
$5,306.41
|
| Rate for Payer: Quartz Beloit One Network |
$2,826.24
|
| Rate for Payer: Quartz Commercial |
$3,460.70
|
| Rate for Payer: WEA Trust Commercial |
$3,172.31
|
| Rate for Payer: WPS Commercial |
$4,272.08
|
|
|
BONE GRAFT DRILL 6MM BG-8006-S
|
Facility
|
IP
|
$5,999.00
|
|
| Hospital Charge Code |
5458712
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,057.09 |
| Max. Negotiated Rate |
$5,739.84 |
| Rate for Payer: Aetna Commercial |
$5,615.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,365.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,306.65
|
| Rate for Payer: Cash Price |
$1,799.70
|
| Rate for Payer: Cigna Commercial |
$5,739.84
|
| Rate for Payer: Health EOS Commercial |
$5,552.67
|
| Rate for Payer: HFN Commercial |
$5,739.84
|
| Rate for Payer: Multiplan Commercial |
$4,991.17
|
| Rate for Payer: Preferred Network Access Commercial |
$5,739.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,057.09
|
| Rate for Payer: Quartz Commercial |
$3,743.38
|
| Rate for Payer: WEA Trust Commercial |
$3,431.43
|
| Rate for Payer: WPS Commercial |
$4,621.03
|
|
|
BONE GRAFT DRILL 6MM BG-8006-S
|
Facility
|
OP
|
$5,999.00
|
|
| Hospital Charge Code |
5458712
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,746.91 |
| Max. Negotiated Rate |
$5,739.84 |
| Rate for Payer: Aetna Commercial |
$5,615.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,365.51
|
| Rate for Payer: Aetna Managed Medicare |
$1,746.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,055.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,119.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,994.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,306.65
|
| Rate for Payer: Cash Price |
$1,799.70
|
| Rate for Payer: Cigna Commercial |
$5,739.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,491.42
|
| Rate for Payer: Health EOS Commercial |
$5,552.67
|
| Rate for Payer: HFN Commercial |
$5,739.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,679.22
|
| Rate for Payer: Multiplan Commercial |
$4,991.17
|
| Rate for Payer: NAPHCARE Commercial |
$3,743.38
|
| Rate for Payer: Preferred Network Access Commercial |
$5,739.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,057.09
|
| Rate for Payer: Quartz Commercial |
$4,055.32
|
| Rate for Payer: Quartz Medicare Advantage |
$3,743.38
|
| Rate for Payer: The Alliance Commercial |
$3,119.48
|
| Rate for Payer: WEA Trust Commercial |
$3,431.43
|
| Rate for Payer: WPS Commercial |
$4,621.03
|
|
|
BONE GRAFT DRILL 8MM BG-8010-S
|
Facility
|
OP
|
$5,768.00
|
|
| Hospital Charge Code |
5458682
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,679.64 |
| Max. Negotiated Rate |
$5,518.82 |
| Rate for Payer: Aetna Commercial |
$5,398.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,158.90
|
| Rate for Payer: Aetna Managed Medicare |
$1,679.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,899.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,999.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,879.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,179.32
|
| Rate for Payer: Cash Price |
$1,730.40
|
| Rate for Payer: Cigna Commercial |
$5,518.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,356.98
|
| Rate for Payer: Health EOS Commercial |
$5,338.86
|
| Rate for Payer: HFN Commercial |
$5,518.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,499.04
|
| Rate for Payer: Multiplan Commercial |
$4,798.98
|
| Rate for Payer: NAPHCARE Commercial |
$3,599.23
|
| Rate for Payer: Preferred Network Access Commercial |
$5,518.82
|
| Rate for Payer: Quartz Beloit One Network |
$2,939.37
|
| Rate for Payer: Quartz Commercial |
$3,899.17
|
| Rate for Payer: Quartz Medicare Advantage |
$3,599.23
|
| Rate for Payer: The Alliance Commercial |
$2,999.36
|
| Rate for Payer: WEA Trust Commercial |
$3,299.30
|
| Rate for Payer: WPS Commercial |
$4,443.09
|
|
|
BONE GRAFT DRILL 8MM BG-8010-S
|
Facility
|
IP
|
$5,768.00
|
|
| Hospital Charge Code |
5458682
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,939.37 |
| Max. Negotiated Rate |
$5,518.82 |
| Rate for Payer: Aetna Commercial |
$5,398.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,158.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,179.32
|
| Rate for Payer: Cash Price |
$1,730.40
|
| Rate for Payer: Cigna Commercial |
$5,518.82
|
| Rate for Payer: Health EOS Commercial |
$5,338.86
|
| Rate for Payer: HFN Commercial |
$5,518.82
|
| Rate for Payer: Multiplan Commercial |
$4,798.98
|
| Rate for Payer: Preferred Network Access Commercial |
$5,518.82
|
| Rate for Payer: Quartz Beloit One Network |
$2,939.37
|
| Rate for Payer: Quartz Commercial |
$3,599.23
|
| Rate for Payer: WEA Trust Commercial |
$3,299.30
|
| Rate for Payer: WPS Commercial |
$4,443.09
|
|
|
BONE GRAFT SUBSTITUTE 2102-2201
|
Facility
|
IP
|
$5,548.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5685829
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,827.26 |
| Max. Negotiated Rate |
$5,308.33 |
| Rate for Payer: Aetna Commercial |
$5,192.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,962.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,058.06
|
| Rate for Payer: Cash Price |
$1,664.40
|
| Rate for Payer: Cigna Commercial |
$5,308.33
|
| Rate for Payer: Health EOS Commercial |
$5,135.23
|
| Rate for Payer: HFN Commercial |
$5,308.33
|
| Rate for Payer: Multiplan Commercial |
$4,615.94
|
| Rate for Payer: Preferred Network Access Commercial |
$5,308.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,827.26
|
| Rate for Payer: Quartz Commercial |
$3,461.95
|
| Rate for Payer: WEA Trust Commercial |
$3,173.46
|
| Rate for Payer: WPS Commercial |
$4,273.62
|
|
