|
COMPRESSION PLATE 5.0 BROAD 11 HL 627571
|
Facility
OP
|
$9,835.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6175223
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,753.80 |
| Max. Negotiated Rate |
$9,048.20 |
| Rate for Payer: Aetna Commercial |
$8,851.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,458.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,753.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,392.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,917.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,720.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,212.55
|
| Rate for Payer: Cash Price |
$2,950.50
|
| Rate for Payer: Cigna Commercial |
$9,048.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,503.67
|
| Rate for Payer: Health EOS Commercial |
$8,753.15
|
| Rate for Payer: HFN Commercial |
$9,048.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,376.25
|
| Rate for Payer: Multiplan Commercial |
$7,868.00
|
| Rate for Payer: NAPHCARE Commercial |
$5,901.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9,048.20
|
| Rate for Payer: Quartz Beloit One Network |
$4,819.15
|
| Rate for Payer: Quartz Commercial |
$6,392.75
|
| Rate for Payer: Quartz Medicare Advantage |
$5,901.00
|
| Rate for Payer: WEA Trust Commercial |
$5,409.25
|
| Rate for Payer: WPS Commercial |
$7,284.78
|
|
|
COMPRESSION SCREW 32.3MM OMEGA 596001S
|
Facility
IP
|
$894.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
5459544
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$438.06 |
| Max. Negotiated Rate |
$822.48 |
| Rate for Payer: Aetna Commercial |
$804.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$473.82
|
| Rate for Payer: Cash Price |
$268.20
|
| Rate for Payer: Cigna Commercial |
$822.48
|
| Rate for Payer: Health EOS Commercial |
$795.66
|
| Rate for Payer: HFN Commercial |
$822.48
|
| Rate for Payer: Multiplan Commercial |
$715.20
|
| Rate for Payer: NAPHCARE Commercial |
$536.40
|
| Rate for Payer: Preferred Network Access Commercial |
$822.48
|
| Rate for Payer: Quartz Beloit One Network |
$438.06
|
| Rate for Payer: Quartz Commercial |
$536.40
|
| Rate for Payer: WEA Trust Commercial |
$491.70
|
| Rate for Payer: WPS Commercial |
$662.19
|
|
|
COMPRESSION SCREW 32.3MM OMEGA 596001S
|
Facility
OP
|
$894.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
5459544
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$250.32 |
| Max. Negotiated Rate |
$1,196.24 |
| Rate for Payer: Aetna Commercial |
$804.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$768.84
|
| Rate for Payer: Aetna Managed Medicare |
$250.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$581.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$447.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$429.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$473.82
|
| Rate for Payer: Cash Price |
$268.20
|
| Rate for Payer: Cash Price |
$268.20
|
| Rate for Payer: Cigna Commercial |
$822.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$500.28
|
| Rate for Payer: Health EOS Commercial |
$795.66
|
| Rate for Payer: HFN Commercial |
$822.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$670.50
|
| Rate for Payer: Multiplan Commercial |
$715.20
|
| Rate for Payer: NAPHCARE Commercial |
$536.40
|
| Rate for Payer: Preferred Network Access Commercial |
$822.48
|
| Rate for Payer: Quartz Beloit One Network |
$438.06
|
| Rate for Payer: Quartz Commercial |
$581.10
|
| Rate for Payer: Quartz Medicare Advantage |
$536.40
|
| Rate for Payer: The Alliance Commercial |
$1,196.24
|
| Rate for Payer: WEA Trust Commercial |
$491.70
|
| Rate for Payer: WPS Commercial |
$662.19
|
|
|
COMPRESSION SCREW/LOCKING CAP KIT 4.5 X 18MM SCREW WHITE EQUINOXE REVERSE SHOULDER 320-20-18
|
Facility
IP
|
$1,137.89
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6248144
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$557.57 |
| Max. Negotiated Rate |
$1,046.86 |
| Rate for Payer: Aetna Commercial |
$1,024.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$603.08
|
| Rate for Payer: Cash Price |
$341.37
|
| Rate for Payer: Cigna Commercial |
$1,046.86
|
| Rate for Payer: Health EOS Commercial |
$1,012.72
|
| Rate for Payer: HFN Commercial |
$1,046.86
|
| Rate for Payer: Multiplan Commercial |
$910.31
|
| Rate for Payer: NAPHCARE Commercial |
$682.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.86
|
| Rate for Payer: Quartz Beloit One Network |
$557.57
|
| Rate for Payer: Quartz Commercial |
$682.73
|
| Rate for Payer: WEA Trust Commercial |
$625.84
|
| Rate for Payer: WPS Commercial |
$842.84
|
|
|
COMPRESSION SCREW/LOCKING CAP KIT 4.5 X 18MM SCREW WHITE EQUINOXE REVERSE SHOULDER 320-20-18
|
Facility
OP
|
$1,137.89
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6248144
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$318.61 |
| Max. Negotiated Rate |
$1,046.86 |
| Rate for Payer: Aetna Commercial |
$1,024.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$978.59
|
| Rate for Payer: Aetna Managed Medicare |
$318.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$739.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$568.94
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$546.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$603.08
|
| Rate for Payer: Cash Price |
$341.37
|
| Rate for Payer: Cigna Commercial |
$1,046.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$636.76
|
| Rate for Payer: Health EOS Commercial |
$1,012.72
|
| Rate for Payer: HFN Commercial |
$1,046.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$853.42
|
| Rate for Payer: Multiplan Commercial |
$910.31
|
| Rate for Payer: NAPHCARE Commercial |
$682.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.86
|
| Rate for Payer: Quartz Beloit One Network |
$557.57
|
| Rate for Payer: Quartz Commercial |
$739.63
|
| Rate for Payer: Quartz Medicare Advantage |
$682.73
|
| Rate for Payer: WEA Trust Commercial |
$625.84
|
| Rate for Payer: WPS Commercial |
$842.84
|
|
|
COMPRESSION SCREW/LOCKING CAP KIT 4.5 X 22MM SCREW BLACK EQUINOXE REVERSE SHOULDER 320-20-22
|
Facility
OP
|
$1,137.89
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6240159
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$318.61 |
| Max. Negotiated Rate |
$1,046.86 |
| Rate for Payer: Aetna Commercial |
$1,024.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$978.59
|
| Rate for Payer: Aetna Managed Medicare |
$318.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$739.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$568.94
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$546.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$603.08
|
| Rate for Payer: Cash Price |
$341.37
|
| Rate for Payer: Cigna Commercial |
$1,046.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$636.76
|
| Rate for Payer: Health EOS Commercial |
$1,012.72
|
| Rate for Payer: HFN Commercial |
$1,046.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$853.42
|
| Rate for Payer: Multiplan Commercial |
$910.31
|
| Rate for Payer: NAPHCARE Commercial |
$682.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.86
|
| Rate for Payer: Quartz Beloit One Network |
$557.57
|
| Rate for Payer: Quartz Commercial |
$739.63
|
| Rate for Payer: Quartz Medicare Advantage |
$682.73
|
| Rate for Payer: WEA Trust Commercial |
$625.84
|
| Rate for Payer: WPS Commercial |
$842.84
|
|
|
COMPRESSION SCREW/LOCKING CAP KIT 4.5 X 22MM SCREW BLACK EQUINOXE REVERSE SHOULDER 320-20-22
|
Facility
IP
|
$1,137.89
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6240159
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$557.57 |
| Max. Negotiated Rate |
$1,046.86 |
| Rate for Payer: Aetna Commercial |
$1,024.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$603.08
|
| Rate for Payer: Cash Price |
$341.37
|
| Rate for Payer: Cigna Commercial |
$1,046.86
|
| Rate for Payer: Health EOS Commercial |
$1,012.72
|
| Rate for Payer: HFN Commercial |
$1,046.86
|
| Rate for Payer: Multiplan Commercial |
$910.31
|
| Rate for Payer: NAPHCARE Commercial |
$682.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.86
|
| Rate for Payer: Quartz Beloit One Network |
$557.57
|
| Rate for Payer: Quartz Commercial |
$682.73
|
| Rate for Payer: WEA Trust Commercial |
$625.84
|
| Rate for Payer: WPS Commercial |
$842.84
|
|
|
COMPRESSION SCREW/LOCKING CAP KIT 4.5 X 30MM SCREW BLUE EQUINOXE REVERSE SHOULDER 320-20-30
|
Facility
OP
|
$1,137.89
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6248145
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$318.61 |
| Max. Negotiated Rate |
$1,046.86 |
| Rate for Payer: Aetna Commercial |
$1,024.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$978.59
|
| Rate for Payer: Aetna Managed Medicare |
$318.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$739.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$568.94
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$546.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$603.08
|
| Rate for Payer: Cash Price |
$341.37
|
| Rate for Payer: Cigna Commercial |
$1,046.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$636.76
|
| Rate for Payer: Health EOS Commercial |
$1,012.72
|
| Rate for Payer: HFN Commercial |
$1,046.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$853.42
|
| Rate for Payer: Multiplan Commercial |
$910.31
|
| Rate for Payer: NAPHCARE Commercial |
$682.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.86
|
| Rate for Payer: Quartz Beloit One Network |
$557.57
|
| Rate for Payer: Quartz Commercial |
$739.63
|
| Rate for Payer: Quartz Medicare Advantage |
$682.73
|
| Rate for Payer: WEA Trust Commercial |
$625.84
|
| Rate for Payer: WPS Commercial |
$842.84
|
|
|
COMPRESSION SCREW/LOCKING CAP KIT 4.5 X 30MM SCREW BLUE EQUINOXE REVERSE SHOULDER 320-20-30
|
Facility
IP
|
$1,137.89
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6248145
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$557.57 |
| Max. Negotiated Rate |
$1,046.86 |
| Rate for Payer: Aetna Commercial |
$1,024.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$603.08
|
| Rate for Payer: Cash Price |
$341.37
|
| Rate for Payer: Cigna Commercial |
$1,046.86
|
| Rate for Payer: Health EOS Commercial |
$1,012.72
|
| Rate for Payer: HFN Commercial |
$1,046.86
|
| Rate for Payer: Multiplan Commercial |
$910.31
|
| Rate for Payer: NAPHCARE Commercial |
$682.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.86
|
| Rate for Payer: Quartz Beloit One Network |
$557.57
|
| Rate for Payer: Quartz Commercial |
$682.73
|
| Rate for Payer: WEA Trust Commercial |
$625.84
|
| Rate for Payer: WPS Commercial |
$842.84
|
|
|
COMPRESSION SCREW/LOCKING CAP KIT 4.5 X 34MM SCREW RED EQUINOXE REVERSE SHOULDER 320-20-34
|
Facility
IP
|
$1,137.89
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6240157
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$557.57 |
| Max. Negotiated Rate |
$1,046.86 |
| Rate for Payer: Aetna Commercial |
$1,024.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$603.08
|
| Rate for Payer: Cash Price |
$341.37
|
| Rate for Payer: Cigna Commercial |
$1,046.86
|
| Rate for Payer: Health EOS Commercial |
$1,012.72
|
| Rate for Payer: HFN Commercial |
$1,046.86
|
| Rate for Payer: Multiplan Commercial |
$910.31
|
| Rate for Payer: NAPHCARE Commercial |
$682.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.86
|
| Rate for Payer: Quartz Beloit One Network |
$557.57
|
| Rate for Payer: Quartz Commercial |
$682.73
|
| Rate for Payer: WEA Trust Commercial |
$625.84
|
| Rate for Payer: WPS Commercial |
$842.84
|
|
|
COMPRESSION SCREW/LOCKING CAP KIT 4.5 X 34MM SCREW RED EQUINOXE REVERSE SHOULDER 320-20-34
|
Facility
OP
|
$1,137.89
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6240157
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$318.61 |
| Max. Negotiated Rate |
$1,046.86 |
| Rate for Payer: Aetna Commercial |
$1,024.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$978.59
|
| Rate for Payer: Aetna Managed Medicare |
$318.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$739.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$568.94
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$546.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$603.08
|
| Rate for Payer: Cash Price |
$341.37
|
| Rate for Payer: Cigna Commercial |
$1,046.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$636.76
|
| Rate for Payer: Health EOS Commercial |
$1,012.72
|
| Rate for Payer: HFN Commercial |
$1,046.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$853.42
|
| Rate for Payer: Multiplan Commercial |
$910.31
|
| Rate for Payer: NAPHCARE Commercial |
$682.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.86
|
| Rate for Payer: Quartz Beloit One Network |
$557.57
|
| Rate for Payer: Quartz Commercial |
$739.63
|
| Rate for Payer: Quartz Medicare Advantage |
$682.73
|
| Rate for Payer: WEA Trust Commercial |
$625.84
|
| Rate for Payer: WPS Commercial |
$842.84
|
|
|
COMPRESSION SCREW/LOCKING CAP KIT 4.5 X 38MM SCREW GREEN EQUINOXE REVERSE SHOULDER 320-20-38
|
Facility
OP
|
$1,137.89
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6240155
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$318.61 |
| Max. Negotiated Rate |
$1,046.86 |
| Rate for Payer: Aetna Commercial |
$1,024.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$978.59
|
| Rate for Payer: Aetna Managed Medicare |
$318.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$739.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$568.94
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$546.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$603.08
|
| Rate for Payer: Cash Price |
$341.37
|
| Rate for Payer: Cigna Commercial |
$1,046.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$636.76
|
| Rate for Payer: Health EOS Commercial |
$1,012.72
|
| Rate for Payer: HFN Commercial |
$1,046.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$853.42
|
| Rate for Payer: Multiplan Commercial |
$910.31
|
| Rate for Payer: NAPHCARE Commercial |
$682.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.86
|
| Rate for Payer: Quartz Beloit One Network |
$557.57
|
| Rate for Payer: Quartz Commercial |
$739.63
|
| Rate for Payer: Quartz Medicare Advantage |
$682.73
|
| Rate for Payer: WEA Trust Commercial |
$625.84
|
| Rate for Payer: WPS Commercial |
$842.84
|
|
|
COMPRESSION SCREW/LOCKING CAP KIT 4.5 X 38MM SCREW GREEN EQUINOXE REVERSE SHOULDER 320-20-38
|
Facility
IP
|
$1,137.89
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6240155
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$557.57 |
| Max. Negotiated Rate |
$1,046.86 |
| Rate for Payer: Aetna Commercial |
$1,024.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$603.08
|
| Rate for Payer: Cash Price |
$341.37
|
| Rate for Payer: Cigna Commercial |
$1,046.86
|
| Rate for Payer: Health EOS Commercial |
$1,012.72
|
| Rate for Payer: HFN Commercial |
$1,046.86
|
| Rate for Payer: Multiplan Commercial |
$910.31
|
| Rate for Payer: NAPHCARE Commercial |
$682.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,046.86
|
| Rate for Payer: Quartz Beloit One Network |
$557.57
|
| Rate for Payer: Quartz Commercial |
$682.73
|
| Rate for Payer: WEA Trust Commercial |
$625.84
|
| Rate for Payer: WPS Commercial |
$842.84
|
|
|
Compression wrap charge
|
Facility
OP
|
$140.00
|
|
|
Service Code
|
HCPCS A6448
|
| Hospital Charge Code |
2844906
|
|
Hospital Revenue Code
|
623
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$128.80 |
| Rate for Payer: Aetna Commercial |
$126.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| Rate for Payer: Aetna Managed Medicare |
$39.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$91.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$70.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$67.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.20
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$128.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$78.34
|
| Rate for Payer: Health EOS Commercial |
$124.60
|
| Rate for Payer: HFN Commercial |
$128.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$105.00
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: NAPHCARE Commercial |
$84.00
|
| Rate for Payer: Preferred Network Access Commercial |
$128.80
|
| Rate for Payer: Quartz Beloit One Network |
$68.60
|
| Rate for Payer: Quartz Commercial |
$91.00
|
| Rate for Payer: Quartz Medicare Advantage |
$84.00
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
Compression wrap charge
|
Facility
IP
|
$140.00
|
|
|
Service Code
|
HCPCS A6448
|
| Hospital Charge Code |
2844906
|
|
Hospital Revenue Code
|
623
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$128.80 |
| Rate for Payer: Aetna Commercial |
$126.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.20
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$128.80
|
| Rate for Payer: Health EOS Commercial |
$124.60
|
| Rate for Payer: HFN Commercial |
$128.80
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: NAPHCARE Commercial |
$84.00
|
| Rate for Payer: Preferred Network Access Commercial |
$128.80
|
| Rate for Payer: Quartz Beloit One Network |
$68.60
|
| Rate for Payer: Quartz Commercial |
$84.00
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
Concentration Fee
|
Professional
|
$62.00
|
|
|
Service Code
|
CPT 87015
|
| Hospital Charge Code |
1654799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$58.90 |
| Rate for Payer: Aetna Commercial |
$58.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.32
|
| Rate for Payer: Aetna Managed Medicare |
$6.68
|
| Rate for Payer: Anthem Medicare Advantage |
$6.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.68
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$58.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.68
|
| Rate for Payer: Health EOS Commercial |
$56.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.68
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: Preferred Network Access Commercial |
$58.90
|
| Rate for Payer: Quartz Beloit One Network |
$27.28
|
| Rate for Payer: Quartz Commercial |
$35.34
|
| Rate for Payer: Quartz Medicare Advantage |
$6.68
|
| Rate for Payer: The Alliance Commercial |
$26.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.68
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: WPS Commercial |
$29.39
|
|
|
Concentration Fee
|
Facility
OP
|
$62.00
|
|
|
Service Code
|
CPT 87015
|
| Hospital Charge Code |
1654799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$248.00 |
| Rate for Payer: Aetna Commercial |
$55.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.32
|
| Rate for Payer: Aetna Managed Medicare |
$6.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.69
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.09
|
| Rate for Payer: Anthem Medicaid |
$5.25
|
| Rate for Payer: Anthem Medicare Advantage |
$6.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.68
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$57.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.25
|
| Rate for Payer: Dean Health Medicaid |
$5.25
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.68
|
| Rate for Payer: Health EOS Commercial |
$55.18
|
| Rate for Payer: HFN Commercial |
$57.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.68
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.68
|
| Rate for Payer: Managed Health Services Medicaid |
$5.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.68
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.68
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: NAPHCARE Commercial |
$10.02
|
| Rate for Payer: Preferred Network Access Commercial |
$57.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.25
|
| Rate for Payer: Quartz Beloit One Network |
$30.38
|
| Rate for Payer: Quartz Commercial |
$40.30
|
| Rate for Payer: Quartz Medicare Advantage |
$6.68
|
| Rate for Payer: The Alliance Commercial |
$248.00
|
| Rate for Payer: United Healthcare Medicaid |
$5.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.68
|
| Rate for Payer: United Healthcare PPO |
$46.50
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: Wellcare Medicare |
$6.68
|
| Rate for Payer: WMAP Medicaid |
$5.25
|
| Rate for Payer: WPS Commercial |
$45.92
|
|
|
Concentration Fee
|
Facility
IP
|
$62.00
|
|
|
Service Code
|
CPT 87015
|
| Hospital Charge Code |
1654799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.38 |
| Max. Negotiated Rate |
$57.04 |
| Rate for Payer: Aetna Commercial |
$55.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.86
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$57.04
|
| Rate for Payer: Health EOS Commercial |
$55.18
|
| Rate for Payer: HFN Commercial |
$57.04
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: NAPHCARE Commercial |
$37.20
|
| Rate for Payer: Preferred Network Access Commercial |
$57.04
|
| Rate for Payer: Quartz Beloit One Network |
$30.38
|
| Rate for Payer: Quartz Commercial |
$37.20
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: WPS Commercial |
$45.92
|
|
|
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES
|
Facility
IP
|
$286,670.00
|
|
|
Service Code
|
MS-DRG 212
|
| Min. Negotiated Rate |
$103,118.64 |
| Max. Negotiated Rate |
$286,670.00 |
| Rate for Payer: Aetna Managed Medicare |
$103,118.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$225,954.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$173,192.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$164,544.06
|
| Rate for Payer: Anthem Medicare Advantage |
$103,118.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$103,118.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$103,118.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$103,118.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182,658.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$103,118.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210,028.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$103,118.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$103,118.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$103,118.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$103,118.64
|
| Rate for Payer: NAPHCARE Commercial |
$154,677.96
|
| Rate for Payer: Quartz Medicare Advantage |
$103,118.64
|
| Rate for Payer: The Alliance Commercial |
$286,670.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$103,118.64
|
| Rate for Payer: United Healthcare PPO |
$163,510.00
|
| Rate for Payer: Wellcare Medicare |
$103,118.64
|
|
|
CONCUSSION WITH CC
|
Facility
IP
|
$30,892.00
|
|
|
Service Code
|
MS-DRG 089
|
| Min. Negotiated Rate |
$11,112.10 |
| Max. Negotiated Rate |
$30,892.00 |
| Rate for Payer: Aetna Managed Medicare |
$11,112.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24,127.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,493.15
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,569.70
|
| Rate for Payer: Anthem Medicare Advantage |
$11,112.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,112.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,112.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,112.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,503.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,112.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22,423.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,112.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,112.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,112.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,112.10
|
| Rate for Payer: NAPHCARE Commercial |
$16,668.15
|
| Rate for Payer: Quartz Medicare Advantage |
$11,112.10
|
| Rate for Payer: The Alliance Commercial |
$30,892.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,112.10
|
| Rate for Payer: United Healthcare PPO |
$17,456.63
|
| Rate for Payer: Wellcare Medicare |
$11,112.10
|
|
|
CONCUSSION WITH MCC
|
Facility
IP
|
$41,098.00
|
|
|
Service Code
|
MS-DRG 088
|
| Min. Negotiated Rate |
$14,783.45 |
| Max. Negotiated Rate |
$41,098.00 |
| Rate for Payer: Aetna Managed Medicare |
$14,783.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32,099.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24,603.93
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23,375.34
|
| Rate for Payer: Anthem Medicare Advantage |
$14,783.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14,783.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14,783.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14,783.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25,948.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14,783.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29,909.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14,783.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14,783.45
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14,783.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14,783.45
|
| Rate for Payer: NAPHCARE Commercial |
$22,175.18
|
| Rate for Payer: Quartz Medicare Advantage |
$14,783.45
|
| Rate for Payer: The Alliance Commercial |
$41,098.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14,783.45
|
| Rate for Payer: United Healthcare PPO |
$23,284.62
|
| Rate for Payer: Wellcare Medicare |
$14,783.45
|
|
|
CONCUSSION WITHOUT CC/MCC
|
Facility
IP
|
$25,173.00
|
|
|
Service Code
|
MS-DRG 090
|
| Min. Negotiated Rate |
$9,055.04 |
| Max. Negotiated Rate |
$25,173.00 |
| Rate for Payer: Aetna Managed Medicare |
$9,055.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,511.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,955.33
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14,208.54
|
| Rate for Payer: Anthem Medicare Advantage |
$9,055.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9,055.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9,055.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9,055.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,772.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9,055.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,228.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9,055.04
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9,055.04
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9,055.04
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9,055.04
|
| Rate for Payer: NAPHCARE Commercial |
$13,582.56
|
| Rate for Payer: Quartz Medicare Advantage |
$9,055.04
|
| Rate for Payer: The Alliance Commercial |
$25,173.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9,055.04
|
| Rate for Payer: United Healthcare PPO |
$14,191.20
|
| Rate for Payer: Wellcare Medicare |
$9,055.04
|
|
|
Conditional Play Audiometry
|
Facility
IP
|
$93.00
|
|
|
Service Code
|
CPT 92582
|
| Hospital Charge Code |
1230805
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$45.57 |
| Max. Negotiated Rate |
$85.56 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.29
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$85.56
|
| Rate for Payer: Health EOS Commercial |
$82.77
|
| Rate for Payer: HFN Commercial |
$85.56
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: NAPHCARE Commercial |
$55.80
|
| Rate for Payer: Preferred Network Access Commercial |
$85.56
|
| Rate for Payer: Quartz Beloit One Network |
$45.57
|
| Rate for Payer: Quartz Commercial |
$55.80
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: WPS Commercial |
$68.89
|
|
|
Conditional Play Audiometry
|
Facility
OP
|
$93.00
|
|
|
Service Code
|
CPT 92582
|
| Hospital Charge Code |
1230805
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$44.64 |
| Max. Negotiated Rate |
$574.33 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.98
|
| Rate for Payer: Aetna Managed Medicare |
$154.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.64
|
| Rate for Payer: Anthem Medicare Advantage |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$154.39
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$85.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$154.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.04
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$154.39
|
| Rate for Payer: Health EOS Commercial |
$82.77
|
| Rate for Payer: HFN Commercial |
$85.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$574.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$154.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$154.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$154.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$154.39
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: NAPHCARE Commercial |
$231.58
|
| Rate for Payer: Preferred Network Access Commercial |
$85.56
|
| Rate for Payer: Quartz Beloit One Network |
$45.57
|
| Rate for Payer: Quartz Commercial |
$60.45
|
| Rate for Payer: Quartz Medicare Advantage |
$154.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$154.39
|
| Rate for Payer: United Healthcare PPO |
$69.75
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: Wellcare Medicare |
$154.39
|
| Rate for Payer: WPS Commercial |
$68.89
|
|
|
Conditional Play Audiometry
|
Professional
|
$93.00
|
|
|
Service Code
|
CPT 92582
|
| Hospital Charge Code |
1230805
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$40.92 |
| Max. Negotiated Rate |
$314.64 |
| Rate for Payer: WPS Commercial |
$314.64
|
| Rate for Payer: Aetna Commercial |
$88.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.98
|
| Rate for Payer: Aetna Managed Medicare |
$78.66
|
| Rate for Payer: Anthem Medicare Advantage |
$78.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$78.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$78.66
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$88.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$46.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$78.66
|
| Rate for Payer: Health EOS Commercial |
$84.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$252.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$252.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$78.66
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: Preferred Network Access Commercial |
$88.35
|
| Rate for Payer: Quartz Beloit One Network |
$40.92
|
| Rate for Payer: Quartz Commercial |
$53.01
|
| Rate for Payer: Quartz Medicare Advantage |
$78.66
|
| Rate for Payer: The Alliance Commercial |
$196.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$78.66
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
|
