|
DRESSING XEROFORM 1 X 8 IN OCCLUSICE GAUZE STRIP 8884433301
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
HCPCS A6222
|
| Hospital Charge Code |
2963792
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.23 |
| Max. Negotiated Rate |
$24.84 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$16.20
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
DRESSING XEROFORM 2X2
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS A6222
|
| Hospital Charge Code |
2974367
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.72 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$21.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20.64
|
| Rate for Payer: Aetna Managed Medicare |
$6.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.72
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.43
|
| Rate for Payer: Health EOS Commercial |
$21.36
|
| Rate for Payer: HFN Commercial |
$22.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$19.20
|
| Rate for Payer: NAPHCARE Commercial |
$14.40
|
| Rate for Payer: Preferred Network Access Commercial |
$22.08
|
| Rate for Payer: Quartz Beloit One Network |
$11.76
|
| Rate for Payer: Quartz Commercial |
$15.60
|
| Rate for Payer: Quartz Medicare Advantage |
$14.40
|
| Rate for Payer: The Alliance Commercial |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$13.20
|
| Rate for Payer: WPS Commercial |
$17.78
|
|
|
DRESSING XEROFORM 2X2
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS A6222
|
| Hospital Charge Code |
2974367
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$21.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$20.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.72
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.08
|
| Rate for Payer: Health EOS Commercial |
$21.36
|
| Rate for Payer: HFN Commercial |
$22.08
|
| Rate for Payer: Multiplan Commercial |
$19.20
|
| Rate for Payer: NAPHCARE Commercial |
$14.40
|
| Rate for Payer: Preferred Network Access Commercial |
$22.08
|
| Rate for Payer: Quartz Beloit One Network |
$11.76
|
| Rate for Payer: Quartz Commercial |
$14.40
|
| Rate for Payer: WEA Trust Commercial |
$13.20
|
| Rate for Payer: WPS Commercial |
$17.78
|
|
|
DRESSING XEROFORM 5x9 IN 8884433605/CUR253590
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS A6223
|
| Hospital Charge Code |
2963703
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.58 |
| Max. Negotiated Rate |
$38.64 |
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.26
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$38.64
|
| Rate for Payer: Health EOS Commercial |
$37.38
|
| Rate for Payer: HFN Commercial |
$38.64
|
| Rate for Payer: Multiplan Commercial |
$33.60
|
| Rate for Payer: NAPHCARE Commercial |
$25.20
|
| Rate for Payer: Preferred Network Access Commercial |
$38.64
|
| Rate for Payer: Quartz Beloit One Network |
$20.58
|
| Rate for Payer: Quartz Commercial |
$25.20
|
| Rate for Payer: WEA Trust Commercial |
$23.10
|
| Rate for Payer: WPS Commercial |
$31.11
|
|
|
DRESSING XEROFORM 5x9 IN 8884433605/CUR253590
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS A6223
|
| Hospital Charge Code |
2963703
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$168.00 |
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36.12
|
| Rate for Payer: Aetna Managed Medicare |
$11.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.26
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$38.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.50
|
| Rate for Payer: Health EOS Commercial |
$37.38
|
| Rate for Payer: HFN Commercial |
$38.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$33.60
|
| Rate for Payer: NAPHCARE Commercial |
$25.20
|
| Rate for Payer: Preferred Network Access Commercial |
$38.64
|
| Rate for Payer: Quartz Beloit One Network |
$20.58
|
| Rate for Payer: Quartz Commercial |
$27.30
|
| Rate for Payer: Quartz Medicare Advantage |
$25.20
|
| Rate for Payer: The Alliance Commercial |
$168.00
|
| Rate for Payer: WEA Trust Commercial |
$23.10
|
| Rate for Payer: WPS Commercial |
$31.11
|
|
|
DRILL 1.1 MINI QC 310.111
|
Facility
|
IP
|
$1,275.00
|
|
| Hospital Charge Code |
2966169
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$624.75 |
| Max. Negotiated Rate |
$1,173.00 |
| Rate for Payer: Aetna Commercial |
$1,147.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,096.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$675.75
|
| Rate for Payer: Cash Price |
$382.50
|
| Rate for Payer: Cigna Commercial |
$1,173.00
|
| Rate for Payer: Health EOS Commercial |
$1,134.75
|
| Rate for Payer: HFN Commercial |
$1,173.00
|
| Rate for Payer: Multiplan Commercial |
$1,020.00
|
| Rate for Payer: NAPHCARE Commercial |
$765.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,173.00
|
| Rate for Payer: Quartz Beloit One Network |
$624.75
|
| Rate for Payer: Quartz Commercial |
$765.00
|
| Rate for Payer: WEA Trust Commercial |
$701.25
|
| Rate for Payer: WPS Commercial |
$944.39
|
|
|
DRILL 1.1 MINI QC 310.111
|
Facility
|
OP
|
$1,275.00
|
|
| Hospital Charge Code |
2966169
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$357.00 |
| Max. Negotiated Rate |
$5,100.00 |
| Rate for Payer: Aetna Commercial |
$1,147.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,096.50
|
| Rate for Payer: Aetna Managed Medicare |
$357.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$828.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$637.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$612.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$675.75
|
| Rate for Payer: Cash Price |
$382.50
|
| Rate for Payer: Cigna Commercial |
$1,173.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$713.49
|
| Rate for Payer: Health EOS Commercial |
$1,134.75
|
| Rate for Payer: HFN Commercial |
$1,173.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$956.25
|
| Rate for Payer: Multiplan Commercial |
$1,020.00
|
| Rate for Payer: NAPHCARE Commercial |
$765.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,173.00
|
| Rate for Payer: Quartz Beloit One Network |
$624.75
|
| Rate for Payer: Quartz Commercial |
$828.75
|
| Rate for Payer: Quartz Medicare Advantage |
$765.00
|
| Rate for Payer: The Alliance Commercial |
$5,100.00
|
| Rate for Payer: WEA Trust Commercial |
$701.25
|
| Rate for Payer: WPS Commercial |
$944.39
|
|
|
DRILL 1X48 DIAMOND E5210
|
Facility
|
OP
|
$1,464.00
|
|
| Hospital Charge Code |
2964912
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$409.92 |
| Max. Negotiated Rate |
$5,856.00 |
| Rate for Payer: Aetna Commercial |
$1,317.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,259.04
|
| Rate for Payer: Aetna Managed Medicare |
$409.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$951.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$732.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$702.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$775.92
|
| Rate for Payer: Cash Price |
$439.20
|
| Rate for Payer: Cigna Commercial |
$1,346.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$819.25
|
| Rate for Payer: Health EOS Commercial |
$1,302.96
|
| Rate for Payer: HFN Commercial |
$1,346.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,098.00
|
| Rate for Payer: Multiplan Commercial |
$1,171.20
|
| Rate for Payer: NAPHCARE Commercial |
$878.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,346.88
|
| Rate for Payer: Quartz Beloit One Network |
$717.36
|
| Rate for Payer: Quartz Commercial |
$951.60
|
| Rate for Payer: Quartz Medicare Advantage |
$878.40
|
| Rate for Payer: The Alliance Commercial |
$5,856.00
|
| Rate for Payer: WEA Trust Commercial |
$805.20
|
| Rate for Payer: WPS Commercial |
$1,084.38
|
|
|
DRILL 1X48 DIAMOND E5210
|
Facility
|
IP
|
$1,464.00
|
|
| Hospital Charge Code |
2964912
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$717.36 |
| Max. Negotiated Rate |
$1,346.88 |
| Rate for Payer: Aetna Commercial |
$1,317.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,259.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$775.92
|
| Rate for Payer: Cash Price |
$439.20
|
| Rate for Payer: Cigna Commercial |
$1,346.88
|
| Rate for Payer: Health EOS Commercial |
$1,302.96
|
| Rate for Payer: HFN Commercial |
$1,346.88
|
| Rate for Payer: Multiplan Commercial |
$1,171.20
|
| Rate for Payer: NAPHCARE Commercial |
$878.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,346.88
|
| Rate for Payer: Quartz Beloit One Network |
$717.36
|
| Rate for Payer: Quartz Commercial |
$878.40
|
| Rate for Payer: WEA Trust Commercial |
$805.20
|
| Rate for Payer: WPS Commercial |
$1,084.38
|
|
|
DRILL 2.0/2.4 OSTEOMED 316-0105
|
Facility
|
IP
|
$2,943.00
|
|
| Hospital Charge Code |
2969472
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,442.07 |
| Max. Negotiated Rate |
$2,707.56 |
| Rate for Payer: Aetna Commercial |
$2,648.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,530.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,559.79
|
| Rate for Payer: Cash Price |
$882.90
|
| Rate for Payer: Cigna Commercial |
$2,707.56
|
| Rate for Payer: Health EOS Commercial |
$2,619.27
|
| Rate for Payer: HFN Commercial |
$2,707.56
|
| Rate for Payer: Multiplan Commercial |
$2,354.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,765.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,707.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,442.07
|
| Rate for Payer: Quartz Commercial |
$1,765.80
|
| Rate for Payer: WEA Trust Commercial |
$1,618.65
|
| Rate for Payer: WPS Commercial |
$2,179.88
|
|
|
DRILL 2.0/2.4 OSTEOMED 316-0105
|
Facility
|
OP
|
$2,943.00
|
|
| Hospital Charge Code |
2969472
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$824.04 |
| Max. Negotiated Rate |
$11,772.00 |
| Rate for Payer: Aetna Commercial |
$2,648.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,530.98
|
| Rate for Payer: Aetna Managed Medicare |
$824.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,912.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,471.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,412.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,559.79
|
| Rate for Payer: Cash Price |
$882.90
|
| Rate for Payer: Cigna Commercial |
$2,707.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,646.90
|
| Rate for Payer: Health EOS Commercial |
$2,619.27
|
| Rate for Payer: HFN Commercial |
$2,707.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,207.25
|
| Rate for Payer: Multiplan Commercial |
$2,354.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,765.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,707.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,442.07
|
| Rate for Payer: Quartz Commercial |
$1,912.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,765.80
|
| Rate for Payer: The Alliance Commercial |
$11,772.00
|
| Rate for Payer: WEA Trust Commercial |
$1,618.65
|
| Rate for Payer: WPS Commercial |
$2,179.88
|
|
|
DRILL 2.0 ACUMED
|
Facility
|
OP
|
$1,025.00
|
|
| Hospital Charge Code |
2964135
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$287.00 |
| Max. Negotiated Rate |
$4,100.00 |
| Rate for Payer: Aetna Commercial |
$922.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$881.50
|
| Rate for Payer: Aetna Managed Medicare |
$287.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$666.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$512.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$492.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$543.25
|
| Rate for Payer: Cash Price |
$307.50
|
| Rate for Payer: Cigna Commercial |
$943.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$573.59
|
| Rate for Payer: Health EOS Commercial |
$912.25
|
| Rate for Payer: HFN Commercial |
$943.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$768.75
|
| Rate for Payer: Multiplan Commercial |
$820.00
|
| Rate for Payer: NAPHCARE Commercial |
$615.00
|
| Rate for Payer: Preferred Network Access Commercial |
$943.00
|
| Rate for Payer: Quartz Beloit One Network |
$502.25
|
| Rate for Payer: Quartz Commercial |
$666.25
|
| Rate for Payer: Quartz Medicare Advantage |
$615.00
|
| Rate for Payer: The Alliance Commercial |
$4,100.00
|
| Rate for Payer: WEA Trust Commercial |
$563.75
|
| Rate for Payer: WPS Commercial |
$759.22
|
|
|
DRILL 2.0 ACUMED
|
Facility
|
IP
|
$1,025.00
|
|
| Hospital Charge Code |
2964135
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$502.25 |
| Max. Negotiated Rate |
$943.00 |
| Rate for Payer: Aetna Commercial |
$922.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$881.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$543.25
|
| Rate for Payer: Cash Price |
$307.50
|
| Rate for Payer: Cigna Commercial |
$943.00
|
| Rate for Payer: Health EOS Commercial |
$912.25
|
| Rate for Payer: HFN Commercial |
$943.00
|
| Rate for Payer: Multiplan Commercial |
$820.00
|
| Rate for Payer: NAPHCARE Commercial |
$615.00
|
| Rate for Payer: Preferred Network Access Commercial |
$943.00
|
| Rate for Payer: Quartz Beloit One Network |
$502.25
|
| Rate for Payer: Quartz Commercial |
$615.00
|
| Rate for Payer: WEA Trust Commercial |
$563.75
|
| Rate for Payer: WPS Commercial |
$759.22
|
|
|
DRILL 2X48 DIAMOND E5220
|
Facility
|
OP
|
$1,738.00
|
|
| Hospital Charge Code |
2964913
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$486.64 |
| Max. Negotiated Rate |
$6,952.00 |
| Rate for Payer: Aetna Commercial |
$1,564.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,494.68
|
| Rate for Payer: Aetna Managed Medicare |
$486.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,129.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$869.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$834.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$921.14
|
| Rate for Payer: Cash Price |
$521.40
|
| Rate for Payer: Cigna Commercial |
$1,598.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$972.58
|
| Rate for Payer: Health EOS Commercial |
$1,546.82
|
| Rate for Payer: HFN Commercial |
$1,598.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,303.50
|
| Rate for Payer: Multiplan Commercial |
$1,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.96
|
| Rate for Payer: Quartz Beloit One Network |
$851.62
|
| Rate for Payer: Quartz Commercial |
$1,129.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,042.80
|
| Rate for Payer: The Alliance Commercial |
$6,952.00
|
| Rate for Payer: WEA Trust Commercial |
$955.90
|
| Rate for Payer: WPS Commercial |
$1,287.34
|
|
|
DRILL 2X48 DIAMOND E5220
|
Facility
|
IP
|
$1,738.00
|
|
| Hospital Charge Code |
2964913
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$851.62 |
| Max. Negotiated Rate |
$1,598.96 |
| Rate for Payer: Aetna Commercial |
$1,564.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,494.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$921.14
|
| Rate for Payer: Cash Price |
$521.40
|
| Rate for Payer: Cigna Commercial |
$1,598.96
|
| Rate for Payer: Health EOS Commercial |
$1,546.82
|
| Rate for Payer: HFN Commercial |
$1,598.96
|
| Rate for Payer: Multiplan Commercial |
$1,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.96
|
| Rate for Payer: Quartz Beloit One Network |
$851.62
|
| Rate for Payer: Quartz Commercial |
$1,042.80
|
| Rate for Payer: WEA Trust Commercial |
$955.90
|
| Rate for Payer: WPS Commercial |
$1,287.34
|
|
|
DRILL 3.2 LONG BIT 71751149
|
Facility
|
OP
|
$2,641.00
|
|
| Hospital Charge Code |
2966009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$739.48 |
| Max. Negotiated Rate |
$10,564.00 |
| Rate for Payer: Aetna Commercial |
$2,376.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,271.26
|
| Rate for Payer: Aetna Managed Medicare |
$739.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,716.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,320.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,267.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,399.73
|
| Rate for Payer: Cash Price |
$792.30
|
| Rate for Payer: Cigna Commercial |
$2,429.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,477.90
|
| Rate for Payer: Health EOS Commercial |
$2,350.49
|
| Rate for Payer: HFN Commercial |
$2,429.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,980.75
|
| Rate for Payer: Multiplan Commercial |
$2,112.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,584.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,429.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,294.09
|
| Rate for Payer: Quartz Commercial |
$1,716.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,584.60
|
| Rate for Payer: The Alliance Commercial |
$10,564.00
|
| Rate for Payer: WEA Trust Commercial |
$1,452.55
|
| Rate for Payer: WPS Commercial |
$1,956.19
|
|
|
DRILL 3.2 LONG BIT 71751149
|
Facility
|
IP
|
$2,641.00
|
|
| Hospital Charge Code |
2966009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,294.09 |
| Max. Negotiated Rate |
$2,429.72 |
| Rate for Payer: Aetna Commercial |
$2,376.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,271.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,399.73
|
| Rate for Payer: Cash Price |
$792.30
|
| Rate for Payer: Cigna Commercial |
$2,429.72
|
| Rate for Payer: Health EOS Commercial |
$2,350.49
|
| Rate for Payer: HFN Commercial |
$2,429.72
|
| Rate for Payer: Multiplan Commercial |
$2,112.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,584.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,429.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,294.09
|
| Rate for Payer: Quartz Commercial |
$1,584.60
|
| Rate for Payer: WEA Trust Commercial |
$1,452.55
|
| Rate for Payer: WPS Commercial |
$1,956.19
|
|
|
DRILL 4 X 38 ROUND CARBIDE #E8140LSO
|
Facility
|
OP
|
$1,602.00
|
|
| Hospital Charge Code |
2964914
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$448.56 |
| Max. Negotiated Rate |
$6,408.00 |
| Rate for Payer: Aetna Commercial |
$1,441.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,377.72
|
| Rate for Payer: Aetna Managed Medicare |
$448.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,041.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$801.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$768.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$849.06
|
| Rate for Payer: Cash Price |
$480.60
|
| Rate for Payer: Cigna Commercial |
$1,473.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$896.48
|
| Rate for Payer: Health EOS Commercial |
$1,425.78
|
| Rate for Payer: HFN Commercial |
$1,473.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,201.50
|
| Rate for Payer: Multiplan Commercial |
$1,281.60
|
| Rate for Payer: NAPHCARE Commercial |
$961.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,473.84
|
| Rate for Payer: Quartz Beloit One Network |
$784.98
|
| Rate for Payer: Quartz Commercial |
$1,041.30
|
| Rate for Payer: Quartz Medicare Advantage |
$961.20
|
| Rate for Payer: The Alliance Commercial |
$6,408.00
|
| Rate for Payer: WEA Trust Commercial |
$881.10
|
| Rate for Payer: WPS Commercial |
$1,186.60
|
|
|
DRILL 4 X 38 ROUND CARBIDE #E8140LSO
|
Facility
|
IP
|
$1,602.00
|
|
| Hospital Charge Code |
2964914
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$784.98 |
| Max. Negotiated Rate |
$1,473.84 |
| Rate for Payer: Aetna Commercial |
$1,441.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,377.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$849.06
|
| Rate for Payer: Cash Price |
$480.60
|
| Rate for Payer: Cigna Commercial |
$1,473.84
|
| Rate for Payer: Health EOS Commercial |
$1,425.78
|
| Rate for Payer: HFN Commercial |
$1,473.84
|
| Rate for Payer: Multiplan Commercial |
$1,281.60
|
| Rate for Payer: NAPHCARE Commercial |
$961.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,473.84
|
| Rate for Payer: Quartz Beloit One Network |
$784.98
|
| Rate for Payer: Quartz Commercial |
$961.20
|
| Rate for Payer: WEA Trust Commercial |
$881.10
|
| Rate for Payer: WPS Commercial |
$1,186.60
|
|
|
DRILL 4X48 DIAMOND E5240
|
Facility
|
OP
|
$1,611.00
|
|
| Hospital Charge Code |
2964915
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$451.08 |
| Max. Negotiated Rate |
$6,444.00 |
| Rate for Payer: Aetna Commercial |
$1,449.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,385.46
|
| Rate for Payer: Aetna Managed Medicare |
$451.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,047.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$805.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$773.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$853.83
|
| Rate for Payer: Cash Price |
$483.30
|
| Rate for Payer: Cigna Commercial |
$1,482.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$901.52
|
| Rate for Payer: Health EOS Commercial |
$1,433.79
|
| Rate for Payer: HFN Commercial |
$1,482.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,208.25
|
| Rate for Payer: Multiplan Commercial |
$1,288.80
|
| Rate for Payer: NAPHCARE Commercial |
$966.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,482.12
|
| Rate for Payer: Quartz Beloit One Network |
$789.39
|
| Rate for Payer: Quartz Commercial |
$1,047.15
|
| Rate for Payer: Quartz Medicare Advantage |
$966.60
|
| Rate for Payer: The Alliance Commercial |
$6,444.00
|
| Rate for Payer: WEA Trust Commercial |
$886.05
|
| Rate for Payer: WPS Commercial |
$1,193.27
|
|
|
DRILL 4X48 DIAMOND E5240
|
Facility
|
IP
|
$1,611.00
|
|
| Hospital Charge Code |
2964915
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$789.39 |
| Max. Negotiated Rate |
$1,482.12 |
| Rate for Payer: Aetna Commercial |
$1,449.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,385.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$853.83
|
| Rate for Payer: Cash Price |
$483.30
|
| Rate for Payer: Cigna Commercial |
$1,482.12
|
| Rate for Payer: Health EOS Commercial |
$1,433.79
|
| Rate for Payer: HFN Commercial |
$1,482.12
|
| Rate for Payer: Multiplan Commercial |
$1,288.80
|
| Rate for Payer: NAPHCARE Commercial |
$966.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,482.12
|
| Rate for Payer: Quartz Beloit One Network |
$789.39
|
| Rate for Payer: Quartz Commercial |
$966.60
|
| Rate for Payer: WEA Trust Commercial |
$886.05
|
| Rate for Payer: WPS Commercial |
$1,193.27
|
|
|
DRILL AND PIN SET 2001-00-000
|
Facility
|
IP
|
$1,615.00
|
|
| Hospital Charge Code |
2967461
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$791.35 |
| Max. Negotiated Rate |
$1,485.80 |
| Rate for Payer: Aetna Commercial |
$1,453.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,388.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$855.95
|
| Rate for Payer: Cash Price |
$484.50
|
| Rate for Payer: Cigna Commercial |
$1,485.80
|
| Rate for Payer: Health EOS Commercial |
$1,437.35
|
| Rate for Payer: HFN Commercial |
$1,485.80
|
| Rate for Payer: Multiplan Commercial |
$1,292.00
|
| Rate for Payer: NAPHCARE Commercial |
$969.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,485.80
|
| Rate for Payer: Quartz Beloit One Network |
$791.35
|
| Rate for Payer: Quartz Commercial |
$969.00
|
| Rate for Payer: WEA Trust Commercial |
$888.25
|
| Rate for Payer: WPS Commercial |
$1,196.23
|
|
|
DRILL AND PIN SET 2001-00-000
|
Facility
|
OP
|
$1,615.00
|
|
| Hospital Charge Code |
2967461
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$452.20 |
| Max. Negotiated Rate |
$6,460.00 |
| Rate for Payer: Aetna Commercial |
$1,453.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,388.90
|
| Rate for Payer: Aetna Managed Medicare |
$452.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,049.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$807.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$775.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$855.95
|
| Rate for Payer: Cash Price |
$484.50
|
| Rate for Payer: Cigna Commercial |
$1,485.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$903.75
|
| Rate for Payer: Health EOS Commercial |
$1,437.35
|
| Rate for Payer: HFN Commercial |
$1,485.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,211.25
|
| Rate for Payer: Multiplan Commercial |
$1,292.00
|
| Rate for Payer: NAPHCARE Commercial |
$969.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,485.80
|
| Rate for Payer: Quartz Beloit One Network |
$791.35
|
| Rate for Payer: Quartz Commercial |
$1,049.75
|
| Rate for Payer: Quartz Medicare Advantage |
$969.00
|
| Rate for Payer: The Alliance Commercial |
$6,460.00
|
| Rate for Payer: WEA Trust Commercial |
$888.25
|
| Rate for Payer: WPS Commercial |
$1,196.23
|
|
|
DRILL BIT
|
Facility
|
OP
|
$1,525.00
|
|
| Hospital Charge Code |
2965382
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$427.00 |
| Max. Negotiated Rate |
$6,100.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Aetna Managed Medicare |
$427.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$991.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$762.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$732.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$853.39
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,143.75
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$991.25
|
| Rate for Payer: Quartz Medicare Advantage |
$915.00
|
| Rate for Payer: The Alliance Commercial |
$6,100.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
DRILL BIT
|
Facility
|
IP
|
$1,525.00
|
|
| Hospital Charge Code |
2965382
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$747.25 |
| Max. Negotiated Rate |
$1,403.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$915.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
