|
DISPOSABLE OVERTUBE BX00711146
|
Facility
|
OP
|
$2,567.00
|
|
| Hospital Charge Code |
2973602
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$747.51 |
| Max. Negotiated Rate |
$2,456.11 |
| Rate for Payer: Aetna Commercial |
$2,402.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,295.92
|
| Rate for Payer: Aetna Managed Medicare |
$747.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,735.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,334.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,281.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,414.93
|
| Rate for Payer: Cash Price |
$770.10
|
| Rate for Payer: Cigna Commercial |
$2,456.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,493.99
|
| Rate for Payer: Health EOS Commercial |
$2,376.02
|
| Rate for Payer: HFN Commercial |
$2,456.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,002.26
|
| Rate for Payer: Multiplan Commercial |
$2,135.74
|
| Rate for Payer: NAPHCARE Commercial |
$1,601.81
|
| Rate for Payer: Preferred Network Access Commercial |
$2,456.11
|
| Rate for Payer: Quartz Beloit One Network |
$1,308.14
|
| Rate for Payer: Quartz Commercial |
$1,735.29
|
| Rate for Payer: Quartz Medicare Advantage |
$1,601.81
|
| Rate for Payer: The Alliance Commercial |
$1,334.84
|
| Rate for Payer: WEA Trust Commercial |
$1,468.32
|
| Rate for Payer: WPS Commercial |
$1,977.36
|
|
|
DISPOSABLE OVERTUBE BX00711146
|
Facility
|
IP
|
$2,567.00
|
|
| Hospital Charge Code |
2973602
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,308.14 |
| Max. Negotiated Rate |
$2,456.11 |
| Rate for Payer: Aetna Commercial |
$2,402.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,295.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,414.93
|
| Rate for Payer: Cash Price |
$770.10
|
| Rate for Payer: Cigna Commercial |
$2,456.11
|
| Rate for Payer: Health EOS Commercial |
$2,376.02
|
| Rate for Payer: HFN Commercial |
$2,456.11
|
| Rate for Payer: Multiplan Commercial |
$2,135.74
|
| Rate for Payer: Preferred Network Access Commercial |
$2,456.11
|
| Rate for Payer: Quartz Beloit One Network |
$1,308.14
|
| Rate for Payer: Quartz Commercial |
$1,601.81
|
| Rate for Payer: WEA Trust Commercial |
$1,468.32
|
| Rate for Payer: WPS Commercial |
$1,977.36
|
|
|
DISSECTOR 3.0MM SMALL JOINT ARTHREX AR-9300DS
|
Facility
|
OP
|
$959.00
|
|
| Hospital Charge Code |
5348977
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$279.26 |
| Max. Negotiated Rate |
$917.57 |
| Rate for Payer: Aetna Commercial |
$897.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$857.73
|
| Rate for Payer: Aetna Managed Medicare |
$279.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$648.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$498.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$478.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$528.60
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$917.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$558.14
|
| Rate for Payer: Health EOS Commercial |
$887.65
|
| Rate for Payer: HFN Commercial |
$917.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$748.02
|
| Rate for Payer: Multiplan Commercial |
$797.89
|
| Rate for Payer: NAPHCARE Commercial |
$598.42
|
| Rate for Payer: Preferred Network Access Commercial |
$917.57
|
| Rate for Payer: Quartz Beloit One Network |
$488.71
|
| Rate for Payer: Quartz Commercial |
$648.28
|
| Rate for Payer: Quartz Medicare Advantage |
$598.42
|
| Rate for Payer: The Alliance Commercial |
$498.68
|
| Rate for Payer: WEA Trust Commercial |
$548.55
|
| Rate for Payer: WPS Commercial |
$738.72
|
|
|
DISSECTOR 3.0MM SMALL JOINT ARTHREX AR-9300DS
|
Facility
|
IP
|
$959.00
|
|
| Hospital Charge Code |
5348977
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$488.71 |
| Max. Negotiated Rate |
$917.57 |
| Rate for Payer: Aetna Commercial |
$897.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$857.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$528.60
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$917.57
|
| Rate for Payer: Health EOS Commercial |
$887.65
|
| Rate for Payer: HFN Commercial |
$917.57
|
| Rate for Payer: Multiplan Commercial |
$797.89
|
| Rate for Payer: Preferred Network Access Commercial |
$917.57
|
| Rate for Payer: Quartz Beloit One Network |
$488.71
|
| Rate for Payer: Quartz Commercial |
$598.42
|
| Rate for Payer: WEA Trust Commercial |
$548.55
|
| Rate for Payer: WPS Commercial |
$738.72
|
|
|
DISSECTOR 3.5MM ARTHROSCOPY ARTHREX AR-8350DS
|
Facility
|
OP
|
$959.00
|
|
| Hospital Charge Code |
5206674
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$279.26 |
| Max. Negotiated Rate |
$917.57 |
| Rate for Payer: Aetna Commercial |
$897.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$857.73
|
| Rate for Payer: Aetna Managed Medicare |
$279.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$648.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$498.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$478.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$528.60
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$917.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$558.14
|
| Rate for Payer: Health EOS Commercial |
$887.65
|
| Rate for Payer: HFN Commercial |
$917.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$748.02
|
| Rate for Payer: Multiplan Commercial |
$797.89
|
| Rate for Payer: NAPHCARE Commercial |
$598.42
|
| Rate for Payer: Preferred Network Access Commercial |
$917.57
|
| Rate for Payer: Quartz Beloit One Network |
$488.71
|
| Rate for Payer: Quartz Commercial |
$648.28
|
| Rate for Payer: Quartz Medicare Advantage |
$598.42
|
| Rate for Payer: The Alliance Commercial |
$498.68
|
| Rate for Payer: WEA Trust Commercial |
$548.55
|
| Rate for Payer: WPS Commercial |
$738.72
|
|
|
DISSECTOR 3.5MM ARTHROSCOPY ARTHREX AR-8350DS
|
Facility
|
IP
|
$959.00
|
|
| Hospital Charge Code |
5206674
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$488.71 |
| Max. Negotiated Rate |
$917.57 |
| Rate for Payer: Aetna Commercial |
$897.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$857.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$528.60
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$917.57
|
| Rate for Payer: Health EOS Commercial |
$887.65
|
| Rate for Payer: HFN Commercial |
$917.57
|
| Rate for Payer: Multiplan Commercial |
$797.89
|
| Rate for Payer: Preferred Network Access Commercial |
$917.57
|
| Rate for Payer: Quartz Beloit One Network |
$488.71
|
| Rate for Payer: Quartz Commercial |
$598.42
|
| Rate for Payer: WEA Trust Commercial |
$548.55
|
| Rate for Payer: WPS Commercial |
$738.72
|
|
|
DISSECTOR 3.5MM CURVED AR-8350CDS
|
Facility
|
IP
|
$1,616.00
|
|
| Hospital Charge Code |
5414904
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$823.51 |
| Max. Negotiated Rate |
$1,546.19 |
| Rate for Payer: Aetna Commercial |
$1,512.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,445.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$890.74
|
| Rate for Payer: Cash Price |
$484.80
|
| Rate for Payer: Cigna Commercial |
$1,546.19
|
| Rate for Payer: Health EOS Commercial |
$1,495.77
|
| Rate for Payer: HFN Commercial |
$1,546.19
|
| Rate for Payer: Multiplan Commercial |
$1,344.51
|
| Rate for Payer: Preferred Network Access Commercial |
$1,546.19
|
| Rate for Payer: Quartz Beloit One Network |
$823.51
|
| Rate for Payer: Quartz Commercial |
$1,008.38
|
| Rate for Payer: WEA Trust Commercial |
$924.35
|
| Rate for Payer: WPS Commercial |
$1,244.80
|
|
|
DISSECTOR 3.5MM CURVED AR-8350CDS
|
Facility
|
OP
|
$1,616.00
|
|
| Hospital Charge Code |
5414904
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$470.58 |
| Max. Negotiated Rate |
$1,546.19 |
| Rate for Payer: Aetna Commercial |
$1,512.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,445.35
|
| Rate for Payer: Aetna Managed Medicare |
$470.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,092.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$840.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$806.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$890.74
|
| Rate for Payer: Cash Price |
$484.80
|
| Rate for Payer: Cigna Commercial |
$1,546.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$940.51
|
| Rate for Payer: Health EOS Commercial |
$1,495.77
|
| Rate for Payer: HFN Commercial |
$1,546.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,260.48
|
| Rate for Payer: Multiplan Commercial |
$1,344.51
|
| Rate for Payer: NAPHCARE Commercial |
$1,008.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,546.19
|
| Rate for Payer: Quartz Beloit One Network |
$823.51
|
| Rate for Payer: Quartz Commercial |
$1,092.42
|
| Rate for Payer: Quartz Medicare Advantage |
$1,008.38
|
| Rate for Payer: The Alliance Commercial |
$840.32
|
| Rate for Payer: WEA Trust Commercial |
$924.35
|
| Rate for Payer: WPS Commercial |
$1,244.80
|
|
|
DISSECTOR 3.5MM SMALL JOINT ARTHREX AR-9350DS
|
Facility
|
IP
|
$959.00
|
|
| Hospital Charge Code |
5348978
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$488.71 |
| Max. Negotiated Rate |
$917.57 |
| Rate for Payer: Aetna Commercial |
$897.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$857.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$528.60
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$917.57
|
| Rate for Payer: Health EOS Commercial |
$887.65
|
| Rate for Payer: HFN Commercial |
$917.57
|
| Rate for Payer: Multiplan Commercial |
$797.89
|
| Rate for Payer: Preferred Network Access Commercial |
$917.57
|
| Rate for Payer: Quartz Beloit One Network |
$488.71
|
| Rate for Payer: Quartz Commercial |
$598.42
|
| Rate for Payer: WEA Trust Commercial |
$548.55
|
| Rate for Payer: WPS Commercial |
$738.72
|
|
|
DISSECTOR 3.5MM SMALL JOINT ARTHREX AR-9350DS
|
Facility
|
OP
|
$959.00
|
|
| Hospital Charge Code |
5348978
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$279.26 |
| Max. Negotiated Rate |
$917.57 |
| Rate for Payer: Aetna Commercial |
$897.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$857.73
|
| Rate for Payer: Aetna Managed Medicare |
$279.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$648.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$498.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$478.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$528.60
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$917.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$558.14
|
| Rate for Payer: Health EOS Commercial |
$887.65
|
| Rate for Payer: HFN Commercial |
$917.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$748.02
|
| Rate for Payer: Multiplan Commercial |
$797.89
|
| Rate for Payer: NAPHCARE Commercial |
$598.42
|
| Rate for Payer: Preferred Network Access Commercial |
$917.57
|
| Rate for Payer: Quartz Beloit One Network |
$488.71
|
| Rate for Payer: Quartz Commercial |
$648.28
|
| Rate for Payer: Quartz Medicare Advantage |
$598.42
|
| Rate for Payer: The Alliance Commercial |
$498.68
|
| Rate for Payer: WEA Trust Commercial |
$548.55
|
| Rate for Payer: WPS Commercial |
$738.72
|
|
|
DISSECTOR 4.0MM ARTHROSCOPY ARTHREX AR-8400DS
|
Facility
|
IP
|
$1,078.00
|
|
| Hospital Charge Code |
5206675
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$549.35 |
| Max. Negotiated Rate |
$1,031.43 |
| Rate for Payer: Aetna Commercial |
$1,009.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$964.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$594.19
|
| Rate for Payer: Cash Price |
$323.40
|
| Rate for Payer: Cigna Commercial |
$1,031.43
|
| Rate for Payer: Health EOS Commercial |
$997.80
|
| Rate for Payer: HFN Commercial |
$1,031.43
|
| Rate for Payer: Multiplan Commercial |
$896.90
|
| Rate for Payer: Preferred Network Access Commercial |
$1,031.43
|
| Rate for Payer: Quartz Beloit One Network |
$549.35
|
| Rate for Payer: Quartz Commercial |
$672.67
|
| Rate for Payer: WEA Trust Commercial |
$616.62
|
| Rate for Payer: WPS Commercial |
$830.38
|
|
|
DISSECTOR 4.0MM ARTHROSCOPY ARTHREX AR-8400DS
|
Facility
|
OP
|
$1,078.00
|
|
| Hospital Charge Code |
5206675
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$313.91 |
| Max. Negotiated Rate |
$1,031.43 |
| Rate for Payer: Aetna Commercial |
$1,009.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$964.16
|
| Rate for Payer: Aetna Managed Medicare |
$313.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$728.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$560.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$538.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$594.19
|
| Rate for Payer: Cash Price |
$323.40
|
| Rate for Payer: Cigna Commercial |
$1,031.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$627.40
|
| Rate for Payer: Health EOS Commercial |
$997.80
|
| Rate for Payer: HFN Commercial |
$1,031.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$840.84
|
| Rate for Payer: Multiplan Commercial |
$896.90
|
| Rate for Payer: NAPHCARE Commercial |
$672.67
|
| Rate for Payer: Preferred Network Access Commercial |
$1,031.43
|
| Rate for Payer: Quartz Beloit One Network |
$549.35
|
| Rate for Payer: Quartz Commercial |
$728.73
|
| Rate for Payer: Quartz Medicare Advantage |
$672.67
|
| Rate for Payer: The Alliance Commercial |
$560.56
|
| Rate for Payer: WEA Trust Commercial |
$616.62
|
| Rate for Payer: WPS Commercial |
$830.38
|
|
|
DISSECTOR 4.0MM ARTHROSCOPY ARTHREX CURVED AR-8400CDS
|
Facility
|
OP
|
$925.00
|
|
| Hospital Charge Code |
5348972
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$269.36 |
| Max. Negotiated Rate |
$885.04 |
| Rate for Payer: Aetna Commercial |
$865.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$827.32
|
| Rate for Payer: Aetna Managed Medicare |
$269.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$625.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$481.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$461.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$509.86
|
| Rate for Payer: Cash Price |
$277.50
|
| Rate for Payer: Cigna Commercial |
$885.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$538.35
|
| Rate for Payer: Health EOS Commercial |
$856.18
|
| Rate for Payer: HFN Commercial |
$885.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$721.50
|
| Rate for Payer: Multiplan Commercial |
$769.60
|
| Rate for Payer: NAPHCARE Commercial |
$577.20
|
| Rate for Payer: Preferred Network Access Commercial |
$885.04
|
| Rate for Payer: Quartz Beloit One Network |
$471.38
|
| Rate for Payer: Quartz Commercial |
$625.30
|
| Rate for Payer: Quartz Medicare Advantage |
$577.20
|
| Rate for Payer: The Alliance Commercial |
$481.00
|
| Rate for Payer: WEA Trust Commercial |
$529.10
|
| Rate for Payer: WPS Commercial |
$712.53
|
|
|
DISSECTOR 4.0MM ARTHROSCOPY ARTHREX CURVED AR-8400CDS
|
Facility
|
IP
|
$925.00
|
|
| Hospital Charge Code |
5348972
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$471.38 |
| Max. Negotiated Rate |
$885.04 |
| Rate for Payer: Aetna Commercial |
$865.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$827.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$509.86
|
| Rate for Payer: Cash Price |
$277.50
|
| Rate for Payer: Cigna Commercial |
$885.04
|
| Rate for Payer: Health EOS Commercial |
$856.18
|
| Rate for Payer: HFN Commercial |
$885.04
|
| Rate for Payer: Multiplan Commercial |
$769.60
|
| Rate for Payer: Preferred Network Access Commercial |
$885.04
|
| Rate for Payer: Quartz Beloit One Network |
$471.38
|
| Rate for Payer: Quartz Commercial |
$577.20
|
| Rate for Payer: WEA Trust Commercial |
$529.10
|
| Rate for Payer: WPS Commercial |
$712.53
|
|
|
DISSECTOR 5.0MM ARTHROSCOPY ARTHREX AR-8500DS
|
Facility
|
IP
|
$1,039.00
|
|
| Hospital Charge Code |
5206676
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$529.47 |
| Max. Negotiated Rate |
$994.12 |
| Rate for Payer: Aetna Commercial |
$972.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$929.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$572.70
|
| Rate for Payer: Cash Price |
$311.70
|
| Rate for Payer: Cigna Commercial |
$994.12
|
| Rate for Payer: Health EOS Commercial |
$961.70
|
| Rate for Payer: HFN Commercial |
$994.12
|
| Rate for Payer: Multiplan Commercial |
$864.45
|
| Rate for Payer: Preferred Network Access Commercial |
$994.12
|
| Rate for Payer: Quartz Beloit One Network |
$529.47
|
| Rate for Payer: Quartz Commercial |
$648.34
|
| Rate for Payer: WEA Trust Commercial |
$594.31
|
| Rate for Payer: WPS Commercial |
$800.34
|
|
|
DISSECTOR 5.0MM ARTHROSCOPY ARTHREX AR-8500DS
|
Facility
|
OP
|
$1,039.00
|
|
| Hospital Charge Code |
5206676
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$302.56 |
| Max. Negotiated Rate |
$994.12 |
| Rate for Payer: Aetna Commercial |
$972.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$929.28
|
| Rate for Payer: Aetna Managed Medicare |
$302.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$702.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$540.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$518.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$572.70
|
| Rate for Payer: Cash Price |
$311.70
|
| Rate for Payer: Cigna Commercial |
$994.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$604.70
|
| Rate for Payer: Health EOS Commercial |
$961.70
|
| Rate for Payer: HFN Commercial |
$994.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$810.42
|
| Rate for Payer: Multiplan Commercial |
$864.45
|
| Rate for Payer: NAPHCARE Commercial |
$648.34
|
| Rate for Payer: Preferred Network Access Commercial |
$994.12
|
| Rate for Payer: Quartz Beloit One Network |
$529.47
|
| Rate for Payer: Quartz Commercial |
$702.36
|
| Rate for Payer: Quartz Medicare Advantage |
$648.34
|
| Rate for Payer: The Alliance Commercial |
$540.28
|
| Rate for Payer: WEA Trust Commercial |
$594.31
|
| Rate for Payer: WPS Commercial |
$800.34
|
|
|
DISSECTOR ENDO PEANUT 5MM 173019
|
Facility
|
OP
|
$204.00
|
|
| Hospital Charge Code |
2963715
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$59.40 |
| Max. Negotiated Rate |
$195.19 |
| Rate for Payer: Aetna Commercial |
$190.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$182.46
|
| Rate for Payer: Aetna Managed Medicare |
$59.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$137.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$106.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$101.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$112.44
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$195.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$118.73
|
| Rate for Payer: Health EOS Commercial |
$188.82
|
| Rate for Payer: HFN Commercial |
$195.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$159.12
|
| Rate for Payer: Multiplan Commercial |
$169.73
|
| Rate for Payer: NAPHCARE Commercial |
$127.30
|
| Rate for Payer: Preferred Network Access Commercial |
$195.19
|
| Rate for Payer: Quartz Beloit One Network |
$103.96
|
| Rate for Payer: Quartz Commercial |
$137.90
|
| Rate for Payer: Quartz Medicare Advantage |
$127.30
|
| Rate for Payer: The Alliance Commercial |
$106.08
|
| Rate for Payer: WEA Trust Commercial |
$116.69
|
| Rate for Payer: WPS Commercial |
$157.14
|
|
|
DISSECTOR ENDO PEANUT 5MM 173019
|
Facility
|
IP
|
$204.00
|
|
| Hospital Charge Code |
2963715
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$103.96 |
| Max. Negotiated Rate |
$195.19 |
| Rate for Payer: Aetna Commercial |
$190.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$182.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$112.44
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Cigna Commercial |
$195.19
|
| Rate for Payer: Health EOS Commercial |
$188.82
|
| Rate for Payer: HFN Commercial |
$195.19
|
| Rate for Payer: Multiplan Commercial |
$169.73
|
| Rate for Payer: Preferred Network Access Commercial |
$195.19
|
| Rate for Payer: Quartz Beloit One Network |
$103.96
|
| Rate for Payer: Quartz Commercial |
$127.30
|
| Rate for Payer: WEA Trust Commercial |
$116.69
|
| Rate for Payer: WPS Commercial |
$157.14
|
|
|
DISSECTOR SEPS BALLOON
|
Facility
|
OP
|
$5,845.00
|
|
| Hospital Charge Code |
2967372
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,702.06 |
| Max. Negotiated Rate |
$5,592.50 |
| Rate for Payer: Aetna Commercial |
$5,470.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,227.77
|
| Rate for Payer: Aetna Managed Medicare |
$1,702.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,951.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,039.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,917.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,221.76
|
| Rate for Payer: Cash Price |
$1,753.50
|
| Rate for Payer: Cigna Commercial |
$5,592.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,401.79
|
| Rate for Payer: Health EOS Commercial |
$5,410.13
|
| Rate for Payer: HFN Commercial |
$5,592.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,559.10
|
| Rate for Payer: Multiplan Commercial |
$4,863.04
|
| Rate for Payer: NAPHCARE Commercial |
$3,647.28
|
| Rate for Payer: Preferred Network Access Commercial |
$5,592.50
|
| Rate for Payer: Quartz Beloit One Network |
$2,978.61
|
| Rate for Payer: Quartz Commercial |
$3,951.22
|
| Rate for Payer: Quartz Medicare Advantage |
$3,647.28
|
| Rate for Payer: The Alliance Commercial |
$3,039.40
|
| Rate for Payer: WEA Trust Commercial |
$3,343.34
|
| Rate for Payer: WPS Commercial |
$4,502.40
|
|
|
DISSECTOR SEPS BALLOON
|
Facility
|
IP
|
$5,845.00
|
|
| Hospital Charge Code |
2967372
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,978.61 |
| Max. Negotiated Rate |
$5,592.50 |
| Rate for Payer: Aetna Commercial |
$5,470.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,227.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,221.76
|
| Rate for Payer: Cash Price |
$1,753.50
|
| Rate for Payer: Cigna Commercial |
$5,592.50
|
| Rate for Payer: Health EOS Commercial |
$5,410.13
|
| Rate for Payer: HFN Commercial |
$5,592.50
|
| Rate for Payer: Multiplan Commercial |
$4,863.04
|
| Rate for Payer: Preferred Network Access Commercial |
$5,592.50
|
| Rate for Payer: Quartz Beloit One Network |
$2,978.61
|
| Rate for Payer: Quartz Commercial |
$3,647.28
|
| Rate for Payer: WEA Trust Commercial |
$3,343.34
|
| Rate for Payer: WPS Commercial |
$4,502.40
|
|
|
DISSECTOR SYSTEM SPACEMAKER PLUS OVAL BALLOON/TROCAR SMBTTOVLX
|
Facility
|
OP
|
$5,309.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4508954
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,545.98 |
| Max. Negotiated Rate |
$5,079.65 |
| Rate for Payer: Aetna Commercial |
$4,969.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,748.37
|
| Rate for Payer: Aetna Managed Medicare |
$1,545.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,588.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,760.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,650.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,926.32
|
| Rate for Payer: Cash Price |
$1,592.70
|
| Rate for Payer: Cigna Commercial |
$5,079.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,089.84
|
| Rate for Payer: Health EOS Commercial |
$4,914.01
|
| Rate for Payer: HFN Commercial |
$5,079.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,141.02
|
| Rate for Payer: Multiplan Commercial |
$4,417.09
|
| Rate for Payer: NAPHCARE Commercial |
$3,312.82
|
| Rate for Payer: Preferred Network Access Commercial |
$5,079.65
|
| Rate for Payer: Quartz Beloit One Network |
$2,705.47
|
| Rate for Payer: Quartz Commercial |
$3,588.88
|
| Rate for Payer: Quartz Medicare Advantage |
$3,312.82
|
| Rate for Payer: The Alliance Commercial |
$2,760.68
|
| Rate for Payer: WEA Trust Commercial |
$3,036.75
|
| Rate for Payer: WPS Commercial |
$4,089.52
|
|
|
DISSECTOR SYSTEM SPACEMAKER PLUS OVAL BALLOON/TROCAR SMBTTOVLX
|
Facility
|
IP
|
$5,309.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
4508954
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,705.47 |
| Max. Negotiated Rate |
$5,079.65 |
| Rate for Payer: Aetna Commercial |
$4,969.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,748.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,926.32
|
| Rate for Payer: Cash Price |
$1,592.70
|
| Rate for Payer: Cigna Commercial |
$5,079.65
|
| Rate for Payer: Health EOS Commercial |
$4,914.01
|
| Rate for Payer: HFN Commercial |
$5,079.65
|
| Rate for Payer: Multiplan Commercial |
$4,417.09
|
| Rate for Payer: Preferred Network Access Commercial |
$5,079.65
|
| Rate for Payer: Quartz Beloit One Network |
$2,705.47
|
| Rate for Payer: Quartz Commercial |
$3,312.82
|
| Rate for Payer: WEA Trust Commercial |
$3,036.75
|
| Rate for Payer: WPS Commercial |
$4,089.52
|
|
|
DISTAL CEMENT SPACER OMNIFIT 10MM 1067-0010
|
Facility
|
IP
|
$860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3431505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$438.26 |
| Max. Negotiated Rate |
$822.85 |
| Rate for Payer: Aetna Commercial |
$804.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$769.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$474.03
|
| Rate for Payer: Cash Price |
$258.00
|
| Rate for Payer: Cigna Commercial |
$822.85
|
| Rate for Payer: Health EOS Commercial |
$796.02
|
| Rate for Payer: HFN Commercial |
$822.85
|
| Rate for Payer: Multiplan Commercial |
$715.52
|
| Rate for Payer: Preferred Network Access Commercial |
$822.85
|
| Rate for Payer: Quartz Beloit One Network |
$438.26
|
| Rate for Payer: Quartz Commercial |
$536.64
|
| Rate for Payer: WEA Trust Commercial |
$491.92
|
| Rate for Payer: WPS Commercial |
$662.46
|
|
|
DISTAL CEMENT SPACER OMNIFIT 10MM 1067-0010
|
Facility
|
OP
|
$860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3431505
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$250.43 |
| Max. Negotiated Rate |
$822.85 |
| Rate for Payer: Aetna Commercial |
$804.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$769.18
|
| Rate for Payer: Aetna Managed Medicare |
$250.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$581.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$447.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$429.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$474.03
|
| Rate for Payer: Cash Price |
$258.00
|
| Rate for Payer: Cigna Commercial |
$822.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$500.52
|
| Rate for Payer: Health EOS Commercial |
$796.02
|
| Rate for Payer: HFN Commercial |
$822.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$670.80
|
| Rate for Payer: Multiplan Commercial |
$715.52
|
| Rate for Payer: NAPHCARE Commercial |
$536.64
|
| Rate for Payer: Preferred Network Access Commercial |
$822.85
|
| Rate for Payer: Quartz Beloit One Network |
$438.26
|
| Rate for Payer: Quartz Commercial |
$581.36
|
| Rate for Payer: Quartz Medicare Advantage |
$536.64
|
| Rate for Payer: The Alliance Commercial |
$447.20
|
| Rate for Payer: WEA Trust Commercial |
$491.92
|
| Rate for Payer: WPS Commercial |
$662.46
|
|
|
DISTAL CEMENT SPACER OMNIFIT 11MM 1067-0011
|
Facility
|
IP
|
$860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729748
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$438.26 |
| Max. Negotiated Rate |
$822.85 |
| Rate for Payer: Aetna Commercial |
$804.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$769.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$474.03
|
| Rate for Payer: Cash Price |
$258.00
|
| Rate for Payer: Cigna Commercial |
$822.85
|
| Rate for Payer: Health EOS Commercial |
$796.02
|
| Rate for Payer: HFN Commercial |
$822.85
|
| Rate for Payer: Multiplan Commercial |
$715.52
|
| Rate for Payer: Preferred Network Access Commercial |
$822.85
|
| Rate for Payer: Quartz Beloit One Network |
$438.26
|
| Rate for Payer: Quartz Commercial |
$536.64
|
| Rate for Payer: WEA Trust Commercial |
$491.92
|
| Rate for Payer: WPS Commercial |
$662.46
|
|
