|
ALLOGRAFT AFFINITY FRESH AMNIOTIC MEMBRAINE (1.5CM X 1.5CM) 2.25CM AF-1150
|
Facility
OP
|
$2,580.00
|
|
|
Service Code
|
HCPCS Q4159
|
| Hospital Charge Code |
5298717
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$346.32 |
| Max. Negotiated Rate |
$2,373.60 |
| Rate for Payer: Aetna Commercial |
$2,322.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,218.80
|
| Rate for Payer: Aetna Managed Medicare |
$722.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,677.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,290.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,238.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,367.40
|
| Rate for Payer: Cash Price |
$774.00
|
| Rate for Payer: Cash Price |
$774.00
|
| Rate for Payer: Cigna Commercial |
$2,373.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$409.57
|
| Rate for Payer: Health EOS Commercial |
$2,296.20
|
| Rate for Payer: HFN Commercial |
$2,373.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,935.00
|
| Rate for Payer: Multiplan Commercial |
$2,064.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,548.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,373.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,264.20
|
| Rate for Payer: Quartz Commercial |
$1,677.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,548.00
|
| Rate for Payer: The Alliance Commercial |
$346.32
|
| Rate for Payer: WEA Trust Commercial |
$1,419.00
|
| Rate for Payer: WPS Commercial |
$1,911.01
|
|
|
ALLOGRAFT AFFINITY FRESH AMNIOTIC MEMBRAINE (2.5CM X 2.5CM) 6.25CM AF-1250
|
Facility
IP
|
$1,401.00
|
|
|
Service Code
|
HCPCS Q4159
|
| Hospital Charge Code |
5298718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$686.49 |
| Max. Negotiated Rate |
$1,288.92 |
| Rate for Payer: Aetna Commercial |
$1,260.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$742.53
|
| Rate for Payer: Cash Price |
$420.30
|
| Rate for Payer: Cigna Commercial |
$1,288.92
|
| Rate for Payer: Health EOS Commercial |
$1,246.89
|
| Rate for Payer: HFN Commercial |
$1,288.92
|
| Rate for Payer: Multiplan Commercial |
$1,120.80
|
| Rate for Payer: NAPHCARE Commercial |
$840.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,288.92
|
| Rate for Payer: Quartz Beloit One Network |
$686.49
|
| Rate for Payer: Quartz Commercial |
$840.60
|
| Rate for Payer: WEA Trust Commercial |
$770.55
|
| Rate for Payer: WPS Commercial |
$1,037.72
|
|
|
ALLOGRAFT AFFINITY FRESH AMNIOTIC MEMBRAINE (2.5CM X 2.5CM) 6.25CM AF-1250
|
Facility
OP
|
$1,401.00
|
|
|
Service Code
|
HCPCS Q4159
|
| Hospital Charge Code |
5298718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$346.32 |
| Max. Negotiated Rate |
$1,288.92 |
| Rate for Payer: Aetna Commercial |
$1,260.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,204.86
|
| Rate for Payer: Aetna Managed Medicare |
$392.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$910.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$700.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$672.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$742.53
|
| Rate for Payer: Cash Price |
$420.30
|
| Rate for Payer: Cash Price |
$420.30
|
| Rate for Payer: Cigna Commercial |
$1,288.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$409.57
|
| Rate for Payer: Health EOS Commercial |
$1,246.89
|
| Rate for Payer: HFN Commercial |
$1,288.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,050.75
|
| Rate for Payer: Multiplan Commercial |
$1,120.80
|
| Rate for Payer: NAPHCARE Commercial |
$840.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,288.92
|
| Rate for Payer: Quartz Beloit One Network |
$686.49
|
| Rate for Payer: Quartz Commercial |
$910.65
|
| Rate for Payer: Quartz Medicare Advantage |
$840.60
|
| Rate for Payer: The Alliance Commercial |
$346.32
|
| Rate for Payer: WEA Trust Commercial |
$770.55
|
| Rate for Payer: WPS Commercial |
$1,037.72
|
|
|
ALLOGRAFT BIOCLEANSE ANTERIOR TIBIALIS TENDON 8.5MM X 275MM FOLDED 443017
|
Facility
OP
|
$13,297.00
|
|
| Hospital Charge Code |
5583378
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,723.16 |
| Max. Negotiated Rate |
$53,188.00 |
| Rate for Payer: Aetna Commercial |
$11,967.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,435.42
|
| Rate for Payer: Aetna Managed Medicare |
$3,723.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,643.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,648.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,382.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,047.41
|
| Rate for Payer: Cash Price |
$3,989.10
|
| Rate for Payer: Cigna Commercial |
$12,233.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,441.00
|
| Rate for Payer: Health EOS Commercial |
$11,834.33
|
| Rate for Payer: HFN Commercial |
$12,233.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,972.75
|
| Rate for Payer: Multiplan Commercial |
$10,637.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,978.20
|
| Rate for Payer: Preferred Network Access Commercial |
$12,233.24
|
| Rate for Payer: Quartz Beloit One Network |
$6,515.53
|
| Rate for Payer: Quartz Commercial |
$8,643.05
|
| Rate for Payer: Quartz Medicare Advantage |
$7,978.20
|
| Rate for Payer: The Alliance Commercial |
$53,188.00
|
| Rate for Payer: WEA Trust Commercial |
$7,313.35
|
| Rate for Payer: WPS Commercial |
$9,849.09
|
|
|
ALLOGRAFT BIOCLEANSE ANTERIOR TIBIALIS TENDON 8.5MM X 275MM FOLDED 443017
|
Facility
IP
|
$13,297.00
|
|
| Hospital Charge Code |
5583378
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,515.53 |
| Max. Negotiated Rate |
$12,233.24 |
| Rate for Payer: Aetna Commercial |
$11,967.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,047.41
|
| Rate for Payer: Cash Price |
$3,989.10
|
| Rate for Payer: Cigna Commercial |
$12,233.24
|
| Rate for Payer: Health EOS Commercial |
$11,834.33
|
| Rate for Payer: HFN Commercial |
$12,233.24
|
| Rate for Payer: Multiplan Commercial |
$10,637.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,978.20
|
| Rate for Payer: Preferred Network Access Commercial |
$12,233.24
|
| Rate for Payer: Quartz Beloit One Network |
$6,515.53
|
| Rate for Payer: Quartz Commercial |
$7,978.20
|
| Rate for Payer: WEA Trust Commercial |
$7,313.35
|
| Rate for Payer: WPS Commercial |
$9,849.09
|
|
|
ALLOGRAFT BIOCLEANSE SEMI-TENDINOSUS TENDON 453015
|
Facility
OP
|
$10,449.00
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
4640836
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,925.72 |
| Max. Negotiated Rate |
$9,613.08 |
| Rate for Payer: Aetna Commercial |
$9,404.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,986.14
|
| Rate for Payer: Aetna Managed Medicare |
$2,925.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,791.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,224.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,015.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,537.97
|
| Rate for Payer: Cash Price |
$3,134.70
|
| Rate for Payer: Cigna Commercial |
$9,613.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,847.26
|
| Rate for Payer: Health EOS Commercial |
$9,299.61
|
| Rate for Payer: HFN Commercial |
$9,613.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,836.75
|
| Rate for Payer: Multiplan Commercial |
$8,359.20
|
| Rate for Payer: NAPHCARE Commercial |
$6,269.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,613.08
|
| Rate for Payer: Quartz Beloit One Network |
$5,120.01
|
| Rate for Payer: Quartz Commercial |
$6,791.85
|
| Rate for Payer: Quartz Medicare Advantage |
$6,269.40
|
| Rate for Payer: WEA Trust Commercial |
$5,746.95
|
| Rate for Payer: WPS Commercial |
$7,739.57
|
|
|
ALLOGRAFT BIOCLEANSE SEMI-TENDINOSUS TENDON 453015
|
Facility
IP
|
$10,449.00
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
4640836
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,120.01 |
| Max. Negotiated Rate |
$9,613.08 |
| Rate for Payer: Aetna Commercial |
$9,404.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,537.97
|
| Rate for Payer: Cash Price |
$3,134.70
|
| Rate for Payer: Cigna Commercial |
$9,613.08
|
| Rate for Payer: Health EOS Commercial |
$9,299.61
|
| Rate for Payer: HFN Commercial |
$9,613.08
|
| Rate for Payer: Multiplan Commercial |
$8,359.20
|
| Rate for Payer: NAPHCARE Commercial |
$6,269.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,613.08
|
| Rate for Payer: Quartz Beloit One Network |
$5,120.01
|
| Rate for Payer: Quartz Commercial |
$6,269.40
|
| Rate for Payer: WEA Trust Commercial |
$5,746.95
|
| Rate for Payer: WPS Commercial |
$7,739.57
|
|
|
ALLOGRAFT CONNECT TENDON FLEXIGRAFT PRE-SUTURED 4.5 X 190MM FCON
|
Facility
IP
|
$9,012.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5917639
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,415.88 |
| Max. Negotiated Rate |
$8,291.04 |
| Rate for Payer: Aetna Commercial |
$8,110.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,776.36
|
| Rate for Payer: Cash Price |
$2,703.60
|
| Rate for Payer: Cigna Commercial |
$8,291.04
|
| Rate for Payer: Health EOS Commercial |
$8,020.68
|
| Rate for Payer: HFN Commercial |
$8,291.04
|
| Rate for Payer: Multiplan Commercial |
$7,209.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,407.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,291.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.88
|
| Rate for Payer: Quartz Commercial |
$5,407.20
|
| Rate for Payer: WEA Trust Commercial |
$4,956.60
|
| Rate for Payer: WPS Commercial |
$6,675.19
|
|
|
ALLOGRAFT CONNECT TENDON FLEXIGRAFT PRE-SUTURED 4.5 X 190MM FCON
|
Facility
OP
|
$9,012.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5917639
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.36 |
| Max. Negotiated Rate |
$8,291.04 |
| Rate for Payer: Aetna Commercial |
$8,110.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,750.32
|
| Rate for Payer: Aetna Managed Medicare |
$2,523.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,857.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,506.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,325.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,776.36
|
| Rate for Payer: Cash Price |
$2,703.60
|
| Rate for Payer: Cigna Commercial |
$8,291.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,043.12
|
| Rate for Payer: Health EOS Commercial |
$8,020.68
|
| Rate for Payer: HFN Commercial |
$8,291.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,759.00
|
| Rate for Payer: Multiplan Commercial |
$7,209.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,407.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,291.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,415.88
|
| Rate for Payer: Quartz Commercial |
$5,857.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,407.20
|
| Rate for Payer: WEA Trust Commercial |
$4,956.60
|
| Rate for Payer: WPS Commercial |
$6,675.19
|
|
|
ALLOGRAFT COSTAL CARTILAGE L60MM D1=9MM D2=10MM FROZEN CCART60
|
Facility
OP
|
$5,179.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5831642
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,450.12 |
| Max. Negotiated Rate |
$4,764.68 |
| Rate for Payer: Aetna Commercial |
$4,661.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,453.94
|
| Rate for Payer: Aetna Managed Medicare |
$1,450.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,366.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,589.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,485.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,744.87
|
| Rate for Payer: Cash Price |
$1,553.70
|
| Rate for Payer: Cigna Commercial |
$4,764.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,898.17
|
| Rate for Payer: Health EOS Commercial |
$4,609.31
|
| Rate for Payer: HFN Commercial |
$4,764.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,884.25
|
| Rate for Payer: Multiplan Commercial |
$4,143.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,107.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,764.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,537.71
|
| Rate for Payer: Quartz Commercial |
$3,366.35
|
| Rate for Payer: Quartz Medicare Advantage |
$3,107.40
|
| Rate for Payer: WEA Trust Commercial |
$2,848.45
|
| Rate for Payer: WPS Commercial |
$3,836.09
|
|
|
ALLOGRAFT COSTAL CARTILAGE L60MM D1=9MM D2=10MM FROZEN CCART60
|
Facility
IP
|
$5,179.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5831642
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,537.71 |
| Max. Negotiated Rate |
$4,764.68 |
| Rate for Payer: Aetna Commercial |
$4,661.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,744.87
|
| Rate for Payer: Cash Price |
$1,553.70
|
| Rate for Payer: Cigna Commercial |
$4,764.68
|
| Rate for Payer: Health EOS Commercial |
$4,609.31
|
| Rate for Payer: HFN Commercial |
$4,764.68
|
| Rate for Payer: Multiplan Commercial |
$4,143.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,107.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,764.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,537.71
|
| Rate for Payer: Quartz Commercial |
$3,107.40
|
| Rate for Payer: WEA Trust Commercial |
$2,848.45
|
| Rate for Payer: WPS Commercial |
$3,836.09
|
|
|
ALLOGRAFT COSTAL CARTILAGE LENGTH < 6CM L1: 4.5CM W: 1.5CM (ROOM TEMP) 12420059
|
Facility
IP
|
$5,320.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5831697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,606.80 |
| Max. Negotiated Rate |
$4,894.40 |
| Rate for Payer: Aetna Commercial |
$4,788.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,819.60
|
| Rate for Payer: Cash Price |
$1,596.00
|
| Rate for Payer: Cigna Commercial |
$4,894.40
|
| Rate for Payer: Health EOS Commercial |
$4,734.80
|
| Rate for Payer: HFN Commercial |
$4,894.40
|
| Rate for Payer: Multiplan Commercial |
$4,256.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,192.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,894.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,606.80
|
| Rate for Payer: Quartz Commercial |
$3,192.00
|
| Rate for Payer: WEA Trust Commercial |
$2,926.00
|
| Rate for Payer: WPS Commercial |
$3,940.52
|
|
|
ALLOGRAFT COSTAL CARTILAGE LENGTH < 6CM L1: 4.5CM W: 1.5CM (ROOM TEMP) 12420059
|
Facility
OP
|
$5,320.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5831697
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,489.60 |
| Max. Negotiated Rate |
$4,894.40 |
| Rate for Payer: Aetna Commercial |
$4,788.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,575.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,489.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,458.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,660.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,553.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,819.60
|
| Rate for Payer: Cash Price |
$1,596.00
|
| Rate for Payer: Cigna Commercial |
$4,894.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,977.07
|
| Rate for Payer: Health EOS Commercial |
$4,734.80
|
| Rate for Payer: HFN Commercial |
$4,894.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,990.00
|
| Rate for Payer: Multiplan Commercial |
$4,256.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,192.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,894.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,606.80
|
| Rate for Payer: Quartz Commercial |
$3,458.00
|
| Rate for Payer: Quartz Medicare Advantage |
$3,192.00
|
| Rate for Payer: WEA Trust Commercial |
$2,926.00
|
| Rate for Payer: WPS Commercial |
$3,940.52
|
|
|
ALLOGRAFT COTTON WEDGE 6MM (H) X 14MM (W) X 24MM (L) 3102-1900
|
Facility
OP
|
$9,001.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5627706
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,520.28 |
| Max. Negotiated Rate |
$8,280.92 |
| Rate for Payer: Aetna Commercial |
$8,100.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,740.86
|
| Rate for Payer: Aetna Managed Medicare |
$2,520.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,850.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,500.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,320.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,770.53
|
| Rate for Payer: Cash Price |
$2,700.30
|
| Rate for Payer: Cigna Commercial |
$8,280.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,036.96
|
| Rate for Payer: Health EOS Commercial |
$8,010.89
|
| Rate for Payer: HFN Commercial |
$8,280.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,750.75
|
| Rate for Payer: Multiplan Commercial |
$7,200.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,400.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,280.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,410.49
|
| Rate for Payer: Quartz Commercial |
$5,850.65
|
| Rate for Payer: Quartz Medicare Advantage |
$5,400.60
|
| Rate for Payer: WEA Trust Commercial |
$4,950.55
|
| Rate for Payer: WPS Commercial |
$6,667.04
|
|
|
ALLOGRAFT COTTON WEDGE 6MM (H) X 14MM (W) X 24MM (L) 3102-1900
|
Facility
IP
|
$9,001.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5627706
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,410.49 |
| Max. Negotiated Rate |
$8,280.92 |
| Rate for Payer: Aetna Commercial |
$8,100.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,770.53
|
| Rate for Payer: Cash Price |
$2,700.30
|
| Rate for Payer: Cigna Commercial |
$8,280.92
|
| Rate for Payer: Health EOS Commercial |
$8,010.89
|
| Rate for Payer: HFN Commercial |
$8,280.92
|
| Rate for Payer: Multiplan Commercial |
$7,200.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,400.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,280.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,410.49
|
| Rate for Payer: Quartz Commercial |
$5,400.60
|
| Rate for Payer: WEA Trust Commercial |
$4,950.55
|
| Rate for Payer: WPS Commercial |
$6,667.04
|
|
|
ALLOGRAFT COTTON WEDGE ALLOPURE BICORTICAL 6MM X 6MM (FREEZE DRIED ) 8666-0006
|
Facility
IP
|
$9,478.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6179807
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,644.22 |
| Max. Negotiated Rate |
$8,719.76 |
| Rate for Payer: Aetna Commercial |
$8,530.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,023.34
|
| Rate for Payer: Cash Price |
$2,843.40
|
| Rate for Payer: Cigna Commercial |
$8,719.76
|
| Rate for Payer: Health EOS Commercial |
$8,435.42
|
| Rate for Payer: HFN Commercial |
$8,719.76
|
| Rate for Payer: Multiplan Commercial |
$7,582.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,686.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,719.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,644.22
|
| Rate for Payer: Quartz Commercial |
$5,686.80
|
| Rate for Payer: WEA Trust Commercial |
$5,212.90
|
| Rate for Payer: WPS Commercial |
$7,020.35
|
|
|
ALLOGRAFT COTTON WEDGE ALLOPURE BICORTICAL 6MM X 6MM (FREEZE DRIED ) 8666-0006
|
Facility
OP
|
$9,478.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6179807
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,653.84 |
| Max. Negotiated Rate |
$8,719.76 |
| Rate for Payer: Aetna Commercial |
$8,530.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,151.08
|
| Rate for Payer: Aetna Managed Medicare |
$2,653.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,160.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,739.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,549.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,023.34
|
| Rate for Payer: Cash Price |
$2,843.40
|
| Rate for Payer: Cigna Commercial |
$8,719.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,303.89
|
| Rate for Payer: Health EOS Commercial |
$8,435.42
|
| Rate for Payer: HFN Commercial |
$8,719.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,108.50
|
| Rate for Payer: Multiplan Commercial |
$7,582.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,686.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,719.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,644.22
|
| Rate for Payer: Quartz Commercial |
$6,160.70
|
| Rate for Payer: Quartz Medicare Advantage |
$5,686.80
|
| Rate for Payer: WEA Trust Commercial |
$5,212.90
|
| Rate for Payer: WPS Commercial |
$7,020.35
|
|
|
ALLOGRAFT CRUSHED CANCELLOUS CHIPS 5CC 3102-1505
|
Facility
OP
|
$2,026.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6167717
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$567.28 |
| Max. Negotiated Rate |
$1,863.92 |
| Rate for Payer: Aetna Commercial |
$1,823.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,742.36
|
| Rate for Payer: Aetna Managed Medicare |
$567.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,316.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,013.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$972.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,073.78
|
| Rate for Payer: Cash Price |
$607.80
|
| Rate for Payer: Cigna Commercial |
$1,863.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,133.75
|
| Rate for Payer: Health EOS Commercial |
$1,803.14
|
| Rate for Payer: HFN Commercial |
$1,863.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,519.50
|
| Rate for Payer: Multiplan Commercial |
$1,620.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,215.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,863.92
|
| Rate for Payer: Quartz Beloit One Network |
$992.74
|
| Rate for Payer: Quartz Commercial |
$1,316.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,215.60
|
| Rate for Payer: WEA Trust Commercial |
$1,114.30
|
| Rate for Payer: WPS Commercial |
$1,500.66
|
|
|
ALLOGRAFT CRUSHED CANCELLOUS CHIPS 5CC 3102-1505
|
Facility
IP
|
$2,026.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6167717
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$992.74 |
| Max. Negotiated Rate |
$1,863.92 |
| Rate for Payer: Aetna Commercial |
$1,823.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,073.78
|
| Rate for Payer: Cash Price |
$607.80
|
| Rate for Payer: Cigna Commercial |
$1,863.92
|
| Rate for Payer: Health EOS Commercial |
$1,803.14
|
| Rate for Payer: HFN Commercial |
$1,863.92
|
| Rate for Payer: Multiplan Commercial |
$1,620.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,215.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,863.92
|
| Rate for Payer: Quartz Beloit One Network |
$992.74
|
| Rate for Payer: Quartz Commercial |
$1,215.60
|
| Rate for Payer: WEA Trust Commercial |
$1,114.30
|
| Rate for Payer: WPS Commercial |
$1,500.66
|
|
|
ALLOGRAFT DISTAL FEMUR SHORT RT 150-250MM 640208
|
Facility
OP
|
$11,287.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
2967969
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,160.36 |
| Max. Negotiated Rate |
$10,384.04 |
| Rate for Payer: Aetna Commercial |
$10,158.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,706.82
|
| Rate for Payer: Aetna Managed Medicare |
$3,160.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,336.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,643.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,417.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,982.11
|
| Rate for Payer: Cash Price |
$3,386.10
|
| Rate for Payer: Cigna Commercial |
$10,384.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,316.21
|
| Rate for Payer: Health EOS Commercial |
$10,045.43
|
| Rate for Payer: HFN Commercial |
$10,384.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,465.25
|
| Rate for Payer: Multiplan Commercial |
$9,029.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,772.20
|
| Rate for Payer: Preferred Network Access Commercial |
$10,384.04
|
| Rate for Payer: Quartz Beloit One Network |
$5,530.63
|
| Rate for Payer: Quartz Commercial |
$7,336.55
|
| Rate for Payer: Quartz Medicare Advantage |
$6,772.20
|
| Rate for Payer: WEA Trust Commercial |
$6,207.85
|
| Rate for Payer: WPS Commercial |
$8,360.28
|
|
|
ALLOGRAFT DISTAL FEMUR SHORT RT 150-250MM 640208
|
Facility
IP
|
$11,287.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
2967969
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,530.63 |
| Max. Negotiated Rate |
$10,384.04 |
| Rate for Payer: Aetna Commercial |
$10,158.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,982.11
|
| Rate for Payer: Cash Price |
$3,386.10
|
| Rate for Payer: Cigna Commercial |
$10,384.04
|
| Rate for Payer: Health EOS Commercial |
$10,045.43
|
| Rate for Payer: HFN Commercial |
$10,384.04
|
| Rate for Payer: Multiplan Commercial |
$9,029.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,772.20
|
| Rate for Payer: Preferred Network Access Commercial |
$10,384.04
|
| Rate for Payer: Quartz Beloit One Network |
$5,530.63
|
| Rate for Payer: Quartz Commercial |
$6,772.20
|
| Rate for Payer: WEA Trust Commercial |
$6,207.85
|
| Rate for Payer: WPS Commercial |
$8,360.28
|
|
|
ALLOGRAFT EVANS WEDGE 10MM (H) X 20MM (W) X 22MM (L) 3102-1910
|
Facility
IP
|
$9,001.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5627708
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,410.49 |
| Max. Negotiated Rate |
$8,280.92 |
| Rate for Payer: Aetna Commercial |
$8,100.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,770.53
|
| Rate for Payer: Cash Price |
$2,700.30
|
| Rate for Payer: Cigna Commercial |
$8,280.92
|
| Rate for Payer: Health EOS Commercial |
$8,010.89
|
| Rate for Payer: HFN Commercial |
$8,280.92
|
| Rate for Payer: Multiplan Commercial |
$7,200.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,400.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,280.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,410.49
|
| Rate for Payer: Quartz Commercial |
$5,400.60
|
| Rate for Payer: WEA Trust Commercial |
$4,950.55
|
| Rate for Payer: WPS Commercial |
$6,667.04
|
|
|
ALLOGRAFT EVANS WEDGE 10MM (H) X 20MM (W) X 22MM (L) 3102-1910
|
Facility
OP
|
$9,001.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5627708
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,520.28 |
| Max. Negotiated Rate |
$8,280.92 |
| Rate for Payer: Aetna Commercial |
$8,100.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,740.86
|
| Rate for Payer: Aetna Managed Medicare |
$2,520.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,850.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,500.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,320.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,770.53
|
| Rate for Payer: Cash Price |
$2,700.30
|
| Rate for Payer: Cigna Commercial |
$8,280.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,036.96
|
| Rate for Payer: Health EOS Commercial |
$8,010.89
|
| Rate for Payer: HFN Commercial |
$8,280.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,750.75
|
| Rate for Payer: Multiplan Commercial |
$7,200.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,400.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,280.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,410.49
|
| Rate for Payer: Quartz Commercial |
$5,850.65
|
| Rate for Payer: Quartz Medicare Advantage |
$5,400.60
|
| Rate for Payer: WEA Trust Commercial |
$4,950.55
|
| Rate for Payer: WPS Commercial |
$6,667.04
|
|
|
ALLOGRAFT EVANS WEDGE 12MM (H) X 20MM (W) X 22MM (L) 3102-1912
|
Facility
OP
|
$9,001.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5627709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,520.28 |
| Max. Negotiated Rate |
$8,280.92 |
| Rate for Payer: Aetna Commercial |
$8,100.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,740.86
|
| Rate for Payer: Aetna Managed Medicare |
$2,520.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,850.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,500.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,320.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,770.53
|
| Rate for Payer: Cash Price |
$2,700.30
|
| Rate for Payer: Cigna Commercial |
$8,280.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,036.96
|
| Rate for Payer: Health EOS Commercial |
$8,010.89
|
| Rate for Payer: HFN Commercial |
$8,280.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,750.75
|
| Rate for Payer: Multiplan Commercial |
$7,200.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,400.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,280.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,410.49
|
| Rate for Payer: Quartz Commercial |
$5,850.65
|
| Rate for Payer: Quartz Medicare Advantage |
$5,400.60
|
| Rate for Payer: WEA Trust Commercial |
$4,950.55
|
| Rate for Payer: WPS Commercial |
$6,667.04
|
|
|
ALLOGRAFT EVANS WEDGE 12MM (H) X 20MM (W) X 22MM (L) 3102-1912
|
Facility
IP
|
$9,001.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5627709
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,410.49 |
| Max. Negotiated Rate |
$8,280.92 |
| Rate for Payer: Aetna Commercial |
$8,100.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,770.53
|
| Rate for Payer: Cash Price |
$2,700.30
|
| Rate for Payer: Cigna Commercial |
$8,280.92
|
| Rate for Payer: Health EOS Commercial |
$8,010.89
|
| Rate for Payer: HFN Commercial |
$8,280.92
|
| Rate for Payer: Multiplan Commercial |
$7,200.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,400.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,280.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,410.49
|
| Rate for Payer: Quartz Commercial |
$5,400.60
|
| Rate for Payer: WEA Trust Commercial |
$4,950.55
|
| Rate for Payer: WPS Commercial |
$6,667.04
|
|
