|
HCG, Serum
|
Facility
|
OP
|
$153.00
|
|
|
Service Code
|
CPT 84702
|
| Hospital Charge Code |
2942984
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.65 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Aetna Managed Medicare |
$15.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.39
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.98
|
| Rate for Payer: Anthem Medicare Advantage |
$15.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.65
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.05
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.65
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.65
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: NAPHCARE Commercial |
$23.48
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$103.43
|
| Rate for Payer: Quartz Medicare Advantage |
$15.65
|
| Rate for Payer: The Alliance Commercial |
$62.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.65
|
| Rate for Payer: United Healthcare PPO |
$119.34
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: Wellcare Medicare |
$15.65
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
HE4, Ovarian Cancer Monitoring
|
Professional
|
Both
|
$568.00
|
|
|
Service Code
|
CPT 86305
|
| Hospital Charge Code |
1039141
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.64 |
| Max. Negotiated Rate |
$561.18 |
| Rate for Payer: Aetna Commercial |
$561.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$508.02
|
| Rate for Payer: Aetna Managed Medicare |
$21.64
|
| Rate for Payer: Anthem Medicare Advantage |
$21.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.64
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$561.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$295.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.64
|
| Rate for Payer: Health EOS Commercial |
$537.56
|
| Rate for Payer: HFN Commercial |
$561.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$76.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.64
|
| Rate for Payer: Multiplan Commercial |
$472.58
|
| Rate for Payer: NAPHCARE Commercial |
$32.46
|
| Rate for Payer: Preferred Network Access Commercial |
$561.18
|
| Rate for Payer: Quartz Beloit One Network |
$259.92
|
| Rate for Payer: Quartz Commercial |
$336.71
|
| Rate for Payer: Quartz Medicare Advantage |
$21.64
|
| Rate for Payer: The Alliance Commercial |
$85.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.64
|
| Rate for Payer: WEA Trust Commercial |
$324.90
|
| Rate for Payer: WPS Commercial |
$95.23
|
|
|
HE4, Ovarian Cancer Monitoring
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
CPT 86305
|
| Hospital Charge Code |
1039141
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.64 |
| Max. Negotiated Rate |
$543.46 |
| Rate for Payer: Aetna Commercial |
$531.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$508.02
|
| Rate for Payer: Aetna Managed Medicare |
$21.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.87
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.93
|
| Rate for Payer: Anthem Medicare Advantage |
$21.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$313.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.64
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$543.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$21.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$330.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$21.64
|
| Rate for Payer: Health EOS Commercial |
$525.74
|
| Rate for Payer: HFN Commercial |
$543.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$21.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$21.64
|
| Rate for Payer: Multiplan Commercial |
$472.58
|
| Rate for Payer: NAPHCARE Commercial |
$32.46
|
| Rate for Payer: Preferred Network Access Commercial |
$543.46
|
| Rate for Payer: Quartz Beloit One Network |
$289.45
|
| Rate for Payer: Quartz Commercial |
$383.97
|
| Rate for Payer: Quartz Medicare Advantage |
$21.64
|
| Rate for Payer: The Alliance Commercial |
$86.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.64
|
| Rate for Payer: United Healthcare PPO |
$443.04
|
| Rate for Payer: WEA Trust Commercial |
$324.90
|
| Rate for Payer: Wellcare Medicare |
$21.64
|
| Rate for Payer: WPS Commercial |
$437.53
|
|
|
HE4, Ovarian Cancer Monitoring
|
Facility
|
IP
|
$568.00
|
|
|
Service Code
|
CPT 86305
|
| Hospital Charge Code |
1039141
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$289.45 |
| Max. Negotiated Rate |
$543.46 |
| Rate for Payer: Aetna Commercial |
$531.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$508.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$313.08
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$543.46
|
| Rate for Payer: Health EOS Commercial |
$525.74
|
| Rate for Payer: HFN Commercial |
$543.46
|
| Rate for Payer: Multiplan Commercial |
$472.58
|
| Rate for Payer: Preferred Network Access Commercial |
$543.46
|
| Rate for Payer: Quartz Beloit One Network |
$289.45
|
| Rate for Payer: Quartz Commercial |
$354.43
|
| Rate for Payer: WEA Trust Commercial |
$324.90
|
| Rate for Payer: WPS Commercial |
$437.53
|
|
|
HEAD 18MM EVOLVE RADIAL
|
Facility
|
OP
|
$12,439.00
|
|
| Hospital Charge Code |
2967398
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,622.24 |
| Max. Negotiated Rate |
$11,901.64 |
| Rate for Payer: Aetna Commercial |
$11,642.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,125.44
|
| Rate for Payer: Aetna Managed Medicare |
$3,622.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,408.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,468.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,209.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,856.38
|
| Rate for Payer: Cash Price |
$3,731.70
|
| Rate for Payer: Cigna Commercial |
$11,901.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,239.50
|
| Rate for Payer: Health EOS Commercial |
$11,513.54
|
| Rate for Payer: HFN Commercial |
$11,901.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,702.42
|
| Rate for Payer: Multiplan Commercial |
$10,349.25
|
| Rate for Payer: NAPHCARE Commercial |
$7,761.94
|
| Rate for Payer: Preferred Network Access Commercial |
$11,901.64
|
| Rate for Payer: Quartz Beloit One Network |
$6,338.91
|
| Rate for Payer: Quartz Commercial |
$8,408.76
|
| Rate for Payer: Quartz Medicare Advantage |
$7,761.94
|
| Rate for Payer: The Alliance Commercial |
$6,468.28
|
| Rate for Payer: WEA Trust Commercial |
$7,115.11
|
| Rate for Payer: WPS Commercial |
$9,581.76
|
|
|
HEAD 18MM EVOLVE RADIAL
|
Facility
|
IP
|
$12,439.00
|
|
| Hospital Charge Code |
2967398
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,338.91 |
| Max. Negotiated Rate |
$11,901.64 |
| Rate for Payer: Aetna Commercial |
$11,642.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,125.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,856.38
|
| Rate for Payer: Cash Price |
$3,731.70
|
| Rate for Payer: Cigna Commercial |
$11,901.64
|
| Rate for Payer: Health EOS Commercial |
$11,513.54
|
| Rate for Payer: HFN Commercial |
$11,901.64
|
| Rate for Payer: Multiplan Commercial |
$10,349.25
|
| Rate for Payer: Preferred Network Access Commercial |
$11,901.64
|
| Rate for Payer: Quartz Beloit One Network |
$6,338.91
|
| Rate for Payer: Quartz Commercial |
$7,761.94
|
| Rate for Payer: WEA Trust Commercial |
$7,115.11
|
| Rate for Payer: WPS Commercial |
$9,581.76
|
|
|
HEAD 46/17.25 HUMERAL
|
Facility
|
IP
|
$13,932.00
|
|
| Hospital Charge Code |
2966252
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,099.75 |
| Max. Negotiated Rate |
$13,330.14 |
| Rate for Payer: Aetna Commercial |
$13,040.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,460.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,679.32
|
| Rate for Payer: Cash Price |
$4,179.60
|
| Rate for Payer: Cigna Commercial |
$13,330.14
|
| Rate for Payer: Health EOS Commercial |
$12,895.46
|
| Rate for Payer: HFN Commercial |
$13,330.14
|
| Rate for Payer: Multiplan Commercial |
$11,591.42
|
| Rate for Payer: Preferred Network Access Commercial |
$13,330.14
|
| Rate for Payer: Quartz Beloit One Network |
$7,099.75
|
| Rate for Payer: Quartz Commercial |
$8,693.57
|
| Rate for Payer: WEA Trust Commercial |
$7,969.10
|
| Rate for Payer: WPS Commercial |
$10,731.82
|
|
|
HEAD 46/17.25 HUMERAL
|
Facility
|
OP
|
$13,932.00
|
|
| Hospital Charge Code |
2966252
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,057.00 |
| Max. Negotiated Rate |
$13,330.14 |
| Rate for Payer: Aetna Commercial |
$13,040.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,460.78
|
| Rate for Payer: Aetna Managed Medicare |
$4,057.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,418.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,244.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,954.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,679.32
|
| Rate for Payer: Cash Price |
$4,179.60
|
| Rate for Payer: Cigna Commercial |
$13,330.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,108.42
|
| Rate for Payer: Health EOS Commercial |
$12,895.46
|
| Rate for Payer: HFN Commercial |
$13,330.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,866.96
|
| Rate for Payer: Multiplan Commercial |
$11,591.42
|
| Rate for Payer: NAPHCARE Commercial |
$8,693.57
|
| Rate for Payer: Preferred Network Access Commercial |
$13,330.14
|
| Rate for Payer: Quartz Beloit One Network |
$7,099.75
|
| Rate for Payer: Quartz Commercial |
$9,418.03
|
| Rate for Payer: Quartz Medicare Advantage |
$8,693.57
|
| Rate for Payer: The Alliance Commercial |
$7,244.64
|
| Rate for Payer: WEA Trust Commercial |
$7,969.10
|
| Rate for Payer: WPS Commercial |
$10,731.82
|
|
|
HEADACHES OTHER THAN MIGRAINE
|
Facility
|
OP
|
$102.20
|
|
|
Service Code
|
EAPG 00530
|
| Min. Negotiated Rate |
$98.27 |
| Max. Negotiated Rate |
$102.20 |
| Rate for Payer: Anthem Medicaid |
$98.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$98.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$98.27
|
| Rate for Payer: Dean Health Medicaid |
$98.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$98.27
|
| Rate for Payer: Managed Health Services Medicaid |
$102.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$98.27
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$98.27
|
| Rate for Payer: United Healthcare Medicaid |
$98.27
|
|
|
HEADACHES WITH MCC
|
Facility
|
IP
|
$33,694.96
|
|
|
Service Code
|
MSDRG 102
|
| Min. Negotiated Rate |
$9,090.87 |
| Max. Negotiated Rate |
$33,694.96 |
| Rate for Payer: Aetna Managed Medicare |
$9,090.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24,457.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,746.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,810.11
|
| Rate for Payer: Anthem Medicare Advantage |
$9,090.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9,090.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9,090.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9,090.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,770.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9,090.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24,469.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9,090.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9,090.87
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9,090.87
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9,090.87
|
| Rate for Payer: NAPHCARE Commercial |
$13,636.30
|
| Rate for Payer: Quartz Medicare Advantage |
$9,090.87
|
| Rate for Payer: The Alliance Commercial |
$33,694.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9,090.87
|
| Rate for Payer: United Healthcare PPO |
$19,050.09
|
| Rate for Payer: Wellcare Medicare |
$9,090.87
|
|
|
HEADACHES WITHOUT MCC
|
Facility
|
IP
|
$23,624.64
|
|
|
Service Code
|
MSDRG 103
|
| Min. Negotiated Rate |
$6,911.33 |
| Max. Negotiated Rate |
$23,624.64 |
| Rate for Payer: Aetna Managed Medicare |
$6,911.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,247.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,986.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,288.07
|
| Rate for Payer: Anthem Medicare Advantage |
$6,911.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,911.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,911.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,911.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,750.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,911.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,083.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,911.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,911.33
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,911.33
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,911.33
|
| Rate for Payer: NAPHCARE Commercial |
$10,367.00
|
| Rate for Payer: Quartz Medicare Advantage |
$6,911.33
|
| Rate for Payer: The Alliance Commercial |
$23,624.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,911.33
|
| Rate for Payer: United Healthcare PPO |
$13,300.01
|
| Rate for Payer: Wellcare Medicare |
$6,911.33
|
|
|
HEADBAND TFI SENSOR #1608
|
Facility
|
IP
|
$131.00
|
|
| Hospital Charge Code |
2974459
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.76 |
| Max. Negotiated Rate |
$125.34 |
| Rate for Payer: Aetna Commercial |
$122.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$117.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$72.21
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cigna Commercial |
$125.34
|
| Rate for Payer: Health EOS Commercial |
$121.25
|
| Rate for Payer: HFN Commercial |
$125.34
|
| Rate for Payer: Multiplan Commercial |
$108.99
|
| Rate for Payer: Preferred Network Access Commercial |
$125.34
|
| Rate for Payer: Quartz Beloit One Network |
$66.76
|
| Rate for Payer: Quartz Commercial |
$81.74
|
| Rate for Payer: WEA Trust Commercial |
$74.93
|
| Rate for Payer: WPS Commercial |
$100.91
|
|
|
HEADBAND TFI SENSOR #1608
|
Facility
|
OP
|
$131.00
|
|
| Hospital Charge Code |
2974459
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.15 |
| Max. Negotiated Rate |
$125.34 |
| Rate for Payer: Aetna Commercial |
$122.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$117.17
|
| Rate for Payer: Aetna Managed Medicare |
$38.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$88.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$68.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$65.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$72.21
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cigna Commercial |
$125.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$76.24
|
| Rate for Payer: Health EOS Commercial |
$121.25
|
| Rate for Payer: HFN Commercial |
$125.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$102.18
|
| Rate for Payer: Multiplan Commercial |
$108.99
|
| Rate for Payer: NAPHCARE Commercial |
$81.74
|
| Rate for Payer: Preferred Network Access Commercial |
$125.34
|
| Rate for Payer: Quartz Beloit One Network |
$66.76
|
| Rate for Payer: Quartz Commercial |
$88.56
|
| Rate for Payer: Quartz Medicare Advantage |
$81.74
|
| Rate for Payer: The Alliance Commercial |
$68.12
|
| Rate for Payer: WEA Trust Commercial |
$74.93
|
| Rate for Payer: WPS Commercial |
$100.91
|
|
|
HEAD COMPONENT EVOLVE 22mm 496-H022
|
Facility
|
IP
|
$12,439.00
|
|
| Hospital Charge Code |
2967399
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,338.91 |
| Max. Negotiated Rate |
$11,901.64 |
| Rate for Payer: Aetna Commercial |
$11,642.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,125.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,856.38
|
| Rate for Payer: Cash Price |
$3,731.70
|
| Rate for Payer: Cigna Commercial |
$11,901.64
|
| Rate for Payer: Health EOS Commercial |
$11,513.54
|
| Rate for Payer: HFN Commercial |
$11,901.64
|
| Rate for Payer: Multiplan Commercial |
$10,349.25
|
| Rate for Payer: Preferred Network Access Commercial |
$11,901.64
|
| Rate for Payer: Quartz Beloit One Network |
$6,338.91
|
| Rate for Payer: Quartz Commercial |
$7,761.94
|
| Rate for Payer: WEA Trust Commercial |
$7,115.11
|
| Rate for Payer: WPS Commercial |
$9,581.76
|
|
|
HEAD COMPONENT EVOLVE 22mm 496-H022
|
Facility
|
OP
|
$12,439.00
|
|
| Hospital Charge Code |
2967399
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,622.24 |
| Max. Negotiated Rate |
$11,901.64 |
| Rate for Payer: Aetna Commercial |
$11,642.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,125.44
|
| Rate for Payer: Aetna Managed Medicare |
$3,622.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,408.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,468.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,209.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,856.38
|
| Rate for Payer: Cash Price |
$3,731.70
|
| Rate for Payer: Cigna Commercial |
$11,901.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,239.50
|
| Rate for Payer: Health EOS Commercial |
$11,513.54
|
| Rate for Payer: HFN Commercial |
$11,901.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,702.42
|
| Rate for Payer: Multiplan Commercial |
$10,349.25
|
| Rate for Payer: NAPHCARE Commercial |
$7,761.94
|
| Rate for Payer: Preferred Network Access Commercial |
$11,901.64
|
| Rate for Payer: Quartz Beloit One Network |
$6,338.91
|
| Rate for Payer: Quartz Commercial |
$8,408.76
|
| Rate for Payer: Quartz Medicare Advantage |
$7,761.94
|
| Rate for Payer: The Alliance Commercial |
$6,468.28
|
| Rate for Payer: WEA Trust Commercial |
$7,115.11
|
| Rate for Payer: WPS Commercial |
$9,581.76
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 38MM 6942-5-038
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4518646
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 38MM 6942-5-038
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4518646
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,485.83 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,043.87
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 39MM 6942-5-039
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4388404
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 39MM 6942-5-039
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4388404
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,485.83 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,043.87
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 40MM 6942-5-040
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4518647
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,485.83 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,043.87
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 40MM 6942-5-040
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4518647
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 41MM 6942-5-041
|
Facility
|
OP
|
$4,878.00
|
|
| Hospital Charge Code |
4518648
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 41MM 6942-5-041
|
Facility
|
IP
|
$4,878.00
|
|
| Hospital Charge Code |
4518648
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,485.83 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,043.87
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 42MM 6942-5-042
|
Facility
|
IP
|
$4,878.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4518649
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,485.83 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,043.87
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
|
HEAD COMPONENT UNITRAX ENDOPROSTHESIS 42MM 6942-5-042
|
Facility
|
OP
|
$4,878.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4518649
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,420.47 |
| Max. Negotiated Rate |
$4,667.27 |
| Rate for Payer: Aetna Commercial |
$4,565.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,362.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,420.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,297.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,536.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,435.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,688.75
|
| Rate for Payer: Cash Price |
$1,463.40
|
| Rate for Payer: Cigna Commercial |
$4,667.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,839.00
|
| Rate for Payer: Health EOS Commercial |
$4,515.08
|
| Rate for Payer: HFN Commercial |
$4,667.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,804.84
|
| Rate for Payer: Multiplan Commercial |
$4,058.50
|
| Rate for Payer: NAPHCARE Commercial |
$3,043.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,667.27
|
| Rate for Payer: Quartz Beloit One Network |
$2,485.83
|
| Rate for Payer: Quartz Commercial |
$3,297.53
|
| Rate for Payer: Quartz Medicare Advantage |
$3,043.87
|
| Rate for Payer: The Alliance Commercial |
$2,536.56
|
| Rate for Payer: WEA Trust Commercial |
$2,790.22
|
| Rate for Payer: WPS Commercial |
$3,757.52
|
|
