|
ALLOGRAFT EVANS WEDGE 8MM (H) X 20MM (W) X 22 (L) 3102-1908
|
Facility
IP
|
$9,001.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5627707
|
|
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 8MM (H) X 20MM (W) X 22 (L) 3102-1908
|
Facility
OP
|
$9,001.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5627707
|
|
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 ALLOPURE BICORTICAL 8MM X 8MM (FREEZE DRIED) 8666-0800
|
Facility
IP
|
$10,062.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6179806
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,930.38 |
| Max. Negotiated Rate |
$9,257.04 |
| Rate for Payer: Aetna Commercial |
$9,055.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,332.86
|
| Rate for Payer: Cash Price |
$3,018.60
|
| Rate for Payer: Cigna Commercial |
$9,257.04
|
| Rate for Payer: Health EOS Commercial |
$8,955.18
|
| Rate for Payer: HFN Commercial |
$9,257.04
|
| Rate for Payer: Multiplan Commercial |
$8,049.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,037.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,257.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,930.38
|
| Rate for Payer: Quartz Commercial |
$6,037.20
|
| Rate for Payer: WEA Trust Commercial |
$5,534.10
|
| Rate for Payer: WPS Commercial |
$7,452.92
|
|
|
ALLOGRAFT EVANS WEDGE ALLOPURE BICORTICAL 8MM X 8MM (FREEZE DRIED) 8666-0800
|
Facility
OP
|
$10,062.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6179806
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.36 |
| Max. Negotiated Rate |
$9,257.04 |
| Rate for Payer: Aetna Commercial |
$9,055.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,653.32
|
| Rate for Payer: Aetna Managed Medicare |
$2,817.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,540.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,031.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,829.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,332.86
|
| Rate for Payer: Cash Price |
$3,018.60
|
| Rate for Payer: Cigna Commercial |
$9,257.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,630.70
|
| Rate for Payer: Health EOS Commercial |
$8,955.18
|
| Rate for Payer: HFN Commercial |
$9,257.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,546.50
|
| Rate for Payer: Multiplan Commercial |
$8,049.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,037.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,257.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,930.38
|
| Rate for Payer: Quartz Commercial |
$6,540.30
|
| Rate for Payer: Quartz Medicare Advantage |
$6,037.20
|
| Rate for Payer: WEA Trust Commercial |
$5,534.10
|
| Rate for Payer: WPS Commercial |
$7,452.92
|
|
|
ALLOGRAFT FASCIALOTA 8x20
|
Facility
IP
|
$11,530.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
2965941
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,649.70 |
| Max. Negotiated Rate |
$10,607.60 |
| Rate for Payer: Aetna Commercial |
$10,377.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,110.90
|
| Rate for Payer: Cash Price |
$3,459.00
|
| Rate for Payer: Cigna Commercial |
$10,607.60
|
| Rate for Payer: Health EOS Commercial |
$10,261.70
|
| Rate for Payer: HFN Commercial |
$10,607.60
|
| Rate for Payer: Multiplan Commercial |
$9,224.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,918.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,607.60
|
| Rate for Payer: Quartz Beloit One Network |
$5,649.70
|
| Rate for Payer: Quartz Commercial |
$6,918.00
|
| Rate for Payer: WEA Trust Commercial |
$6,341.50
|
| Rate for Payer: WPS Commercial |
$8,540.27
|
|
|
ALLOGRAFT FASCIALOTA 8x20
|
Facility
OP
|
$11,530.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
2965941
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,228.40 |
| Max. Negotiated Rate |
$10,607.60 |
| Rate for Payer: Aetna Commercial |
$10,377.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,915.80
|
| Rate for Payer: Aetna Managed Medicare |
$3,228.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,494.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,765.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,534.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,110.90
|
| Rate for Payer: Cash Price |
$3,459.00
|
| Rate for Payer: Cigna Commercial |
$10,607.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,452.19
|
| Rate for Payer: Health EOS Commercial |
$10,261.70
|
| Rate for Payer: HFN Commercial |
$10,607.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,647.50
|
| Rate for Payer: Multiplan Commercial |
$9,224.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,918.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,607.60
|
| Rate for Payer: Quartz Beloit One Network |
$5,649.70
|
| Rate for Payer: Quartz Commercial |
$7,494.50
|
| Rate for Payer: Quartz Medicare Advantage |
$6,918.00
|
| Rate for Payer: WEA Trust Commercial |
$6,341.50
|
| Rate for Payer: WPS Commercial |
$8,540.27
|
|
|
ALLOGRAFT GRAFTLINK FGL
|
Facility
OP
|
$12,979.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5308125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,634.12 |
| Max. Negotiated Rate |
$11,940.68 |
| Rate for Payer: Aetna Commercial |
$11,681.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,161.94
|
| Rate for Payer: Aetna Managed Medicare |
$3,634.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,436.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,489.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,229.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,878.87
|
| Rate for Payer: Cash Price |
$3,893.70
|
| Rate for Payer: Cigna Commercial |
$11,940.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,263.05
|
| Rate for Payer: Health EOS Commercial |
$11,551.31
|
| Rate for Payer: HFN Commercial |
$11,940.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,734.25
|
| Rate for Payer: Multiplan Commercial |
$10,383.20
|
| Rate for Payer: NAPHCARE Commercial |
$7,787.40
|
| Rate for Payer: Preferred Network Access Commercial |
$11,940.68
|
| Rate for Payer: Quartz Beloit One Network |
$6,359.71
|
| Rate for Payer: Quartz Commercial |
$8,436.35
|
| Rate for Payer: Quartz Medicare Advantage |
$7,787.40
|
| Rate for Payer: WEA Trust Commercial |
$7,138.45
|
| Rate for Payer: WPS Commercial |
$9,613.55
|
|
|
ALLOGRAFT GRAFTLINK FGL
|
Facility
IP
|
$12,979.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5308125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,359.71 |
| Max. Negotiated Rate |
$11,940.68 |
| Rate for Payer: Aetna Commercial |
$11,681.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,878.87
|
| Rate for Payer: Cash Price |
$3,893.70
|
| Rate for Payer: Cigna Commercial |
$11,940.68
|
| Rate for Payer: Health EOS Commercial |
$11,551.31
|
| Rate for Payer: HFN Commercial |
$11,940.68
|
| Rate for Payer: Multiplan Commercial |
$10,383.20
|
| Rate for Payer: NAPHCARE Commercial |
$7,787.40
|
| Rate for Payer: Preferred Network Access Commercial |
$11,940.68
|
| Rate for Payer: Quartz Beloit One Network |
$6,359.71
|
| Rate for Payer: Quartz Commercial |
$7,787.40
|
| Rate for Payer: WEA Trust Commercial |
$7,138.45
|
| Rate for Payer: WPS Commercial |
$9,613.55
|
|
|
ALLOGRAFT GRAFTLINK TRIPLE STRAND FGLTS
|
Facility
IP
|
$12,117.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5611646
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,937.33 |
| Max. Negotiated Rate |
$11,147.64 |
| Rate for Payer: Aetna Commercial |
$10,905.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,422.01
|
| Rate for Payer: Cash Price |
$3,635.10
|
| Rate for Payer: Cigna Commercial |
$11,147.64
|
| Rate for Payer: Health EOS Commercial |
$10,784.13
|
| Rate for Payer: HFN Commercial |
$11,147.64
|
| Rate for Payer: Multiplan Commercial |
$9,693.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,270.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,147.64
|
| Rate for Payer: Quartz Beloit One Network |
$5,937.33
|
| Rate for Payer: Quartz Commercial |
$7,270.20
|
| Rate for Payer: WEA Trust Commercial |
$6,664.35
|
| Rate for Payer: WPS Commercial |
$8,975.06
|
|
|
ALLOGRAFT GRAFTLINK TRIPLE STRAND FGLTS
|
Facility
OP
|
$12,117.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5611646
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,392.76 |
| Max. Negotiated Rate |
$11,147.64 |
| Rate for Payer: Aetna Commercial |
$10,905.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,420.62
|
| Rate for Payer: Aetna Managed Medicare |
$3,392.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,876.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,058.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,816.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,422.01
|
| Rate for Payer: Cash Price |
$3,635.10
|
| Rate for Payer: Cigna Commercial |
$11,147.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,780.67
|
| Rate for Payer: Health EOS Commercial |
$10,784.13
|
| Rate for Payer: HFN Commercial |
$11,147.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,087.75
|
| Rate for Payer: Multiplan Commercial |
$9,693.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,270.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,147.64
|
| Rate for Payer: Quartz Beloit One Network |
$5,937.33
|
| Rate for Payer: Quartz Commercial |
$7,876.05
|
| Rate for Payer: Quartz Medicare Advantage |
$7,270.20
|
| Rate for Payer: WEA Trust Commercial |
$6,664.35
|
| Rate for Payer: WPS Commercial |
$8,975.06
|
|
|
ALLOGRAFT HUMAN DBM 2.5CC
|
Facility
IP
|
$4,713.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
2965924
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,309.37 |
| Max. Negotiated Rate |
$4,335.96 |
| Rate for Payer: Aetna Commercial |
$4,241.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,497.89
|
| Rate for Payer: Cash Price |
$1,413.90
|
| Rate for Payer: Cigna Commercial |
$4,335.96
|
| Rate for Payer: Health EOS Commercial |
$4,194.57
|
| Rate for Payer: HFN Commercial |
$4,335.96
|
| Rate for Payer: Multiplan Commercial |
$3,770.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,827.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,335.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,309.37
|
| Rate for Payer: Quartz Commercial |
$2,827.80
|
| Rate for Payer: WEA Trust Commercial |
$2,592.15
|
| Rate for Payer: WPS Commercial |
$3,490.92
|
|
|
ALLOGRAFT HUMAN DBM 2.5CC
|
Facility
OP
|
$4,713.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
2965924
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,319.64 |
| Max. Negotiated Rate |
$4,335.96 |
| Rate for Payer: Aetna Commercial |
$4,241.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,053.18
|
| Rate for Payer: Aetna Managed Medicare |
$1,319.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,063.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,356.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,262.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,497.89
|
| Rate for Payer: Cash Price |
$1,413.90
|
| Rate for Payer: Cigna Commercial |
$4,335.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,637.39
|
| Rate for Payer: Health EOS Commercial |
$4,194.57
|
| Rate for Payer: HFN Commercial |
$4,335.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,534.75
|
| Rate for Payer: Multiplan Commercial |
$3,770.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,827.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,335.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,309.37
|
| Rate for Payer: Quartz Commercial |
$3,063.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,827.80
|
| Rate for Payer: WEA Trust Commercial |
$2,592.15
|
| Rate for Payer: WPS Commercial |
$3,490.92
|
|
|
ALLOGRAFT NUSHIELD DEHYDRATED PLACENTAL 1.6SQ CM DISC NO-1160c
|
Facility
IP
|
$2,895.00
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
5298725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,418.55 |
| Max. Negotiated Rate |
$2,663.40 |
| Rate for Payer: Aetna Commercial |
$2,605.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,534.35
|
| Rate for Payer: Cash Price |
$868.50
|
| Rate for Payer: Cigna Commercial |
$2,663.40
|
| Rate for Payer: Health EOS Commercial |
$2,576.55
|
| Rate for Payer: HFN Commercial |
$2,663.40
|
| Rate for Payer: Multiplan Commercial |
$2,316.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,737.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,663.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,418.55
|
| Rate for Payer: Quartz Commercial |
$1,737.00
|
| Rate for Payer: WEA Trust Commercial |
$1,592.25
|
| Rate for Payer: WPS Commercial |
$2,144.33
|
|
|
ALLOGRAFT NUSHIELD DEHYDRATED PLACENTAL 1.6SQ CM DISC NO-1160c
|
Facility
OP
|
$2,895.00
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
5298725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$125.58 |
| Max. Negotiated Rate |
$2,663.40 |
| Rate for Payer: Aetna Commercial |
$2,605.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,489.70
|
| Rate for Payer: Aetna Managed Medicare |
$810.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,881.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,389.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,534.35
|
| Rate for Payer: Cash Price |
$868.50
|
| Rate for Payer: Cash Price |
$868.50
|
| Rate for Payer: Cigna Commercial |
$2,663.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.58
|
| Rate for Payer: Health EOS Commercial |
$2,576.55
|
| Rate for Payer: HFN Commercial |
$2,663.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,171.25
|
| Rate for Payer: Multiplan Commercial |
$2,316.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,737.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,663.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,418.55
|
| Rate for Payer: Quartz Commercial |
$1,881.75
|
| Rate for Payer: Quartz Medicare Advantage |
$1,737.00
|
| Rate for Payer: The Alliance Commercial |
$595.32
|
| Rate for Payer: WEA Trust Commercial |
$1,592.25
|
| Rate for Payer: WPS Commercial |
$2,144.33
|
|
|
ALLOGRAFT NUSHIELD DEHYDRATED PLACENTAL (2 X 3) 6SQ CM NO-1230
|
Facility
OP
|
$1,165.00
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
5298719
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$125.58 |
| Max. Negotiated Rate |
$1,071.80 |
| Rate for Payer: Aetna Commercial |
$1,048.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,001.90
|
| Rate for Payer: Aetna Managed Medicare |
$326.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$757.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$582.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$559.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$617.45
|
| Rate for Payer: Cash Price |
$349.50
|
| Rate for Payer: Cash Price |
$349.50
|
| Rate for Payer: Cigna Commercial |
$1,071.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.58
|
| Rate for Payer: Health EOS Commercial |
$1,036.85
|
| Rate for Payer: HFN Commercial |
$1,071.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$873.75
|
| Rate for Payer: Multiplan Commercial |
$932.00
|
| Rate for Payer: NAPHCARE Commercial |
$699.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,071.80
|
| Rate for Payer: Quartz Beloit One Network |
$570.85
|
| Rate for Payer: Quartz Commercial |
$757.25
|
| Rate for Payer: Quartz Medicare Advantage |
$699.00
|
| Rate for Payer: The Alliance Commercial |
$595.32
|
| Rate for Payer: WEA Trust Commercial |
$640.75
|
| Rate for Payer: WPS Commercial |
$862.92
|
|
|
ALLOGRAFT NUSHIELD DEHYDRATED PLACENTAL (2 X 3) 6SQ CM NO-1230
|
Facility
IP
|
$1,165.00
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
5298719
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$570.85 |
| Max. Negotiated Rate |
$1,071.80 |
| Rate for Payer: Aetna Commercial |
$1,048.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$617.45
|
| Rate for Payer: Cash Price |
$349.50
|
| Rate for Payer: Cigna Commercial |
$1,071.80
|
| Rate for Payer: Health EOS Commercial |
$1,036.85
|
| Rate for Payer: HFN Commercial |
$1,071.80
|
| Rate for Payer: Multiplan Commercial |
$932.00
|
| Rate for Payer: NAPHCARE Commercial |
$699.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,071.80
|
| Rate for Payer: Quartz Beloit One Network |
$570.85
|
| Rate for Payer: Quartz Commercial |
$699.00
|
| Rate for Payer: WEA Trust Commercial |
$640.75
|
| Rate for Payer: WPS Commercial |
$862.92
|
|
|
ALLOGRAFT NUSHIELD DEHYDRATED PLACENTAL (2 X 4) 8SQ CM NO-1240
|
Facility
IP
|
$1,044.00
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
5298720
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$511.56 |
| Max. Negotiated Rate |
$960.48 |
| Rate for Payer: Aetna Commercial |
$939.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$553.32
|
| Rate for Payer: Cash Price |
$313.20
|
| Rate for Payer: Cigna Commercial |
$960.48
|
| Rate for Payer: Health EOS Commercial |
$929.16
|
| Rate for Payer: HFN Commercial |
$960.48
|
| Rate for Payer: Multiplan Commercial |
$835.20
|
| Rate for Payer: NAPHCARE Commercial |
$626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$960.48
|
| Rate for Payer: Quartz Beloit One Network |
$511.56
|
| Rate for Payer: Quartz Commercial |
$626.40
|
| Rate for Payer: WEA Trust Commercial |
$574.20
|
| Rate for Payer: WPS Commercial |
$773.29
|
|
|
ALLOGRAFT NUSHIELD DEHYDRATED PLACENTAL (2 X 4) 8SQ CM NO-1240
|
Facility
OP
|
$1,044.00
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
5298720
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$125.58 |
| Max. Negotiated Rate |
$960.48 |
| Rate for Payer: Aetna Commercial |
$939.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$897.84
|
| Rate for Payer: Aetna Managed Medicare |
$292.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$678.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$522.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$501.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$553.32
|
| Rate for Payer: Cash Price |
$313.20
|
| Rate for Payer: Cash Price |
$313.20
|
| Rate for Payer: Cigna Commercial |
$960.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.58
|
| Rate for Payer: Health EOS Commercial |
$929.16
|
| Rate for Payer: HFN Commercial |
$960.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$783.00
|
| Rate for Payer: Multiplan Commercial |
$835.20
|
| Rate for Payer: NAPHCARE Commercial |
$626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$960.48
|
| Rate for Payer: Quartz Beloit One Network |
$511.56
|
| Rate for Payer: Quartz Commercial |
$678.60
|
| Rate for Payer: Quartz Medicare Advantage |
$626.40
|
| Rate for Payer: The Alliance Commercial |
$595.32
|
| Rate for Payer: WEA Trust Commercial |
$574.20
|
| Rate for Payer: WPS Commercial |
$773.29
|
|
|
ALLOGRAFT NUSHIELD DEHYDRATED PLACENTAL (3 X 4) 12SQ CM NO-1340
|
Facility
OP
|
$682.00
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
5298721
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$125.58 |
| Max. Negotiated Rate |
$627.44 |
| Rate for Payer: Aetna Commercial |
$613.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$586.52
|
| Rate for Payer: Aetna Managed Medicare |
$190.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$443.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$341.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$327.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$361.46
|
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cigna Commercial |
$627.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.58
|
| Rate for Payer: Health EOS Commercial |
$606.98
|
| Rate for Payer: HFN Commercial |
$627.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$511.50
|
| Rate for Payer: Multiplan Commercial |
$545.60
|
| Rate for Payer: NAPHCARE Commercial |
$409.20
|
| Rate for Payer: Preferred Network Access Commercial |
$627.44
|
| Rate for Payer: Quartz Beloit One Network |
$334.18
|
| Rate for Payer: Quartz Commercial |
$443.30
|
| Rate for Payer: Quartz Medicare Advantage |
$409.20
|
| Rate for Payer: The Alliance Commercial |
$595.32
|
| Rate for Payer: WEA Trust Commercial |
$375.10
|
| Rate for Payer: WPS Commercial |
$505.16
|
|
|
ALLOGRAFT NUSHIELD DEHYDRATED PLACENTAL (3 X 4) 12SQ CM NO-1340
|
Facility
IP
|
$682.00
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
5298721
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$334.18 |
| Max. Negotiated Rate |
$627.44 |
| Rate for Payer: Aetna Commercial |
$613.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$361.46
|
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cigna Commercial |
$627.44
|
| Rate for Payer: Health EOS Commercial |
$606.98
|
| Rate for Payer: HFN Commercial |
$627.44
|
| Rate for Payer: Multiplan Commercial |
$545.60
|
| Rate for Payer: NAPHCARE Commercial |
$409.20
|
| Rate for Payer: Preferred Network Access Commercial |
$627.44
|
| Rate for Payer: Quartz Beloit One Network |
$334.18
|
| Rate for Payer: Quartz Commercial |
$409.20
|
| Rate for Payer: WEA Trust Commercial |
$375.10
|
| Rate for Payer: WPS Commercial |
$505.16
|
|
|
ALLOGRAFT NUSHIELD DEHYDRATED PLACENTAL (4 X 4) 16SQ CM NO-1440
|
Facility
OP
|
$680.00
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
5298722
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$125.58 |
| Max. Negotiated Rate |
$625.60 |
| Rate for Payer: Aetna Commercial |
$612.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$584.80
|
| Rate for Payer: Aetna Managed Medicare |
$190.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$442.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$340.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$326.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$360.40
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cigna Commercial |
$625.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.58
|
| Rate for Payer: Health EOS Commercial |
$605.20
|
| Rate for Payer: HFN Commercial |
$625.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$510.00
|
| Rate for Payer: Multiplan Commercial |
$544.00
|
| Rate for Payer: NAPHCARE Commercial |
$408.00
|
| Rate for Payer: Preferred Network Access Commercial |
$625.60
|
| Rate for Payer: Quartz Beloit One Network |
$333.20
|
| Rate for Payer: Quartz Commercial |
$442.00
|
| Rate for Payer: Quartz Medicare Advantage |
$408.00
|
| Rate for Payer: The Alliance Commercial |
$595.32
|
| Rate for Payer: WEA Trust Commercial |
$374.00
|
| Rate for Payer: WPS Commercial |
$503.68
|
|
|
ALLOGRAFT NUSHIELD DEHYDRATED PLACENTAL (4 X 4) 16SQ CM NO-1440
|
Facility
IP
|
$680.00
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
5298722
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$333.20 |
| Max. Negotiated Rate |
$625.60 |
| Rate for Payer: Aetna Commercial |
$612.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$360.40
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cigna Commercial |
$625.60
|
| Rate for Payer: Health EOS Commercial |
$605.20
|
| Rate for Payer: HFN Commercial |
$625.60
|
| Rate for Payer: Multiplan Commercial |
$544.00
|
| Rate for Payer: NAPHCARE Commercial |
$408.00
|
| Rate for Payer: Preferred Network Access Commercial |
$625.60
|
| Rate for Payer: Quartz Beloit One Network |
$333.20
|
| Rate for Payer: Quartz Commercial |
$408.00
|
| Rate for Payer: WEA Trust Commercial |
$374.00
|
| Rate for Payer: WPS Commercial |
$503.68
|
|
|
ALLOGRAFT NUSHIELD DEHYDRATED PLACENTAL (4 X 6) 36SQ CM NO-1460
|
Facility
IP
|
$636.00
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
5298723
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$311.64 |
| Max. Negotiated Rate |
$585.12 |
| Rate for Payer: Aetna Commercial |
$572.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$337.08
|
| Rate for Payer: Cash Price |
$190.80
|
| Rate for Payer: Cigna Commercial |
$585.12
|
| Rate for Payer: Health EOS Commercial |
$566.04
|
| Rate for Payer: HFN Commercial |
$585.12
|
| Rate for Payer: Multiplan Commercial |
$508.80
|
| Rate for Payer: NAPHCARE Commercial |
$381.60
|
| Rate for Payer: Preferred Network Access Commercial |
$585.12
|
| Rate for Payer: Quartz Beloit One Network |
$311.64
|
| Rate for Payer: Quartz Commercial |
$381.60
|
| Rate for Payer: WEA Trust Commercial |
$349.80
|
| Rate for Payer: WPS Commercial |
$471.09
|
|
|
ALLOGRAFT NUSHIELD DEHYDRATED PLACENTAL (4 X 6) 36SQ CM NO-1460
|
Facility
OP
|
$636.00
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
5298723
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$125.58 |
| Max. Negotiated Rate |
$595.32 |
| Rate for Payer: Aetna Commercial |
$572.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$546.96
|
| Rate for Payer: Aetna Managed Medicare |
$178.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$413.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$318.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$305.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$337.08
|
| Rate for Payer: Cash Price |
$190.80
|
| Rate for Payer: Cash Price |
$190.80
|
| Rate for Payer: Cigna Commercial |
$585.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.58
|
| Rate for Payer: Health EOS Commercial |
$566.04
|
| Rate for Payer: HFN Commercial |
$585.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$477.00
|
| Rate for Payer: Multiplan Commercial |
$508.80
|
| Rate for Payer: NAPHCARE Commercial |
$381.60
|
| Rate for Payer: Preferred Network Access Commercial |
$585.12
|
| Rate for Payer: Quartz Beloit One Network |
$311.64
|
| Rate for Payer: Quartz Commercial |
$413.40
|
| Rate for Payer: Quartz Medicare Advantage |
$381.60
|
| Rate for Payer: The Alliance Commercial |
$595.32
|
| Rate for Payer: WEA Trust Commercial |
$349.80
|
| Rate for Payer: WPS Commercial |
$471.09
|
|
|
ALLOGRAFT NUSHIELD DEHYDRATED PLACENTAL (6 X 6) 36SQ CM NO-1660
|
Facility
OP
|
$578.00
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
5298724
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$125.58 |
| Max. Negotiated Rate |
$595.32 |
| Rate for Payer: NAPHCARE Commercial |
$346.80
|
| Rate for Payer: Aetna Commercial |
$520.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$497.08
|
| Rate for Payer: Aetna Managed Medicare |
$161.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$375.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$289.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$277.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$306.34
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cigna Commercial |
$531.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.58
|
| Rate for Payer: Health EOS Commercial |
$514.42
|
| Rate for Payer: HFN Commercial |
$531.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$433.50
|
| Rate for Payer: Multiplan Commercial |
$462.40
|
| Rate for Payer: Preferred Network Access Commercial |
$531.76
|
| Rate for Payer: Quartz Beloit One Network |
$283.22
|
| Rate for Payer: Quartz Commercial |
$375.70
|
| Rate for Payer: Quartz Medicare Advantage |
$346.80
|
| Rate for Payer: The Alliance Commercial |
$595.32
|
| Rate for Payer: WEA Trust Commercial |
$317.90
|
| Rate for Payer: WPS Commercial |
$428.12
|
|
