|
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
|
|
|
ALLOGRAFT PATELLAR PRE-SHAPE BTB 10/10MM 453001
|
Facility
IP
|
$21,954.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4519825
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,757.46 |
| Max. Negotiated Rate |
$20,197.68 |
| Rate for Payer: Aetna Commercial |
$19,758.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,635.62
|
| Rate for Payer: Cash Price |
$6,586.20
|
| Rate for Payer: Cigna Commercial |
$20,197.68
|
| Rate for Payer: Health EOS Commercial |
$19,539.06
|
| Rate for Payer: HFN Commercial |
$20,197.68
|
| Rate for Payer: Multiplan Commercial |
$17,563.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,172.40
|
| Rate for Payer: Preferred Network Access Commercial |
$20,197.68
|
| Rate for Payer: Quartz Beloit One Network |
$10,757.46
|
| Rate for Payer: Quartz Commercial |
$13,172.40
|
| Rate for Payer: WEA Trust Commercial |
$12,074.70
|
| Rate for Payer: WPS Commercial |
$16,261.33
|
|
|
ALLOGRAFT PATELLAR PRE-SHAPE BTB 10/10MM 453001
|
Facility
OP
|
$21,954.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
4519825
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,147.12 |
| Max. Negotiated Rate |
$20,197.68 |
| Rate for Payer: Aetna Commercial |
$19,758.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,880.44
|
| Rate for Payer: Aetna Managed Medicare |
$6,147.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,270.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,977.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,537.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,635.62
|
| Rate for Payer: Cash Price |
$6,586.20
|
| Rate for Payer: Cigna Commercial |
$20,197.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,285.46
|
| Rate for Payer: Health EOS Commercial |
$19,539.06
|
| Rate for Payer: HFN Commercial |
$20,197.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,465.50
|
| Rate for Payer: Multiplan Commercial |
$17,563.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,172.40
|
| Rate for Payer: Preferred Network Access Commercial |
$20,197.68
|
| Rate for Payer: Quartz Beloit One Network |
$10,757.46
|
| Rate for Payer: Quartz Commercial |
$14,270.10
|
| Rate for Payer: Quartz Medicare Advantage |
$13,172.40
|
| Rate for Payer: WEA Trust Commercial |
$12,074.70
|
| Rate for Payer: WPS Commercial |
$16,261.33
|
|
|
ALLOGRAFT PATELLAR PRE-SHAPE BTB 10MM REG 453002
|
Facility
OP
|
$21,954.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,147.12 |
| Max. Negotiated Rate |
$20,197.68 |
| Rate for Payer: Aetna Commercial |
$19,758.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,880.44
|
| Rate for Payer: Aetna Managed Medicare |
$6,147.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,270.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,977.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,537.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,635.62
|
| Rate for Payer: Cash Price |
$6,586.20
|
| Rate for Payer: Cigna Commercial |
$20,197.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,285.46
|
| Rate for Payer: Health EOS Commercial |
$19,539.06
|
| Rate for Payer: HFN Commercial |
$20,197.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,465.50
|
| Rate for Payer: Multiplan Commercial |
$17,563.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,172.40
|
| Rate for Payer: Preferred Network Access Commercial |
$20,197.68
|
| Rate for Payer: Quartz Beloit One Network |
$10,757.46
|
| Rate for Payer: Quartz Commercial |
$14,270.10
|
| Rate for Payer: Quartz Medicare Advantage |
$13,172.40
|
| Rate for Payer: WEA Trust Commercial |
$12,074.70
|
| Rate for Payer: WPS Commercial |
$16,261.33
|
|
|
ALLOGRAFT PATELLAR PRE-SHAPE BTB 10MM REG 453002
|
Facility
IP
|
$21,954.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2967964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,757.46 |
| Max. Negotiated Rate |
$20,197.68 |
| Rate for Payer: Aetna Commercial |
$19,758.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,635.62
|
| Rate for Payer: Cash Price |
$6,586.20
|
| Rate for Payer: Cigna Commercial |
$20,197.68
|
| Rate for Payer: Health EOS Commercial |
$19,539.06
|
| Rate for Payer: HFN Commercial |
$20,197.68
|
| Rate for Payer: Multiplan Commercial |
$17,563.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,172.40
|
| Rate for Payer: Preferred Network Access Commercial |
$20,197.68
|
| Rate for Payer: Quartz Beloit One Network |
$10,757.46
|
| Rate for Payer: Quartz Commercial |
$13,172.40
|
| Rate for Payer: WEA Trust Commercial |
$12,074.70
|
| Rate for Payer: WPS Commercial |
$16,261.33
|
|
|
ALLOGRAFT PATELLAR PRE-SHAPE BTB 10MM SHORT 443002
|
Facility
OP
|
$21,954.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3887354
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,147.12 |
| Max. Negotiated Rate |
$20,197.68 |
| Rate for Payer: Aetna Commercial |
$19,758.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,880.44
|
| Rate for Payer: Aetna Managed Medicare |
$6,147.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,270.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,977.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,537.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,635.62
|
| Rate for Payer: Cash Price |
$6,586.20
|
| Rate for Payer: Cigna Commercial |
$20,197.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,285.46
|
| Rate for Payer: Health EOS Commercial |
$19,539.06
|
| Rate for Payer: HFN Commercial |
$20,197.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,465.50
|
| Rate for Payer: Multiplan Commercial |
$17,563.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,172.40
|
| Rate for Payer: Preferred Network Access Commercial |
$20,197.68
|
| Rate for Payer: Quartz Beloit One Network |
$10,757.46
|
| Rate for Payer: Quartz Commercial |
$14,270.10
|
| Rate for Payer: Quartz Medicare Advantage |
$13,172.40
|
| Rate for Payer: WEA Trust Commercial |
$12,074.70
|
| Rate for Payer: WPS Commercial |
$16,261.33
|
|
|
ALLOGRAFT PATELLAR PRE-SHAPE BTB 10MM SHORT 443002
|
Facility
IP
|
$21,954.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3887354
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,757.46 |
| Max. Negotiated Rate |
$20,197.68 |
| Rate for Payer: Aetna Commercial |
$19,758.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,635.62
|
| Rate for Payer: Cash Price |
$6,586.20
|
| Rate for Payer: Cigna Commercial |
$20,197.68
|
| Rate for Payer: Health EOS Commercial |
$19,539.06
|
| Rate for Payer: HFN Commercial |
$20,197.68
|
| Rate for Payer: Multiplan Commercial |
$17,563.20
|
| Rate for Payer: NAPHCARE Commercial |
$13,172.40
|
| Rate for Payer: Preferred Network Access Commercial |
$20,197.68
|
| Rate for Payer: Quartz Beloit One Network |
$10,757.46
|
| Rate for Payer: Quartz Commercial |
$13,172.40
|
| Rate for Payer: WEA Trust Commercial |
$12,074.70
|
| Rate for Payer: WPS Commercial |
$16,261.33
|
|
|
ALLOGRAFT POSTERIOR TIBIALIS 453016
|
Facility
IP
|
$15,864.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2965399
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,773.36 |
| Max. Negotiated Rate |
$14,594.88 |
| Rate for Payer: Aetna Commercial |
$14,277.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,407.92
|
| Rate for Payer: Cash Price |
$4,759.20
|
| Rate for Payer: Cigna Commercial |
$14,594.88
|
| Rate for Payer: Health EOS Commercial |
$14,118.96
|
| Rate for Payer: HFN Commercial |
$14,594.88
|
| Rate for Payer: Multiplan Commercial |
$12,691.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,594.88
|
| Rate for Payer: Quartz Beloit One Network |
$7,773.36
|
| Rate for Payer: Quartz Commercial |
$9,518.40
|
| Rate for Payer: WEA Trust Commercial |
$8,725.20
|
| Rate for Payer: WPS Commercial |
$11,750.46
|
|
|
ALLOGRAFT POSTERIOR TIBIALIS 453016
|
Facility
OP
|
$15,864.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2965399
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,441.92 |
| Max. Negotiated Rate |
$14,594.88 |
| Rate for Payer: Aetna Commercial |
$14,277.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,643.04
|
| Rate for Payer: Aetna Managed Medicare |
$4,441.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,311.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,932.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,614.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,407.92
|
| Rate for Payer: Cash Price |
$4,759.20
|
| Rate for Payer: Cigna Commercial |
$14,594.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,877.49
|
| Rate for Payer: Health EOS Commercial |
$14,118.96
|
| Rate for Payer: HFN Commercial |
$14,594.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,898.00
|
| Rate for Payer: Multiplan Commercial |
$12,691.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,594.88
|
| Rate for Payer: Quartz Beloit One Network |
$7,773.36
|
| Rate for Payer: Quartz Commercial |
$10,311.60
|
| Rate for Payer: Quartz Medicare Advantage |
$9,518.40
|
| Rate for Payer: WEA Trust Commercial |
$8,725.20
|
| Rate for Payer: WPS Commercial |
$11,750.46
|
|
|
ALLOGRAFT QUADLINK FQL
|
Facility
OP
|
$12,979.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6172860
|
|
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 QUADLINK FQL
|
Facility
IP
|
$12,979.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6172860
|
|
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 SEMI-TENDINOSUS TENDON FLEXIGRAFT FST
|
Facility
IP
|
$10,834.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6174829
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,308.66 |
| Max. Negotiated Rate |
$9,967.28 |
| Rate for Payer: Aetna Commercial |
$9,750.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,742.02
|
| Rate for Payer: Cash Price |
$3,250.20
|
| Rate for Payer: Cigna Commercial |
$9,967.28
|
| Rate for Payer: Health EOS Commercial |
$9,642.26
|
| Rate for Payer: HFN Commercial |
$9,967.28
|
| Rate for Payer: Multiplan Commercial |
$8,667.20
|
| Rate for Payer: NAPHCARE Commercial |
$6,500.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,967.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,308.66
|
| Rate for Payer: Quartz Commercial |
$6,500.40
|
| Rate for Payer: WEA Trust Commercial |
$5,958.70
|
| Rate for Payer: WPS Commercial |
$8,024.74
|
|
|
ALLOGRAFT SEMI-TENDINOSUS TENDON FLEXIGRAFT FST
|
Facility
OP
|
$10,834.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6174829
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,033.52 |
| Max. Negotiated Rate |
$9,967.28 |
| Rate for Payer: Aetna Commercial |
$9,750.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,317.24
|
| Rate for Payer: Aetna Managed Medicare |
$3,033.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,042.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,417.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,200.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,742.02
|
| Rate for Payer: Cash Price |
$3,250.20
|
| Rate for Payer: Cigna Commercial |
$9,967.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,062.71
|
| Rate for Payer: Health EOS Commercial |
$9,642.26
|
| Rate for Payer: HFN Commercial |
$9,967.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,125.50
|
| Rate for Payer: Multiplan Commercial |
$8,667.20
|
| Rate for Payer: NAPHCARE Commercial |
$6,500.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,967.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,308.66
|
| Rate for Payer: Quartz Commercial |
$7,042.10
|
| Rate for Payer: Quartz Medicare Advantage |
$6,500.40
|
| Rate for Payer: WEA Trust Commercial |
$5,958.70
|
| Rate for Payer: WPS Commercial |
$8,024.74
|
|
|
ALLOGRAFT SEMI-TENDINOSUS TENDON FLEXIGRAFT PRE-SUTURED FSTP
|
Facility
OP
|
$10,623.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5459612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,974.44 |
| Max. Negotiated Rate |
$9,773.16 |
| Rate for Payer: Aetna Commercial |
$9,560.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,135.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,974.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,904.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,311.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,099.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,630.19
|
| Rate for Payer: Cash Price |
$3,186.90
|
| Rate for Payer: Cigna Commercial |
$9,773.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,944.63
|
| Rate for Payer: Health EOS Commercial |
$9,454.47
|
| Rate for Payer: HFN Commercial |
$9,773.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,967.25
|
| Rate for Payer: Multiplan Commercial |
$8,498.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,373.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,773.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,205.27
|
| Rate for Payer: Quartz Commercial |
$6,904.95
|
| Rate for Payer: Quartz Medicare Advantage |
$6,373.80
|
| Rate for Payer: WEA Trust Commercial |
$5,842.65
|
| Rate for Payer: WPS Commercial |
$7,868.46
|
|
|
ALLOGRAFT SEMI-TENDINOSUS TENDON FLEXIGRAFT PRE-SUTURED FSTP
|
Facility
IP
|
$10,623.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
5459612
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,205.27 |
| Max. Negotiated Rate |
$9,773.16 |
| Rate for Payer: Aetna Commercial |
$9,560.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,630.19
|
| Rate for Payer: Cash Price |
$3,186.90
|
| Rate for Payer: Cigna Commercial |
$9,773.16
|
| Rate for Payer: Health EOS Commercial |
$9,454.47
|
| Rate for Payer: HFN Commercial |
$9,773.16
|
| Rate for Payer: Multiplan Commercial |
$8,498.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,373.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,773.16
|
| Rate for Payer: Quartz Beloit One Network |
$5,205.27
|
| Rate for Payer: Quartz Commercial |
$6,373.80
|
| Rate for Payer: WEA Trust Commercial |
$5,842.65
|
| Rate for Payer: WPS Commercial |
$7,868.46
|
|
|
ALLOSYNC EXPAND DBM 5CC ABS-2017-05
|
Facility
IP
|
$5,984.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5603731
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,932.16 |
| Max. Negotiated Rate |
$5,505.28 |
| Rate for Payer: Aetna Commercial |
$5,385.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,171.52
|
| Rate for Payer: Cash Price |
$1,795.20
|
| Rate for Payer: Cigna Commercial |
$5,505.28
|
| Rate for Payer: Health EOS Commercial |
$5,325.76
|
| Rate for Payer: HFN Commercial |
$5,505.28
|
| Rate for Payer: Multiplan Commercial |
$4,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,590.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,505.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,932.16
|
| Rate for Payer: Quartz Commercial |
$3,590.40
|
| Rate for Payer: WEA Trust Commercial |
$3,291.20
|
| Rate for Payer: WPS Commercial |
$4,432.35
|
|
|
ALLOSYNC EXPAND DBM 5CC ABS-2017-05
|
Facility
OP
|
$5,984.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5603731
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,675.52 |
| Max. Negotiated Rate |
$5,505.28 |
| Rate for Payer: Aetna Commercial |
$5,385.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,146.24
|
| Rate for Payer: Aetna Managed Medicare |
$1,675.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,889.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,992.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,872.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,171.52
|
| Rate for Payer: Cash Price |
$1,795.20
|
| Rate for Payer: Cigna Commercial |
$5,505.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,348.65
|
| Rate for Payer: Health EOS Commercial |
$5,325.76
|
| Rate for Payer: HFN Commercial |
$5,505.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,488.00
|
| Rate for Payer: Multiplan Commercial |
$4,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,590.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,505.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,932.16
|
| Rate for Payer: Quartz Commercial |
$3,889.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,590.40
|
| Rate for Payer: WEA Trust Commercial |
$3,291.20
|
| Rate for Payer: WPS Commercial |
$4,432.35
|
|
|
ALLOSYNC GEL DBM 2.5CC ABS-2008-02
|
Facility
OP
|
$6,582.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5861740
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,842.96 |
| Max. Negotiated Rate |
$6,055.44 |
| Rate for Payer: Aetna Commercial |
$5,923.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,660.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,842.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,278.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,291.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,159.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,488.46
|
| Rate for Payer: Cash Price |
$1,974.60
|
| Rate for Payer: Cigna Commercial |
$6,055.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,683.29
|
| Rate for Payer: Health EOS Commercial |
$5,857.98
|
| Rate for Payer: HFN Commercial |
$6,055.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,936.50
|
| Rate for Payer: Multiplan Commercial |
$5,265.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,949.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,055.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,225.18
|
| Rate for Payer: Quartz Commercial |
$4,278.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,949.20
|
| Rate for Payer: WEA Trust Commercial |
$3,620.10
|
| Rate for Payer: WPS Commercial |
$4,875.29
|
|
|
ALLOSYNC GEL DBM 2.5CC ABS-2008-02
|
Facility
IP
|
$6,582.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5861740
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,225.18 |
| Max. Negotiated Rate |
$6,055.44 |
| Rate for Payer: Aetna Commercial |
$5,923.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,488.46
|
| Rate for Payer: Cash Price |
$1,974.60
|
| Rate for Payer: Cigna Commercial |
$6,055.44
|
| Rate for Payer: Health EOS Commercial |
$5,857.98
|
| Rate for Payer: HFN Commercial |
$6,055.44
|
| Rate for Payer: Multiplan Commercial |
$5,265.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,949.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,055.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,225.18
|
| Rate for Payer: Quartz Commercial |
$3,949.20
|
| Rate for Payer: WEA Trust Commercial |
$3,620.10
|
| Rate for Payer: WPS Commercial |
$4,875.29
|
|
|
ALLOSYNC GEL DBM 5CC ABS-2013-05
|
Facility
OP
|
$6,893.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5458901
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,930.04 |
| Max. Negotiated Rate |
$6,341.56 |
| Rate for Payer: Aetna Commercial |
$6,203.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,927.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,930.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,480.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,446.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,308.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,653.29
|
| Rate for Payer: Cash Price |
$2,067.90
|
| Rate for Payer: Cigna Commercial |
$6,341.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,857.32
|
| Rate for Payer: Health EOS Commercial |
$6,134.77
|
| Rate for Payer: HFN Commercial |
$6,341.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,169.75
|
| Rate for Payer: Multiplan Commercial |
$5,514.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,135.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,341.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,377.57
|
| Rate for Payer: Quartz Commercial |
$4,480.45
|
| Rate for Payer: Quartz Medicare Advantage |
$4,135.80
|
| Rate for Payer: WEA Trust Commercial |
$3,791.15
|
| Rate for Payer: WPS Commercial |
$5,105.65
|
|
|
ALLOSYNC GEL DBM 5CC ABS-2013-05
|
Facility
IP
|
$6,893.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5458901
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,377.57 |
| Max. Negotiated Rate |
$6,341.56 |
| Rate for Payer: Aetna Commercial |
$6,203.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,653.29
|
| Rate for Payer: Cash Price |
$2,067.90
|
| Rate for Payer: Cigna Commercial |
$6,341.56
|
| Rate for Payer: Health EOS Commercial |
$6,134.77
|
| Rate for Payer: HFN Commercial |
$6,341.56
|
| Rate for Payer: Multiplan Commercial |
$5,514.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,135.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,341.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,377.57
|
| Rate for Payer: Quartz Commercial |
$4,135.80
|
| Rate for Payer: WEA Trust Commercial |
$3,791.15
|
| Rate for Payer: WPS Commercial |
$5,105.65
|
|
|
ALLOSYNC PURE DBM 5CC ABS-2010-05
|
Facility
IP
|
$7,308.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5729690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,580.92 |
| Max. Negotiated Rate |
$6,723.36 |
| Rate for Payer: Aetna Commercial |
$6,577.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,873.24
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$6,723.36
|
| Rate for Payer: Health EOS Commercial |
$6,504.12
|
| Rate for Payer: HFN Commercial |
$6,723.36
|
| Rate for Payer: Multiplan Commercial |
$5,846.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,384.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,723.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,580.92
|
| Rate for Payer: Quartz Commercial |
$4,384.80
|
| Rate for Payer: WEA Trust Commercial |
$4,019.40
|
| Rate for Payer: WPS Commercial |
$5,413.04
|
|
|
ALLOSYNC PURE DBM 5CC ABS-2010-05
|
Facility
OP
|
$7,308.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5729690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,046.24 |
| Max. Negotiated Rate |
$6,723.36 |
| Rate for Payer: Aetna Commercial |
$6,577.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,284.88
|
| Rate for Payer: Aetna Managed Medicare |
$2,046.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,750.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,654.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,507.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,873.24
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$6,723.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,089.56
|
| Rate for Payer: Health EOS Commercial |
$6,504.12
|
| Rate for Payer: HFN Commercial |
$6,723.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,481.00
|
| Rate for Payer: Multiplan Commercial |
$5,846.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,384.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,723.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,580.92
|
| Rate for Payer: Quartz Commercial |
$4,750.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,384.80
|
| Rate for Payer: WEA Trust Commercial |
$4,019.40
|
| Rate for Payer: WPS Commercial |
$5,413.04
|
|
|
ALLOSYNC PUTTY CB DBM 5CC ABS-2014-05
|
Facility
IP
|
$5,984.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5459395
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,932.16 |
| Max. Negotiated Rate |
$5,505.28 |
| Rate for Payer: Aetna Commercial |
$5,385.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,171.52
|
| Rate for Payer: Cash Price |
$1,795.20
|
| Rate for Payer: Cigna Commercial |
$5,505.28
|
| Rate for Payer: Health EOS Commercial |
$5,325.76
|
| Rate for Payer: HFN Commercial |
$5,505.28
|
| Rate for Payer: Multiplan Commercial |
$4,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,590.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,505.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,932.16
|
| Rate for Payer: Quartz Commercial |
$3,590.40
|
| Rate for Payer: WEA Trust Commercial |
$3,291.20
|
| Rate for Payer: WPS Commercial |
$4,432.35
|
|
|
ALLOSYNC PUTTY CB DBM 5CC ABS-2014-05
|
Facility
OP
|
$5,984.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5459395
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,675.52 |
| Max. Negotiated Rate |
$5,505.28 |
| Rate for Payer: Aetna Commercial |
$5,385.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,146.24
|
| Rate for Payer: Aetna Managed Medicare |
$1,675.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,889.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,992.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,872.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,171.52
|
| Rate for Payer: Cash Price |
$1,795.20
|
| Rate for Payer: Cigna Commercial |
$5,505.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,348.65
|
| Rate for Payer: Health EOS Commercial |
$5,325.76
|
| Rate for Payer: HFN Commercial |
$5,505.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,488.00
|
| Rate for Payer: Multiplan Commercial |
$4,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,590.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,505.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,932.16
|
| Rate for Payer: Quartz Commercial |
$3,889.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,590.40
|
| Rate for Payer: WEA Trust Commercial |
$3,291.20
|
| Rate for Payer: WPS Commercial |
$4,432.35
|
|
