|
Hu Antibody Screen w/ Reflex
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
1040944
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$178.92 |
| Rate for Payer: Aetna Commercial |
$175.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$167.25
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.93
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.80
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$178.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.83
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$173.09
|
| Rate for Payer: HFN Commercial |
$178.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$155.58
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$178.92
|
| Rate for Payer: Quartz Beloit One Network |
$95.30
|
| Rate for Payer: Quartz Commercial |
$126.41
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$50.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: United Healthcare PPO |
$145.86
|
| Rate for Payer: WEA Trust Commercial |
$106.96
|
| Rate for Payer: Wellcare Medicare |
$12.53
|
| Rate for Payer: WPS Commercial |
$144.05
|
|
|
Human Anti-Mouse Antibody
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
4378669
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$202.82 |
| Max. Negotiated Rate |
$380.81 |
| Rate for Payer: Aetna Commercial |
$372.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$219.38
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$380.81
|
| Rate for Payer: Health EOS Commercial |
$368.39
|
| Rate for Payer: HFN Commercial |
$380.81
|
| Rate for Payer: Multiplan Commercial |
$331.14
|
| Rate for Payer: Preferred Network Access Commercial |
$380.81
|
| Rate for Payer: Quartz Beloit One Network |
$202.82
|
| Rate for Payer: Quartz Commercial |
$248.35
|
| Rate for Payer: WEA Trust Commercial |
$227.66
|
| Rate for Payer: WPS Commercial |
$306.58
|
|
|
Human Anti-Mouse Antibody
|
Professional
|
Both
|
$398.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
4378669
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$393.22 |
| Rate for Payer: Aetna Commercial |
$393.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.97
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$393.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$206.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$376.67
|
| Rate for Payer: HFN Commercial |
$393.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$331.14
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$393.22
|
| Rate for Payer: Quartz Beloit One Network |
$182.12
|
| Rate for Payer: Quartz Commercial |
$235.93
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$70.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: WEA Trust Commercial |
$227.66
|
| Rate for Payer: WPS Commercial |
$79.03
|
|
|
Human Anti-Mouse Antibody
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
4378669
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$380.81 |
| Rate for Payer: Aetna Commercial |
$372.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.97
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.81
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$219.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$380.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$231.64
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$368.39
|
| Rate for Payer: HFN Commercial |
$380.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$331.14
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$380.81
|
| Rate for Payer: Quartz Beloit One Network |
$202.82
|
| Rate for Payer: Quartz Commercial |
$269.05
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$71.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: United Healthcare PPO |
$310.44
|
| Rate for Payer: WEA Trust Commercial |
$227.66
|
| Rate for Payer: Wellcare Medicare |
$17.96
|
| Rate for Payer: WPS Commercial |
$306.58
|
|
|
Human Tranforming Growth Factor Beta 1
|
Professional
|
Both
|
$119.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
5322769
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$117.57 |
| Rate for Payer: Aetna Commercial |
$117.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$106.43
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$117.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$61.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$112.62
|
| Rate for Payer: HFN Commercial |
$117.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$99.01
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$117.57
|
| Rate for Payer: Quartz Beloit One Network |
$54.45
|
| Rate for Payer: Quartz Commercial |
$70.54
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$70.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: WEA Trust Commercial |
$68.07
|
| Rate for Payer: WPS Commercial |
$79.03
|
|
|
Human Tranforming Growth Factor Beta 1
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
5322769
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$113.86 |
| Rate for Payer: Aetna Commercial |
$111.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$106.43
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.81
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$113.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$110.15
|
| Rate for Payer: HFN Commercial |
$113.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$99.01
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$113.86
|
| Rate for Payer: Quartz Beloit One Network |
$60.64
|
| Rate for Payer: Quartz Commercial |
$80.44
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$71.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: United Healthcare PPO |
$92.82
|
| Rate for Payer: WEA Trust Commercial |
$68.07
|
| Rate for Payer: Wellcare Medicare |
$17.96
|
| Rate for Payer: WPS Commercial |
$91.67
|
|
|
Human Tranforming Growth Factor Beta 1
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
5322769
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$60.64 |
| Max. Negotiated Rate |
$113.86 |
| Rate for Payer: Aetna Commercial |
$111.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$106.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.59
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$113.86
|
| Rate for Payer: Health EOS Commercial |
$110.15
|
| Rate for Payer: HFN Commercial |
$113.86
|
| Rate for Payer: Multiplan Commercial |
$99.01
|
| Rate for Payer: Preferred Network Access Commercial |
$113.86
|
| Rate for Payer: Quartz Beloit One Network |
$60.64
|
| Rate for Payer: Quartz Commercial |
$74.26
|
| Rate for Payer: WEA Trust Commercial |
$68.07
|
| Rate for Payer: WPS Commercial |
$91.67
|
|
|
HUMERAL FRACTURE, PROXIMAL PERCUTANEOUS PINNING
|
Facility
|
OP
|
$1,397.00
|
|
| Hospital Charge Code |
2950340
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$406.81 |
| Max. Negotiated Rate |
$1,336.65 |
| Rate for Payer: Aetna Commercial |
$1,307.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,249.48
|
| Rate for Payer: Aetna Managed Medicare |
$406.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$944.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$726.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$697.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$770.03
|
| Rate for Payer: Cash Price |
$419.10
|
| Rate for Payer: Cigna Commercial |
$1,336.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$813.05
|
| Rate for Payer: Health EOS Commercial |
$1,293.06
|
| Rate for Payer: HFN Commercial |
$1,336.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,089.66
|
| Rate for Payer: Multiplan Commercial |
$1,162.30
|
| Rate for Payer: NAPHCARE Commercial |
$871.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,336.65
|
| Rate for Payer: Quartz Beloit One Network |
$711.91
|
| Rate for Payer: Quartz Commercial |
$944.37
|
| Rate for Payer: Quartz Medicare Advantage |
$871.73
|
| Rate for Payer: The Alliance Commercial |
$726.44
|
| Rate for Payer: WEA Trust Commercial |
$799.08
|
| Rate for Payer: WPS Commercial |
$1,076.11
|
|
|
HUMERAL FRACTURE, PROXIMAL PERCUTANEOUS PINNING
|
Facility
|
IP
|
$1,397.00
|
|
| Hospital Charge Code |
2950340
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$711.91 |
| Max. Negotiated Rate |
$1,336.65 |
| Rate for Payer: Aetna Commercial |
$1,307.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,249.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$770.03
|
| Rate for Payer: Cash Price |
$419.10
|
| Rate for Payer: Cigna Commercial |
$1,336.65
|
| Rate for Payer: Health EOS Commercial |
$1,293.06
|
| Rate for Payer: HFN Commercial |
$1,336.65
|
| Rate for Payer: Multiplan Commercial |
$1,162.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,336.65
|
| Rate for Payer: Quartz Beloit One Network |
$711.91
|
| Rate for Payer: Quartz Commercial |
$871.73
|
| Rate for Payer: WEA Trust Commercial |
$799.08
|
| Rate for Payer: WPS Commercial |
$1,076.11
|
|
|
HUMERAL HEAD 43/16 AR-9343-16
|
Facility
|
IP
|
$7,979.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5603588
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,066.10 |
| Max. Negotiated Rate |
$7,634.31 |
| Rate for Payer: Aetna Commercial |
$7,468.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,136.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,398.02
|
| Rate for Payer: Cash Price |
$2,393.70
|
| Rate for Payer: Cigna Commercial |
$7,634.31
|
| Rate for Payer: Health EOS Commercial |
$7,385.36
|
| Rate for Payer: HFN Commercial |
$7,634.31
|
| Rate for Payer: Multiplan Commercial |
$6,638.53
|
| Rate for Payer: Preferred Network Access Commercial |
$7,634.31
|
| Rate for Payer: Quartz Beloit One Network |
$4,066.10
|
| Rate for Payer: Quartz Commercial |
$4,978.90
|
| Rate for Payer: WEA Trust Commercial |
$4,563.99
|
| Rate for Payer: WPS Commercial |
$6,146.22
|
|
|
HUMERAL HEAD 43/16 AR-9343-16
|
Facility
|
OP
|
$7,979.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5603588
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,323.48 |
| Max. Negotiated Rate |
$7,634.31 |
| Rate for Payer: Aetna Commercial |
$7,468.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,136.42
|
| Rate for Payer: Aetna Managed Medicare |
$2,323.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,393.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,149.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,983.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,398.02
|
| Rate for Payer: Cash Price |
$2,393.70
|
| Rate for Payer: Cigna Commercial |
$7,634.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,643.78
|
| Rate for Payer: Health EOS Commercial |
$7,385.36
|
| Rate for Payer: HFN Commercial |
$7,634.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,223.62
|
| Rate for Payer: Multiplan Commercial |
$6,638.53
|
| Rate for Payer: NAPHCARE Commercial |
$4,978.90
|
| Rate for Payer: Preferred Network Access Commercial |
$7,634.31
|
| Rate for Payer: Quartz Beloit One Network |
$4,066.10
|
| Rate for Payer: Quartz Commercial |
$5,393.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,978.90
|
| Rate for Payer: The Alliance Commercial |
$4,149.08
|
| Rate for Payer: WEA Trust Commercial |
$4,563.99
|
| Rate for Payer: WPS Commercial |
$6,146.22
|
|
|
HUMERAL HEAD 45/19 AR-9345-19
|
Facility
|
IP
|
$7,672.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729772
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,909.65 |
| Max. Negotiated Rate |
$7,340.57 |
| Rate for Payer: Aetna Commercial |
$7,180.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,861.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,228.81
|
| Rate for Payer: Cash Price |
$2,301.60
|
| Rate for Payer: Cigna Commercial |
$7,340.57
|
| Rate for Payer: Health EOS Commercial |
$7,101.20
|
| Rate for Payer: HFN Commercial |
$7,340.57
|
| Rate for Payer: Multiplan Commercial |
$6,383.10
|
| Rate for Payer: Preferred Network Access Commercial |
$7,340.57
|
| Rate for Payer: Quartz Beloit One Network |
$3,909.65
|
| Rate for Payer: Quartz Commercial |
$4,787.33
|
| Rate for Payer: WEA Trust Commercial |
$4,388.38
|
| Rate for Payer: WPS Commercial |
$5,909.74
|
|
|
HUMERAL HEAD 45/19 AR-9345-19
|
Facility
|
OP
|
$7,672.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5729772
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,234.09 |
| Max. Negotiated Rate |
$7,340.57 |
| Rate for Payer: Aetna Commercial |
$7,180.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,861.84
|
| Rate for Payer: Aetna Managed Medicare |
$2,234.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,186.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,989.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,829.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,228.81
|
| Rate for Payer: Cash Price |
$2,301.60
|
| Rate for Payer: Cigna Commercial |
$7,340.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,465.10
|
| Rate for Payer: Health EOS Commercial |
$7,101.20
|
| Rate for Payer: HFN Commercial |
$7,340.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,984.16
|
| Rate for Payer: Multiplan Commercial |
$6,383.10
|
| Rate for Payer: NAPHCARE Commercial |
$4,787.33
|
| Rate for Payer: Preferred Network Access Commercial |
$7,340.57
|
| Rate for Payer: Quartz Beloit One Network |
$3,909.65
|
| Rate for Payer: Quartz Commercial |
$5,186.27
|
| Rate for Payer: Quartz Medicare Advantage |
$4,787.33
|
| Rate for Payer: The Alliance Commercial |
$3,989.44
|
| Rate for Payer: WEA Trust Commercial |
$4,388.38
|
| Rate for Payer: WPS Commercial |
$5,909.74
|
|
|
HUMERAL HEAD 49/18 AR-9349-18
|
Facility
|
IP
|
$7,093.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563219
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,614.59 |
| Max. Negotiated Rate |
$6,786.58 |
| Rate for Payer: Aetna Commercial |
$6,639.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,343.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,909.66
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,786.58
|
| Rate for Payer: Health EOS Commercial |
$6,565.28
|
| Rate for Payer: HFN Commercial |
$6,786.58
|
| Rate for Payer: Multiplan Commercial |
$5,901.38
|
| Rate for Payer: Preferred Network Access Commercial |
$6,786.58
|
| Rate for Payer: Quartz Beloit One Network |
$3,614.59
|
| Rate for Payer: Quartz Commercial |
$4,426.03
|
| Rate for Payer: WEA Trust Commercial |
$4,057.20
|
| Rate for Payer: WPS Commercial |
$5,463.74
|
|
|
HUMERAL HEAD 49/18 AR-9349-18
|
Facility
|
OP
|
$7,093.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5563219
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,065.48 |
| Max. Negotiated Rate |
$6,786.58 |
| Rate for Payer: Aetna Commercial |
$6,639.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,343.98
|
| Rate for Payer: Aetna Managed Medicare |
$2,065.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,794.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,688.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,540.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,909.66
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,786.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,128.13
|
| Rate for Payer: Health EOS Commercial |
$6,565.28
|
| Rate for Payer: HFN Commercial |
$6,786.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,532.54
|
| Rate for Payer: Multiplan Commercial |
$5,901.38
|
| Rate for Payer: NAPHCARE Commercial |
$4,426.03
|
| Rate for Payer: Preferred Network Access Commercial |
$6,786.58
|
| Rate for Payer: Quartz Beloit One Network |
$3,614.59
|
| Rate for Payer: Quartz Commercial |
$4,794.87
|
| Rate for Payer: Quartz Medicare Advantage |
$4,426.03
|
| Rate for Payer: The Alliance Commercial |
$3,688.36
|
| Rate for Payer: WEA Trust Commercial |
$4,057.20
|
| Rate for Payer: WPS Commercial |
$5,463.74
|
|
|
HUMERAL HEAD 49/20 AR-9349-20
|
Facility
|
OP
|
$7,093.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6217177
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,065.48 |
| Max. Negotiated Rate |
$6,786.58 |
| Rate for Payer: Aetna Commercial |
$6,639.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,343.98
|
| Rate for Payer: Aetna Managed Medicare |
$2,065.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,794.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,688.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,540.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,909.66
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,786.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,128.13
|
| Rate for Payer: Health EOS Commercial |
$6,565.28
|
| Rate for Payer: HFN Commercial |
$6,786.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,532.54
|
| Rate for Payer: Multiplan Commercial |
$5,901.38
|
| Rate for Payer: NAPHCARE Commercial |
$4,426.03
|
| Rate for Payer: Preferred Network Access Commercial |
$6,786.58
|
| Rate for Payer: Quartz Beloit One Network |
$3,614.59
|
| Rate for Payer: Quartz Commercial |
$4,794.87
|
| Rate for Payer: Quartz Medicare Advantage |
$4,426.03
|
| Rate for Payer: The Alliance Commercial |
$3,688.36
|
| Rate for Payer: WEA Trust Commercial |
$4,057.20
|
| Rate for Payer: WPS Commercial |
$5,463.74
|
|
|
HUMERAL HEAD 49/20 AR-9349-20
|
Facility
|
IP
|
$7,093.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6217177
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,614.59 |
| Max. Negotiated Rate |
$6,786.58 |
| Rate for Payer: Aetna Commercial |
$6,639.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,343.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,909.66
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,786.58
|
| Rate for Payer: Health EOS Commercial |
$6,565.28
|
| Rate for Payer: HFN Commercial |
$6,786.58
|
| Rate for Payer: Multiplan Commercial |
$5,901.38
|
| Rate for Payer: Preferred Network Access Commercial |
$6,786.58
|
| Rate for Payer: Quartz Beloit One Network |
$3,614.59
|
| Rate for Payer: Quartz Commercial |
$4,426.03
|
| Rate for Payer: WEA Trust Commercial |
$4,057.20
|
| Rate for Payer: WPS Commercial |
$5,463.74
|
|
|
HUMERAL HEAD B-F 21 X 46MM 00-4300-046-21
|
Facility
|
IP
|
$8,421.00
|
|
| Hospital Charge Code |
2967491
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,291.34 |
| Max. Negotiated Rate |
$8,057.21 |
| Rate for Payer: Aetna Commercial |
$7,882.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,531.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,641.66
|
| Rate for Payer: Cash Price |
$2,526.30
|
| Rate for Payer: Cigna Commercial |
$8,057.21
|
| Rate for Payer: Health EOS Commercial |
$7,794.48
|
| Rate for Payer: HFN Commercial |
$8,057.21
|
| Rate for Payer: Multiplan Commercial |
$7,006.27
|
| Rate for Payer: Preferred Network Access Commercial |
$8,057.21
|
| Rate for Payer: Quartz Beloit One Network |
$4,291.34
|
| Rate for Payer: Quartz Commercial |
$5,254.70
|
| Rate for Payer: WEA Trust Commercial |
$4,816.81
|
| Rate for Payer: WPS Commercial |
$6,486.70
|
|
|
HUMERAL HEAD B-F 21 X 46MM 00-4300-046-21
|
Facility
|
OP
|
$8,421.00
|
|
| Hospital Charge Code |
2967491
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,452.20 |
| Max. Negotiated Rate |
$8,057.21 |
| Rate for Payer: Aetna Commercial |
$7,882.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,531.74
|
| Rate for Payer: Aetna Managed Medicare |
$2,452.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,692.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,378.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,203.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,641.66
|
| Rate for Payer: Cash Price |
$2,526.30
|
| Rate for Payer: Cigna Commercial |
$8,057.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,901.02
|
| Rate for Payer: Health EOS Commercial |
$7,794.48
|
| Rate for Payer: HFN Commercial |
$8,057.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,568.38
|
| Rate for Payer: Multiplan Commercial |
$7,006.27
|
| Rate for Payer: NAPHCARE Commercial |
$5,254.70
|
| Rate for Payer: Preferred Network Access Commercial |
$8,057.21
|
| Rate for Payer: Quartz Beloit One Network |
$4,291.34
|
| Rate for Payer: Quartz Commercial |
$5,692.60
|
| Rate for Payer: Quartz Medicare Advantage |
$5,254.70
|
| Rate for Payer: The Alliance Commercial |
$4,378.92
|
| Rate for Payer: WEA Trust Commercial |
$4,816.81
|
| Rate for Payer: WPS Commercial |
$6,486.70
|
|
|
HUMERAL HEAD COCR 44/16 5331-44/16
|
Facility
|
IP
|
$4,841.00
|
|
| Hospital Charge Code |
3072416
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,466.97 |
| Max. Negotiated Rate |
$4,631.87 |
| Rate for Payer: Aetna Commercial |
$4,531.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,329.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,668.36
|
| Rate for Payer: Cash Price |
$1,452.30
|
| Rate for Payer: Cigna Commercial |
$4,631.87
|
| Rate for Payer: Health EOS Commercial |
$4,480.83
|
| Rate for Payer: HFN Commercial |
$4,631.87
|
| Rate for Payer: Multiplan Commercial |
$4,027.71
|
| Rate for Payer: Preferred Network Access Commercial |
$4,631.87
|
| Rate for Payer: Quartz Beloit One Network |
$2,466.97
|
| Rate for Payer: Quartz Commercial |
$3,020.78
|
| Rate for Payer: WEA Trust Commercial |
$2,769.05
|
| Rate for Payer: WPS Commercial |
$3,729.02
|
|
|
HUMERAL HEAD COCR 44/16 5331-44/16
|
Facility
|
OP
|
$4,841.00
|
|
| Hospital Charge Code |
3072416
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,409.70 |
| Max. Negotiated Rate |
$4,631.87 |
| Rate for Payer: Aetna Commercial |
$4,531.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,329.79
|
| Rate for Payer: Aetna Managed Medicare |
$1,409.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,272.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,517.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,416.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,668.36
|
| Rate for Payer: Cash Price |
$1,452.30
|
| Rate for Payer: Cigna Commercial |
$4,631.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,817.46
|
| Rate for Payer: Health EOS Commercial |
$4,480.83
|
| Rate for Payer: HFN Commercial |
$4,631.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,775.98
|
| Rate for Payer: Multiplan Commercial |
$4,027.71
|
| Rate for Payer: NAPHCARE Commercial |
$3,020.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,631.87
|
| Rate for Payer: Quartz Beloit One Network |
$2,466.97
|
| Rate for Payer: Quartz Commercial |
$3,272.52
|
| Rate for Payer: Quartz Medicare Advantage |
$3,020.78
|
| Rate for Payer: The Alliance Commercial |
$2,517.32
|
| Rate for Payer: WEA Trust Commercial |
$2,769.05
|
| Rate for Payer: WPS Commercial |
$3,729.02
|
|
|
HUMERAL HEAD COCR 50/18.75
|
Facility
|
IP
|
$4,101.00
|
|
| Hospital Charge Code |
2966253
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,089.87 |
| Max. Negotiated Rate |
$3,923.84 |
| Rate for Payer: Aetna Commercial |
$3,838.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,667.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,260.47
|
| Rate for Payer: Cash Price |
$1,230.30
|
| Rate for Payer: Cigna Commercial |
$3,923.84
|
| Rate for Payer: Health EOS Commercial |
$3,795.89
|
| Rate for Payer: HFN Commercial |
$3,923.84
|
| Rate for Payer: Multiplan Commercial |
$3,412.03
|
| Rate for Payer: Preferred Network Access Commercial |
$3,923.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,089.87
|
| Rate for Payer: Quartz Commercial |
$2,559.02
|
| Rate for Payer: WEA Trust Commercial |
$2,345.77
|
| Rate for Payer: WPS Commercial |
$3,159.00
|
|
|
HUMERAL HEAD COCR 50/18.75
|
Facility
|
OP
|
$4,101.00
|
|
| Hospital Charge Code |
2966253
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.21 |
| Max. Negotiated Rate |
$3,923.84 |
| Rate for Payer: Aetna Commercial |
$3,838.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,667.93
|
| Rate for Payer: Aetna Managed Medicare |
$1,194.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,772.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,132.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,047.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,260.47
|
| Rate for Payer: Cash Price |
$1,230.30
|
| Rate for Payer: Cigna Commercial |
$3,923.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,386.78
|
| Rate for Payer: Health EOS Commercial |
$3,795.89
|
| Rate for Payer: HFN Commercial |
$3,923.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,198.78
|
| Rate for Payer: Multiplan Commercial |
$3,412.03
|
| Rate for Payer: NAPHCARE Commercial |
$2,559.02
|
| Rate for Payer: Preferred Network Access Commercial |
$3,923.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,089.87
|
| Rate for Payer: Quartz Commercial |
$2,772.28
|
| Rate for Payer: Quartz Medicare Advantage |
$2,559.02
|
| Rate for Payer: The Alliance Commercial |
$2,132.52
|
| Rate for Payer: WEA Trust Commercial |
$2,345.77
|
| Rate for Payer: WPS Commercial |
$3,159.00
|
|
|
HUMERAL HEAD ECLIPSE 39/16 AR-9339-16
|
Facility
|
IP
|
$7,093.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6178084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,614.59 |
| Max. Negotiated Rate |
$6,786.58 |
| Rate for Payer: Aetna Commercial |
$6,639.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,343.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,909.66
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,786.58
|
| Rate for Payer: Health EOS Commercial |
$6,565.28
|
| Rate for Payer: HFN Commercial |
$6,786.58
|
| Rate for Payer: Multiplan Commercial |
$5,901.38
|
| Rate for Payer: Preferred Network Access Commercial |
$6,786.58
|
| Rate for Payer: Quartz Beloit One Network |
$3,614.59
|
| Rate for Payer: Quartz Commercial |
$4,426.03
|
| Rate for Payer: WEA Trust Commercial |
$4,057.20
|
| Rate for Payer: WPS Commercial |
$5,463.74
|
|
|
HUMERAL HEAD ECLIPSE 39/16 AR-9339-16
|
Facility
|
OP
|
$7,093.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6178084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,065.48 |
| Max. Negotiated Rate |
$6,786.58 |
| Rate for Payer: Aetna Commercial |
$6,639.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,343.98
|
| Rate for Payer: Aetna Managed Medicare |
$2,065.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,794.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,688.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,540.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,909.66
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,786.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,128.13
|
| Rate for Payer: Health EOS Commercial |
$6,565.28
|
| Rate for Payer: HFN Commercial |
$6,786.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,532.54
|
| Rate for Payer: Multiplan Commercial |
$5,901.38
|
| Rate for Payer: NAPHCARE Commercial |
$4,426.03
|
| Rate for Payer: Preferred Network Access Commercial |
$6,786.58
|
| Rate for Payer: Quartz Beloit One Network |
$3,614.59
|
| Rate for Payer: Quartz Commercial |
$4,794.87
|
| Rate for Payer: Quartz Medicare Advantage |
$4,426.03
|
| Rate for Payer: The Alliance Commercial |
$3,688.36
|
| Rate for Payer: WEA Trust Commercial |
$4,057.20
|
| Rate for Payer: WPS Commercial |
$5,463.74
|
|
