|
HTLV I/II Antibody w/ Reflex
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
CPT 86790
|
| Hospital Charge Code |
1039265
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.68 |
| Max. Negotiated Rate |
$121.44 |
| Rate for Payer: Aetna Commercial |
$118.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$113.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$69.96
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna Commercial |
$121.44
|
| Rate for Payer: Health EOS Commercial |
$117.48
|
| Rate for Payer: HFN Commercial |
$121.44
|
| Rate for Payer: Multiplan Commercial |
$105.60
|
| Rate for Payer: NAPHCARE Commercial |
$79.20
|
| Rate for Payer: Preferred Network Access Commercial |
$121.44
|
| Rate for Payer: Quartz Beloit One Network |
$64.68
|
| Rate for Payer: Quartz Commercial |
$79.20
|
| Rate for Payer: WEA Trust Commercial |
$72.60
|
| Rate for Payer: WPS Commercial |
$97.77
|
|
|
Hu Antibody Screen w/ Reflex
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
1040944
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$91.63 |
| Max. Negotiated Rate |
$172.04 |
| Rate for Payer: Aetna Commercial |
$168.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$160.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.11
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$172.04
|
| Rate for Payer: Health EOS Commercial |
$166.43
|
| Rate for Payer: HFN Commercial |
$172.04
|
| Rate for Payer: Multiplan Commercial |
$149.60
|
| Rate for Payer: NAPHCARE Commercial |
$112.20
|
| Rate for Payer: Preferred Network Access Commercial |
$172.04
|
| Rate for Payer: Quartz Beloit One Network |
$91.63
|
| Rate for Payer: Quartz Commercial |
$112.20
|
| Rate for Payer: WEA Trust Commercial |
$102.85
|
| Rate for Payer: WPS Commercial |
$138.51
|
|
|
Hu Antibody Screen w/ Reflex
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
1040944
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$172.04 |
| Rate for Payer: Aetna Commercial |
$168.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$160.82
|
| Rate for Payer: Aetna Managed Medicare |
$12.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.00
|
| Rate for Payer: Anthem Medicaid |
$12.45
|
| Rate for Payer: Anthem Medicare Advantage |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.05
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$172.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104.65
|
| Rate for Payer: Dean Health Medicaid |
$12.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.05
|
| Rate for Payer: Health EOS Commercial |
$166.43
|
| Rate for Payer: HFN Commercial |
$172.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.05
|
| Rate for Payer: Managed Health Services Medicaid |
$12.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.05
|
| Rate for Payer: Multiplan Commercial |
$149.60
|
| Rate for Payer: NAPHCARE Commercial |
$18.08
|
| Rate for Payer: Preferred Network Access Commercial |
$172.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.45
|
| Rate for Payer: Quartz Beloit One Network |
$91.63
|
| Rate for Payer: Quartz Commercial |
$121.55
|
| Rate for Payer: Quartz Medicare Advantage |
$12.05
|
| Rate for Payer: The Alliance Commercial |
$48.20
|
| Rate for Payer: United Healthcare Medicaid |
$12.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.05
|
| Rate for Payer: United Healthcare PPO |
$140.25
|
| Rate for Payer: WEA Trust Commercial |
$102.85
|
| Rate for Payer: Wellcare Medicare |
$12.05
|
| Rate for Payer: WMAP Medicaid |
$12.45
|
| Rate for Payer: WPS Commercial |
$138.51
|
|
|
Hu Antibody Screen w/ Reflex
|
Professional
|
Both
|
$187.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
1040944
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Aetna Commercial |
$177.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$160.82
|
| Rate for Payer: Anthem Commercial |
$16.61
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$177.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$93.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.20
|
| Rate for Payer: Health EOS Commercial |
$170.17
|
| Rate for Payer: HFN Commercial |
$177.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.54
|
| Rate for Payer: Multiplan Commercial |
$149.60
|
| Rate for Payer: Preferred Network Access Commercial |
$177.65
|
| Rate for Payer: Quartz Beloit One Network |
$82.28
|
| Rate for Payer: Quartz Commercial |
$106.59
|
| Rate for Payer: The Alliance Commercial |
$93.50
|
| Rate for Payer: WEA Trust Commercial |
$102.85
|
| Rate for Payer: WPS Commercial |
$138.51
|
|
|
Human Anti-Mouse Antibody
|
Professional
|
Both
|
$398.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
4378669
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$60.96 |
| Max. Negotiated Rate |
$378.10 |
| Rate for Payer: Aetna Commercial |
$378.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.28
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$378.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$199.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$238.80
|
| Rate for Payer: Health EOS Commercial |
$362.18
|
| Rate for Payer: HFN Commercial |
$378.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.96
|
| Rate for Payer: Multiplan Commercial |
$318.40
|
| Rate for Payer: Preferred Network Access Commercial |
$378.10
|
| Rate for Payer: Quartz Beloit One Network |
$175.12
|
| Rate for Payer: Quartz Commercial |
$226.86
|
| Rate for Payer: The Alliance Commercial |
$199.00
|
| Rate for Payer: WEA Trust Commercial |
$218.90
|
| Rate for Payer: WPS Commercial |
$294.80
|
|
|
Human Anti-Mouse Antibody
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
4378669
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$366.16 |
| Rate for Payer: Aetna Commercial |
$358.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.28
|
| Rate for Payer: Aetna Managed Medicare |
$17.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.67
|
| Rate for Payer: Anthem Medicaid |
$17.85
|
| Rate for Payer: Anthem Medicare Advantage |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.27
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$366.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.72
|
| Rate for Payer: Dean Health Medicaid |
$17.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.27
|
| Rate for Payer: Health EOS Commercial |
$354.22
|
| Rate for Payer: HFN Commercial |
$366.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.27
|
| Rate for Payer: Managed Health Services Medicaid |
$18.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.27
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.27
|
| Rate for Payer: Multiplan Commercial |
$318.40
|
| Rate for Payer: NAPHCARE Commercial |
$25.90
|
| Rate for Payer: Preferred Network Access Commercial |
$366.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.85
|
| Rate for Payer: Quartz Beloit One Network |
$195.02
|
| Rate for Payer: Quartz Commercial |
$258.70
|
| Rate for Payer: Quartz Medicare Advantage |
$17.27
|
| Rate for Payer: The Alliance Commercial |
$69.08
|
| Rate for Payer: United Healthcare Medicaid |
$17.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.27
|
| Rate for Payer: United Healthcare PPO |
$298.50
|
| Rate for Payer: WEA Trust Commercial |
$218.90
|
| Rate for Payer: Wellcare Medicare |
$17.27
|
| Rate for Payer: WMAP Medicaid |
$17.85
|
| Rate for Payer: WPS Commercial |
$294.80
|
|
|
Human Anti-Mouse Antibody
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
4378669
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$195.02 |
| Max. Negotiated Rate |
$366.16 |
| Rate for Payer: Aetna Commercial |
$358.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.94
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$366.16
|
| Rate for Payer: Health EOS Commercial |
$354.22
|
| Rate for Payer: HFN Commercial |
$366.16
|
| Rate for Payer: Multiplan Commercial |
$318.40
|
| Rate for Payer: NAPHCARE Commercial |
$238.80
|
| Rate for Payer: Preferred Network Access Commercial |
$366.16
|
| Rate for Payer: Quartz Beloit One Network |
$195.02
|
| Rate for Payer: Quartz Commercial |
$238.80
|
| Rate for Payer: WEA Trust Commercial |
$218.90
|
| Rate for Payer: WPS Commercial |
$294.80
|
|
|
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 |
$58.31 |
| Max. Negotiated Rate |
$109.48 |
| Rate for Payer: Aetna Commercial |
$107.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.07
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$109.48
|
| Rate for Payer: Health EOS Commercial |
$105.91
|
| Rate for Payer: HFN Commercial |
$109.48
|
| Rate for Payer: Multiplan Commercial |
$95.20
|
| Rate for Payer: NAPHCARE Commercial |
$71.40
|
| Rate for Payer: Preferred Network Access Commercial |
$109.48
|
| Rate for Payer: Quartz Beloit One Network |
$58.31
|
| Rate for Payer: Quartz Commercial |
$71.40
|
| Rate for Payer: WEA Trust Commercial |
$65.45
|
| Rate for Payer: WPS Commercial |
$88.14
|
|
|
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 |
$17.27 |
| Max. Negotiated Rate |
$109.48 |
| Rate for Payer: Aetna Commercial |
$107.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.34
|
| Rate for Payer: Aetna Managed Medicare |
$17.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.67
|
| Rate for Payer: Anthem Medicaid |
$17.85
|
| Rate for Payer: Anthem Medicare Advantage |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.27
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$109.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.59
|
| Rate for Payer: Dean Health Medicaid |
$17.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.27
|
| Rate for Payer: Health EOS Commercial |
$105.91
|
| Rate for Payer: HFN Commercial |
$109.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.27
|
| Rate for Payer: Managed Health Services Medicaid |
$18.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.27
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.27
|
| Rate for Payer: Multiplan Commercial |
$95.20
|
| Rate for Payer: NAPHCARE Commercial |
$25.90
|
| Rate for Payer: Preferred Network Access Commercial |
$109.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.85
|
| Rate for Payer: Quartz Beloit One Network |
$58.31
|
| Rate for Payer: Quartz Commercial |
$77.35
|
| Rate for Payer: Quartz Medicare Advantage |
$17.27
|
| Rate for Payer: The Alliance Commercial |
$69.08
|
| Rate for Payer: United Healthcare Medicaid |
$17.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.27
|
| Rate for Payer: United Healthcare PPO |
$89.25
|
| Rate for Payer: WEA Trust Commercial |
$65.45
|
| Rate for Payer: Wellcare Medicare |
$17.27
|
| Rate for Payer: WMAP Medicaid |
$17.85
|
| Rate for Payer: WPS Commercial |
$88.14
|
|
|
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 |
$52.36 |
| Max. Negotiated Rate |
$113.05 |
| Rate for Payer: Aetna Commercial |
$113.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.34
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$113.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$59.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.40
|
| Rate for Payer: Health EOS Commercial |
$108.29
|
| Rate for Payer: HFN Commercial |
$113.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.96
|
| Rate for Payer: Multiplan Commercial |
$95.20
|
| Rate for Payer: Preferred Network Access Commercial |
$113.05
|
| Rate for Payer: Quartz Beloit One Network |
$52.36
|
| Rate for Payer: Quartz Commercial |
$67.83
|
| Rate for Payer: The Alliance Commercial |
$59.50
|
| Rate for Payer: WEA Trust Commercial |
$65.45
|
| Rate for Payer: WPS Commercial |
$88.14
|
|
|
HUMERAL FRACTURE, PROXIMAL PERCUTANEOUS PINNING
|
Facility
|
OP
|
$1,397.00
|
|
| Hospital Charge Code |
2950340
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$391.16 |
| Max. Negotiated Rate |
$5,588.00 |
| Rate for Payer: Aetna Commercial |
$1,257.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,201.42
|
| Rate for Payer: Aetna Managed Medicare |
$391.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$908.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$698.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$670.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$740.41
|
| Rate for Payer: Cash Price |
$419.10
|
| Rate for Payer: Cigna Commercial |
$1,285.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$781.76
|
| Rate for Payer: Health EOS Commercial |
$1,243.33
|
| Rate for Payer: HFN Commercial |
$1,285.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,047.75
|
| Rate for Payer: Multiplan Commercial |
$1,117.60
|
| Rate for Payer: NAPHCARE Commercial |
$838.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,285.24
|
| Rate for Payer: Quartz Beloit One Network |
$684.53
|
| Rate for Payer: Quartz Commercial |
$908.05
|
| Rate for Payer: Quartz Medicare Advantage |
$838.20
|
| Rate for Payer: The Alliance Commercial |
$5,588.00
|
| Rate for Payer: WEA Trust Commercial |
$768.35
|
| Rate for Payer: WPS Commercial |
$1,034.76
|
|
|
HUMERAL FRACTURE, PROXIMAL PERCUTANEOUS PINNING
|
Facility
|
IP
|
$1,397.00
|
|
| Hospital Charge Code |
2950340
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$684.53 |
| Max. Negotiated Rate |
$1,285.24 |
| Rate for Payer: Aetna Commercial |
$1,257.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,201.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$740.41
|
| Rate for Payer: Cash Price |
$419.10
|
| Rate for Payer: Cigna Commercial |
$1,285.24
|
| Rate for Payer: Health EOS Commercial |
$1,243.33
|
| Rate for Payer: HFN Commercial |
$1,285.24
|
| Rate for Payer: Multiplan Commercial |
$1,117.60
|
| Rate for Payer: NAPHCARE Commercial |
$838.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,285.24
|
| Rate for Payer: Quartz Beloit One Network |
$684.53
|
| Rate for Payer: Quartz Commercial |
$838.20
|
| Rate for Payer: WEA Trust Commercial |
$768.35
|
| Rate for Payer: WPS Commercial |
$1,034.76
|
|
|
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 |
$3,909.71 |
| Max. Negotiated Rate |
$7,340.68 |
| Rate for Payer: Aetna Commercial |
$7,181.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,861.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,228.87
|
| Rate for Payer: Cash Price |
$2,393.70
|
| Rate for Payer: Cigna Commercial |
$7,340.68
|
| Rate for Payer: Health EOS Commercial |
$7,101.31
|
| Rate for Payer: HFN Commercial |
$7,340.68
|
| Rate for Payer: Multiplan Commercial |
$6,383.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,787.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,340.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,909.71
|
| Rate for Payer: Quartz Commercial |
$4,787.40
|
| Rate for Payer: WEA Trust Commercial |
$4,388.45
|
| Rate for Payer: WPS Commercial |
$5,910.05
|
|
|
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 |
$2,234.12 |
| Max. Negotiated Rate |
$31,916.00 |
| Rate for Payer: Aetna Commercial |
$7,181.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,861.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,234.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,186.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,989.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,829.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,228.87
|
| Rate for Payer: Cash Price |
$2,393.70
|
| Rate for Payer: Cigna Commercial |
$7,340.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,465.05
|
| Rate for Payer: Health EOS Commercial |
$7,101.31
|
| Rate for Payer: HFN Commercial |
$7,340.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,984.25
|
| Rate for Payer: Multiplan Commercial |
$6,383.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,787.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,340.68
|
| Rate for Payer: Quartz Beloit One Network |
$3,909.71
|
| Rate for Payer: Quartz Commercial |
$5,186.35
|
| Rate for Payer: Quartz Medicare Advantage |
$4,787.40
|
| Rate for Payer: The Alliance Commercial |
$31,916.00
|
| Rate for Payer: WEA Trust Commercial |
$4,388.45
|
| Rate for Payer: WPS Commercial |
$5,910.05
|
|
|
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 |
$2,148.16 |
| Max. Negotiated Rate |
$30,688.00 |
| Rate for Payer: Aetna Commercial |
$6,904.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,597.92
|
| Rate for Payer: Aetna Managed Medicare |
$2,148.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,986.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,836.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,682.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,066.16
|
| Rate for Payer: Cash Price |
$2,301.60
|
| Rate for Payer: Cigna Commercial |
$7,058.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,293.25
|
| Rate for Payer: Health EOS Commercial |
$6,828.08
|
| Rate for Payer: HFN Commercial |
$7,058.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,754.00
|
| Rate for Payer: Multiplan Commercial |
$6,137.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,603.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,058.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,759.28
|
| Rate for Payer: Quartz Commercial |
$4,986.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,603.20
|
| Rate for Payer: The Alliance Commercial |
$30,688.00
|
| Rate for Payer: WEA Trust Commercial |
$4,219.60
|
| Rate for Payer: WPS Commercial |
$5,682.65
|
|
|
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 |
$3,759.28 |
| Max. Negotiated Rate |
$7,058.24 |
| Rate for Payer: Aetna Commercial |
$6,904.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,597.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,066.16
|
| Rate for Payer: Cash Price |
$2,301.60
|
| Rate for Payer: Cigna Commercial |
$7,058.24
|
| Rate for Payer: Health EOS Commercial |
$6,828.08
|
| Rate for Payer: HFN Commercial |
$7,058.24
|
| Rate for Payer: Multiplan Commercial |
$6,137.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,603.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,058.24
|
| Rate for Payer: Quartz Beloit One Network |
$3,759.28
|
| Rate for Payer: Quartz Commercial |
$4,603.20
|
| Rate for Payer: WEA Trust Commercial |
$4,219.60
|
| Rate for Payer: WPS Commercial |
$5,682.65
|
|
|
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 |
$1,986.04 |
| Max. Negotiated Rate |
$28,372.00 |
| Rate for Payer: Aetna Commercial |
$6,383.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,099.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,986.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,610.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,546.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,404.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,759.29
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,525.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,969.24
|
| Rate for Payer: Health EOS Commercial |
$6,312.77
|
| Rate for Payer: HFN Commercial |
$6,525.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,319.75
|
| Rate for Payer: Multiplan Commercial |
$5,674.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,255.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,525.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,475.57
|
| Rate for Payer: Quartz Commercial |
$4,610.45
|
| Rate for Payer: Quartz Medicare Advantage |
$4,255.80
|
| Rate for Payer: The Alliance Commercial |
$28,372.00
|
| Rate for Payer: WEA Trust Commercial |
$3,901.15
|
| Rate for Payer: WPS Commercial |
$5,253.79
|
|
|
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 |
$3,475.57 |
| Max. Negotiated Rate |
$6,525.56 |
| Rate for Payer: Aetna Commercial |
$6,383.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,099.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,759.29
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,525.56
|
| Rate for Payer: Health EOS Commercial |
$6,312.77
|
| Rate for Payer: HFN Commercial |
$6,525.56
|
| Rate for Payer: Multiplan Commercial |
$5,674.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,255.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,525.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,475.57
|
| Rate for Payer: Quartz Commercial |
$4,255.80
|
| Rate for Payer: WEA Trust Commercial |
$3,901.15
|
| Rate for Payer: WPS Commercial |
$5,253.79
|
|
|
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 |
$3,475.57 |
| Max. Negotiated Rate |
$6,525.56 |
| Rate for Payer: Aetna Commercial |
$6,383.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,099.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,759.29
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,525.56
|
| Rate for Payer: Health EOS Commercial |
$6,312.77
|
| Rate for Payer: HFN Commercial |
$6,525.56
|
| Rate for Payer: Multiplan Commercial |
$5,674.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,255.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,525.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,475.57
|
| Rate for Payer: Quartz Commercial |
$4,255.80
|
| Rate for Payer: WEA Trust Commercial |
$3,901.15
|
| Rate for Payer: WPS Commercial |
$5,253.79
|
|
|
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 |
$1,986.04 |
| Max. Negotiated Rate |
$28,372.00 |
| Rate for Payer: Aetna Commercial |
$6,383.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,099.98
|
| Rate for Payer: Aetna Managed Medicare |
$1,986.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,610.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,546.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,404.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,759.29
|
| Rate for Payer: Cash Price |
$2,127.90
|
| Rate for Payer: Cigna Commercial |
$6,525.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,969.24
|
| Rate for Payer: Health EOS Commercial |
$6,312.77
|
| Rate for Payer: HFN Commercial |
$6,525.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,319.75
|
| Rate for Payer: Multiplan Commercial |
$5,674.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,255.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,525.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,475.57
|
| Rate for Payer: Quartz Commercial |
$4,610.45
|
| Rate for Payer: Quartz Medicare Advantage |
$4,255.80
|
| Rate for Payer: The Alliance Commercial |
$28,372.00
|
| Rate for Payer: WEA Trust Commercial |
$3,901.15
|
| Rate for Payer: WPS Commercial |
$5,253.79
|
|
|
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 |
$4,126.29 |
| Max. Negotiated Rate |
$7,747.32 |
| Rate for Payer: Aetna Commercial |
$7,578.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,242.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,463.13
|
| Rate for Payer: Cash Price |
$2,526.30
|
| Rate for Payer: Cigna Commercial |
$7,747.32
|
| Rate for Payer: Health EOS Commercial |
$7,494.69
|
| Rate for Payer: HFN Commercial |
$7,747.32
|
| Rate for Payer: Multiplan Commercial |
$6,736.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,052.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,747.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,126.29
|
| Rate for Payer: Quartz Commercial |
$5,052.60
|
| Rate for Payer: WEA Trust Commercial |
$4,631.55
|
| Rate for Payer: WPS Commercial |
$6,237.43
|
|
|
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 |
$2,357.88 |
| Max. Negotiated Rate |
$33,684.00 |
| Rate for Payer: Aetna Commercial |
$7,578.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,242.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,357.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,473.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,210.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,042.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,463.13
|
| Rate for Payer: Cash Price |
$2,526.30
|
| Rate for Payer: Cigna Commercial |
$7,747.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,712.39
|
| Rate for Payer: Health EOS Commercial |
$7,494.69
|
| Rate for Payer: HFN Commercial |
$7,747.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,315.75
|
| Rate for Payer: Multiplan Commercial |
$6,736.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,052.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,747.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,126.29
|
| Rate for Payer: Quartz Commercial |
$5,473.65
|
| Rate for Payer: Quartz Medicare Advantage |
$5,052.60
|
| Rate for Payer: The Alliance Commercial |
$33,684.00
|
| Rate for Payer: WEA Trust Commercial |
$4,631.55
|
| Rate for Payer: WPS Commercial |
$6,237.43
|
|
|
HUMERAL HEAD COCR 44/16 5331-44/16
|
Facility
|
OP
|
$4,841.00
|
|
| Hospital Charge Code |
3072416
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,355.48 |
| Max. Negotiated Rate |
$19,364.00 |
| Rate for Payer: Aetna Commercial |
$4,356.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,163.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,355.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,146.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,420.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,323.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,565.73
|
| Rate for Payer: Cash Price |
$1,452.30
|
| Rate for Payer: Cigna Commercial |
$4,453.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,709.02
|
| Rate for Payer: Health EOS Commercial |
$4,308.49
|
| Rate for Payer: HFN Commercial |
$4,453.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,630.75
|
| Rate for Payer: Multiplan Commercial |
$3,872.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,904.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,453.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,372.09
|
| Rate for Payer: Quartz Commercial |
$3,146.65
|
| Rate for Payer: Quartz Medicare Advantage |
$2,904.60
|
| Rate for Payer: The Alliance Commercial |
$19,364.00
|
| Rate for Payer: WEA Trust Commercial |
$2,662.55
|
| Rate for Payer: WPS Commercial |
$3,585.73
|
|
|
HUMERAL HEAD COCR 44/16 5331-44/16
|
Facility
|
IP
|
$4,841.00
|
|
| Hospital Charge Code |
3072416
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,372.09 |
| Max. Negotiated Rate |
$4,453.72 |
| Rate for Payer: Aetna Commercial |
$4,356.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,163.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,565.73
|
| Rate for Payer: Cash Price |
$1,452.30
|
| Rate for Payer: Cigna Commercial |
$4,453.72
|
| Rate for Payer: Health EOS Commercial |
$4,308.49
|
| Rate for Payer: HFN Commercial |
$4,453.72
|
| Rate for Payer: Multiplan Commercial |
$3,872.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,904.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,453.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,372.09
|
| Rate for Payer: Quartz Commercial |
$2,904.60
|
| Rate for Payer: WEA Trust Commercial |
$2,662.55
|
| Rate for Payer: WPS Commercial |
$3,585.73
|
|
|
HUMERAL HEAD COCR 50/18.75
|
Facility
|
OP
|
$4,101.00
|
|
| Hospital Charge Code |
2966253
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,148.28 |
| Max. Negotiated Rate |
$16,404.00 |
| Rate for Payer: Aetna Commercial |
$3,690.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,526.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,148.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,665.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,050.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,968.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,173.53
|
| Rate for Payer: Cash Price |
$1,230.30
|
| Rate for Payer: Cigna Commercial |
$3,772.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,294.92
|
| Rate for Payer: Health EOS Commercial |
$3,649.89
|
| Rate for Payer: HFN Commercial |
$3,772.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,075.75
|
| Rate for Payer: Multiplan Commercial |
$3,280.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,460.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,772.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,009.49
|
| Rate for Payer: Quartz Commercial |
$2,665.65
|
| Rate for Payer: Quartz Medicare Advantage |
$2,460.60
|
| Rate for Payer: The Alliance Commercial |
$16,404.00
|
| Rate for Payer: WEA Trust Commercial |
$2,255.55
|
| Rate for Payer: WPS Commercial |
$3,037.61
|
|
