|
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 |
$11,187.76 |
| Max. Negotiated Rate |
$21,005.59 |
| Rate for Payer: Aetna Commercial |
$20,548.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19,635.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12,101.04
|
| Rate for Payer: Cash Price |
$6,586.20
|
| Rate for Payer: Cigna Commercial |
$21,005.59
|
| Rate for Payer: Health EOS Commercial |
$20,320.62
|
| Rate for Payer: HFN Commercial |
$21,005.59
|
| Rate for Payer: Multiplan Commercial |
$18,265.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21,005.59
|
| Rate for Payer: Quartz Beloit One Network |
$11,187.76
|
| Rate for Payer: Quartz Commercial |
$13,699.30
|
| Rate for Payer: WEA Trust Commercial |
$12,557.69
|
| Rate for Payer: WPS Commercial |
$16,911.17
|
|
|
ALLOGRAFT POSTERIOR TIBIALIS 453016
|
Facility
|
IP
|
$15,864.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2965399
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,084.29 |
| Max. Negotiated Rate |
$15,178.68 |
| Rate for Payer: Aetna Commercial |
$14,848.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,188.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,744.24
|
| Rate for Payer: Cash Price |
$4,759.20
|
| Rate for Payer: Cigna Commercial |
$15,178.68
|
| Rate for Payer: Health EOS Commercial |
$14,683.72
|
| Rate for Payer: HFN Commercial |
$15,178.68
|
| Rate for Payer: Multiplan Commercial |
$13,198.85
|
| Rate for Payer: Preferred Network Access Commercial |
$15,178.68
|
| Rate for Payer: Quartz Beloit One Network |
$8,084.29
|
| Rate for Payer: Quartz Commercial |
$9,899.14
|
| Rate for Payer: WEA Trust Commercial |
$9,074.21
|
| Rate for Payer: WPS Commercial |
$12,220.04
|
|
|
ALLOGRAFT POSTERIOR TIBIALIS 453016
|
Facility
|
OP
|
$15,864.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
2965399
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,619.60 |
| Max. Negotiated Rate |
$15,178.68 |
| Rate for Payer: Aetna Commercial |
$14,848.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,188.76
|
| Rate for Payer: Aetna Managed Medicare |
$4,619.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,724.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,249.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,919.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,744.24
|
| Rate for Payer: Cash Price |
$4,759.20
|
| Rate for Payer: Cigna Commercial |
$15,178.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,232.85
|
| Rate for Payer: Health EOS Commercial |
$14,683.72
|
| Rate for Payer: HFN Commercial |
$15,178.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,373.92
|
| Rate for Payer: Multiplan Commercial |
$13,198.85
|
| Rate for Payer: NAPHCARE Commercial |
$9,899.14
|
| Rate for Payer: Preferred Network Access Commercial |
$15,178.68
|
| Rate for Payer: Quartz Beloit One Network |
$8,084.29
|
| Rate for Payer: Quartz Commercial |
$10,724.06
|
| Rate for Payer: Quartz Medicare Advantage |
$9,899.14
|
| Rate for Payer: The Alliance Commercial |
$8,249.28
|
| Rate for Payer: WEA Trust Commercial |
$9,074.21
|
| Rate for Payer: WPS Commercial |
$12,220.04
|
|
|
ALLOGRAFT QUADLINK FQL
|
Facility
|
IP
|
$12,979.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6172860
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,614.10 |
| Max. Negotiated Rate |
$12,418.31 |
| Rate for Payer: Aetna Commercial |
$12,148.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,608.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,154.02
|
| Rate for Payer: Cash Price |
$3,893.70
|
| Rate for Payer: Cigna Commercial |
$12,418.31
|
| Rate for Payer: Health EOS Commercial |
$12,013.36
|
| Rate for Payer: HFN Commercial |
$12,418.31
|
| Rate for Payer: Multiplan Commercial |
$10,798.53
|
| Rate for Payer: Preferred Network Access Commercial |
$12,418.31
|
| Rate for Payer: Quartz Beloit One Network |
$6,614.10
|
| Rate for Payer: Quartz Commercial |
$8,098.90
|
| Rate for Payer: WEA Trust Commercial |
$7,423.99
|
| Rate for Payer: WPS Commercial |
$9,997.72
|
|
|
ALLOGRAFT QUADLINK FQL
|
Facility
|
OP
|
$12,979.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
6172860
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,779.48 |
| Max. Negotiated Rate |
$12,418.31 |
| Rate for Payer: Aetna Commercial |
$12,148.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,608.42
|
| Rate for Payer: Aetna Managed Medicare |
$3,779.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,773.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,749.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,479.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,154.02
|
| Rate for Payer: Cash Price |
$3,893.70
|
| Rate for Payer: Cigna Commercial |
$12,418.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,553.78
|
| Rate for Payer: Health EOS Commercial |
$12,013.36
|
| Rate for Payer: HFN Commercial |
$12,418.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,123.62
|
| Rate for Payer: Multiplan Commercial |
$10,798.53
|
| Rate for Payer: NAPHCARE Commercial |
$8,098.90
|
| Rate for Payer: Preferred Network Access Commercial |
$12,418.31
|
| Rate for Payer: Quartz Beloit One Network |
$6,614.10
|
| Rate for Payer: Quartz Commercial |
$8,773.80
|
| Rate for Payer: Quartz Medicare Advantage |
$8,098.90
|
| Rate for Payer: The Alliance Commercial |
$6,749.08
|
| Rate for Payer: WEA Trust Commercial |
$7,423.99
|
| Rate for Payer: WPS Commercial |
$9,997.72
|
|
|
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 |
$3,154.86 |
| Max. Negotiated Rate |
$10,365.97 |
| Rate for Payer: Aetna Commercial |
$10,140.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,689.93
|
| Rate for Payer: Aetna Managed Medicare |
$3,154.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,323.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,633.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,408.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,971.70
|
| Rate for Payer: Cash Price |
$3,250.20
|
| Rate for Payer: Cigna Commercial |
$10,365.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,305.39
|
| Rate for Payer: Health EOS Commercial |
$10,027.95
|
| Rate for Payer: HFN Commercial |
$10,365.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,450.52
|
| Rate for Payer: Multiplan Commercial |
$9,013.89
|
| Rate for Payer: NAPHCARE Commercial |
$6,760.42
|
| Rate for Payer: Preferred Network Access Commercial |
$10,365.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,521.01
|
| Rate for Payer: Quartz Commercial |
$7,323.78
|
| Rate for Payer: Quartz Medicare Advantage |
$6,760.42
|
| Rate for Payer: The Alliance Commercial |
$5,633.68
|
| Rate for Payer: WEA Trust Commercial |
$6,197.05
|
| Rate for Payer: WPS Commercial |
$8,345.43
|
|
|
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 |
$5,521.01 |
| Max. Negotiated Rate |
$10,365.97 |
| Rate for Payer: Aetna Commercial |
$10,140.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,689.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,971.70
|
| Rate for Payer: Cash Price |
$3,250.20
|
| Rate for Payer: Cigna Commercial |
$10,365.97
|
| Rate for Payer: Health EOS Commercial |
$10,027.95
|
| Rate for Payer: HFN Commercial |
$10,365.97
|
| Rate for Payer: Multiplan Commercial |
$9,013.89
|
| Rate for Payer: Preferred Network Access Commercial |
$10,365.97
|
| Rate for Payer: Quartz Beloit One Network |
$5,521.01
|
| Rate for Payer: Quartz Commercial |
$6,760.42
|
| Rate for Payer: WEA Trust Commercial |
$6,197.05
|
| Rate for Payer: WPS Commercial |
$8,345.43
|
|
|
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 |
$3,093.42 |
| Max. Negotiated Rate |
$10,164.09 |
| Rate for Payer: Aetna Commercial |
$9,943.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,501.21
|
| Rate for Payer: Aetna Managed Medicare |
$3,093.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,181.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,523.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,303.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,855.40
|
| Rate for Payer: Cash Price |
$3,186.90
|
| Rate for Payer: Cigna Commercial |
$10,164.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,182.59
|
| Rate for Payer: Health EOS Commercial |
$9,832.65
|
| Rate for Payer: HFN Commercial |
$10,164.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,285.94
|
| Rate for Payer: Multiplan Commercial |
$8,838.34
|
| Rate for Payer: NAPHCARE Commercial |
$6,628.75
|
| Rate for Payer: Preferred Network Access Commercial |
$10,164.09
|
| Rate for Payer: Quartz Beloit One Network |
$5,413.48
|
| Rate for Payer: Quartz Commercial |
$7,181.15
|
| Rate for Payer: Quartz Medicare Advantage |
$6,628.75
|
| Rate for Payer: The Alliance Commercial |
$5,523.96
|
| Rate for Payer: WEA Trust Commercial |
$6,076.36
|
| Rate for Payer: WPS Commercial |
$8,182.90
|
|
|
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 |
$5,413.48 |
| Max. Negotiated Rate |
$10,164.09 |
| Rate for Payer: Aetna Commercial |
$9,943.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,501.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,855.40
|
| Rate for Payer: Cash Price |
$3,186.90
|
| Rate for Payer: Cigna Commercial |
$10,164.09
|
| Rate for Payer: Health EOS Commercial |
$9,832.65
|
| Rate for Payer: HFN Commercial |
$10,164.09
|
| Rate for Payer: Multiplan Commercial |
$8,838.34
|
| Rate for Payer: Preferred Network Access Commercial |
$10,164.09
|
| Rate for Payer: Quartz Beloit One Network |
$5,413.48
|
| Rate for Payer: Quartz Commercial |
$6,628.75
|
| Rate for Payer: WEA Trust Commercial |
$6,076.36
|
| Rate for Payer: WPS Commercial |
$8,182.90
|
|
|
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 |
$3,049.45 |
| Max. Negotiated Rate |
$5,725.49 |
| Rate for Payer: Aetna Commercial |
$5,601.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,352.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,298.38
|
| Rate for Payer: Cash Price |
$1,795.20
|
| Rate for Payer: Cigna Commercial |
$5,725.49
|
| Rate for Payer: Health EOS Commercial |
$5,538.79
|
| Rate for Payer: HFN Commercial |
$5,725.49
|
| Rate for Payer: Multiplan Commercial |
$4,978.69
|
| Rate for Payer: Preferred Network Access Commercial |
$5,725.49
|
| Rate for Payer: Quartz Beloit One Network |
$3,049.45
|
| Rate for Payer: Quartz Commercial |
$3,734.02
|
| Rate for Payer: WEA Trust Commercial |
$3,422.85
|
| Rate for Payer: WPS Commercial |
$4,609.48
|
|
|
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 |
$1,742.54 |
| Max. Negotiated Rate |
$5,725.49 |
| Rate for Payer: Aetna Commercial |
$5,601.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,352.09
|
| Rate for Payer: Aetna Managed Medicare |
$1,742.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,045.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,111.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,987.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,298.38
|
| Rate for Payer: Cash Price |
$1,795.20
|
| Rate for Payer: Cigna Commercial |
$5,725.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,482.69
|
| Rate for Payer: Health EOS Commercial |
$5,538.79
|
| Rate for Payer: HFN Commercial |
$5,725.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,667.52
|
| Rate for Payer: Multiplan Commercial |
$4,978.69
|
| Rate for Payer: NAPHCARE Commercial |
$3,734.02
|
| Rate for Payer: Preferred Network Access Commercial |
$5,725.49
|
| Rate for Payer: Quartz Beloit One Network |
$3,049.45
|
| Rate for Payer: Quartz Commercial |
$4,045.18
|
| Rate for Payer: Quartz Medicare Advantage |
$3,734.02
|
| Rate for Payer: The Alliance Commercial |
$3,111.68
|
| Rate for Payer: WEA Trust Commercial |
$3,422.85
|
| Rate for Payer: WPS Commercial |
$4,609.48
|
|
|
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 |
$1,916.68 |
| Max. Negotiated Rate |
$6,297.66 |
| Rate for Payer: Aetna Commercial |
$6,160.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,886.94
|
| Rate for Payer: Aetna Managed Medicare |
$1,916.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,449.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,422.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,285.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,628.00
|
| Rate for Payer: Cash Price |
$1,974.60
|
| Rate for Payer: Cigna Commercial |
$6,297.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,830.72
|
| Rate for Payer: Health EOS Commercial |
$6,092.30
|
| Rate for Payer: HFN Commercial |
$6,297.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,133.96
|
| Rate for Payer: Multiplan Commercial |
$5,476.22
|
| Rate for Payer: NAPHCARE Commercial |
$4,107.17
|
| Rate for Payer: Preferred Network Access Commercial |
$6,297.66
|
| Rate for Payer: Quartz Beloit One Network |
$3,354.19
|
| Rate for Payer: Quartz Commercial |
$4,449.43
|
| Rate for Payer: Quartz Medicare Advantage |
$4,107.17
|
| Rate for Payer: The Alliance Commercial |
$3,422.64
|
| Rate for Payer: WEA Trust Commercial |
$3,764.90
|
| Rate for Payer: WPS Commercial |
$5,070.11
|
|
|
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 |
$3,354.19 |
| Max. Negotiated Rate |
$6,297.66 |
| Rate for Payer: Aetna Commercial |
$6,160.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,886.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,628.00
|
| Rate for Payer: Cash Price |
$1,974.60
|
| Rate for Payer: Cigna Commercial |
$6,297.66
|
| Rate for Payer: Health EOS Commercial |
$6,092.30
|
| Rate for Payer: HFN Commercial |
$6,297.66
|
| Rate for Payer: Multiplan Commercial |
$5,476.22
|
| Rate for Payer: Preferred Network Access Commercial |
$6,297.66
|
| Rate for Payer: Quartz Beloit One Network |
$3,354.19
|
| Rate for Payer: Quartz Commercial |
$4,107.17
|
| Rate for Payer: WEA Trust Commercial |
$3,764.90
|
| Rate for Payer: WPS Commercial |
$5,070.11
|
|
|
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 |
$2,007.24 |
| Max. Negotiated Rate |
$6,595.22 |
| Rate for Payer: Aetna Commercial |
$6,451.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,165.10
|
| Rate for Payer: Aetna Managed Medicare |
$2,007.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,659.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,584.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,440.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,799.42
|
| Rate for Payer: Cash Price |
$2,067.90
|
| Rate for Payer: Cigna Commercial |
$6,595.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,011.73
|
| Rate for Payer: Health EOS Commercial |
$6,380.16
|
| Rate for Payer: HFN Commercial |
$6,595.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,376.54
|
| Rate for Payer: Multiplan Commercial |
$5,734.98
|
| Rate for Payer: NAPHCARE Commercial |
$4,301.23
|
| Rate for Payer: Preferred Network Access Commercial |
$6,595.22
|
| Rate for Payer: Quartz Beloit One Network |
$3,512.67
|
| Rate for Payer: Quartz Commercial |
$4,659.67
|
| Rate for Payer: Quartz Medicare Advantage |
$4,301.23
|
| Rate for Payer: The Alliance Commercial |
$3,584.36
|
| Rate for Payer: WEA Trust Commercial |
$3,942.80
|
| Rate for Payer: WPS Commercial |
$5,309.68
|
|
|
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 |
$3,512.67 |
| Max. Negotiated Rate |
$6,595.22 |
| Rate for Payer: Aetna Commercial |
$6,451.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,165.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,799.42
|
| Rate for Payer: Cash Price |
$2,067.90
|
| Rate for Payer: Cigna Commercial |
$6,595.22
|
| Rate for Payer: Health EOS Commercial |
$6,380.16
|
| Rate for Payer: HFN Commercial |
$6,595.22
|
| Rate for Payer: Multiplan Commercial |
$5,734.98
|
| Rate for Payer: Preferred Network Access Commercial |
$6,595.22
|
| Rate for Payer: Quartz Beloit One Network |
$3,512.67
|
| Rate for Payer: Quartz Commercial |
$4,301.23
|
| Rate for Payer: WEA Trust Commercial |
$3,942.80
|
| Rate for Payer: WPS Commercial |
$5,309.68
|
|
|
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 |
$2,128.09 |
| Max. Negotiated Rate |
$6,992.29 |
| Rate for Payer: Aetna Commercial |
$6,840.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,536.28
|
| Rate for Payer: Aetna Managed Medicare |
$2,128.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,940.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,800.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,648.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,028.17
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$6,992.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,253.26
|
| Rate for Payer: Health EOS Commercial |
$6,764.28
|
| Rate for Payer: HFN Commercial |
$6,992.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,700.24
|
| Rate for Payer: Multiplan Commercial |
$6,080.26
|
| Rate for Payer: NAPHCARE Commercial |
$4,560.19
|
| Rate for Payer: Preferred Network Access Commercial |
$6,992.29
|
| Rate for Payer: Quartz Beloit One Network |
$3,724.16
|
| Rate for Payer: Quartz Commercial |
$4,940.21
|
| Rate for Payer: Quartz Medicare Advantage |
$4,560.19
|
| Rate for Payer: The Alliance Commercial |
$3,800.16
|
| Rate for Payer: WEA Trust Commercial |
$4,180.18
|
| Rate for Payer: WPS Commercial |
$5,629.35
|
|
|
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 |
$3,724.16 |
| Max. Negotiated Rate |
$6,992.29 |
| Rate for Payer: Aetna Commercial |
$6,840.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,536.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,028.17
|
| Rate for Payer: Cash Price |
$2,192.40
|
| Rate for Payer: Cigna Commercial |
$6,992.29
|
| Rate for Payer: Health EOS Commercial |
$6,764.28
|
| Rate for Payer: HFN Commercial |
$6,992.29
|
| Rate for Payer: Multiplan Commercial |
$6,080.26
|
| Rate for Payer: Preferred Network Access Commercial |
$6,992.29
|
| Rate for Payer: Quartz Beloit One Network |
$3,724.16
|
| Rate for Payer: Quartz Commercial |
$4,560.19
|
| Rate for Payer: WEA Trust Commercial |
$4,180.18
|
| Rate for Payer: WPS Commercial |
$5,629.35
|
|
|
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 |
$3,049.45 |
| Max. Negotiated Rate |
$5,725.49 |
| Rate for Payer: Aetna Commercial |
$5,601.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,352.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,298.38
|
| Rate for Payer: Cash Price |
$1,795.20
|
| Rate for Payer: Cigna Commercial |
$5,725.49
|
| Rate for Payer: Health EOS Commercial |
$5,538.79
|
| Rate for Payer: HFN Commercial |
$5,725.49
|
| Rate for Payer: Multiplan Commercial |
$4,978.69
|
| Rate for Payer: Preferred Network Access Commercial |
$5,725.49
|
| Rate for Payer: Quartz Beloit One Network |
$3,049.45
|
| Rate for Payer: Quartz Commercial |
$3,734.02
|
| Rate for Payer: WEA Trust Commercial |
$3,422.85
|
| Rate for Payer: WPS Commercial |
$4,609.48
|
|
|
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 |
$1,742.54 |
| Max. Negotiated Rate |
$5,725.49 |
| Rate for Payer: Aetna Commercial |
$5,601.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,352.09
|
| Rate for Payer: Aetna Managed Medicare |
$1,742.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,045.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,111.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,987.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,298.38
|
| Rate for Payer: Cash Price |
$1,795.20
|
| Rate for Payer: Cigna Commercial |
$5,725.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,482.69
|
| Rate for Payer: Health EOS Commercial |
$5,538.79
|
| Rate for Payer: HFN Commercial |
$5,725.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,667.52
|
| Rate for Payer: Multiplan Commercial |
$4,978.69
|
| Rate for Payer: NAPHCARE Commercial |
$3,734.02
|
| Rate for Payer: Preferred Network Access Commercial |
$5,725.49
|
| Rate for Payer: Quartz Beloit One Network |
$3,049.45
|
| Rate for Payer: Quartz Commercial |
$4,045.18
|
| Rate for Payer: Quartz Medicare Advantage |
$3,734.02
|
| Rate for Payer: The Alliance Commercial |
$3,111.68
|
| Rate for Payer: WEA Trust Commercial |
$3,422.85
|
| Rate for Payer: WPS Commercial |
$4,609.48
|
|
|
Aloxi 25 mcg Charge
|
Professional
|
Both
|
$182.00
|
|
|
Service Code
|
HCPCS J2469
|
| Hospital Charge Code |
2958937
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$179.82 |
| Rate for Payer: Aetna Commercial |
$179.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.78
|
| Rate for Payer: Aetna Managed Medicare |
$0.36
|
| Rate for Payer: Anthem Medicare Advantage |
$0.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.36
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$179.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.24
|
| Rate for Payer: Health EOS Commercial |
$172.24
|
| Rate for Payer: HFN Commercial |
$179.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.19
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$151.42
|
| Rate for Payer: NAPHCARE Commercial |
$0.55
|
| Rate for Payer: Preferred Network Access Commercial |
$179.82
|
| Rate for Payer: Quartz Beloit One Network |
$83.28
|
| Rate for Payer: Quartz Commercial |
$107.89
|
| Rate for Payer: Quartz Medicare Advantage |
$0.36
|
| Rate for Payer: The Alliance Commercial |
$1.00
|
| Rate for Payer: United Healthcare Medicaid |
$0.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.36
|
| Rate for Payer: WEA Trust Commercial |
$104.10
|
| Rate for Payer: WPS Commercial |
$3.10
|
|
|
Aloxi 25 mcg Charge
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
HCPCS J2469
|
| Hospital Charge Code |
2958937
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.75 |
| Max. Negotiated Rate |
$174.14 |
| Rate for Payer: Aetna Commercial |
$170.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.32
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$174.14
|
| Rate for Payer: Health EOS Commercial |
$168.46
|
| Rate for Payer: HFN Commercial |
$174.14
|
| Rate for Payer: Multiplan Commercial |
$151.42
|
| Rate for Payer: Preferred Network Access Commercial |
$174.14
|
| Rate for Payer: Quartz Beloit One Network |
$92.75
|
| Rate for Payer: Quartz Commercial |
$113.57
|
| Rate for Payer: WEA Trust Commercial |
$104.10
|
| Rate for Payer: WPS Commercial |
$140.19
|
|
|
Aloxi 25 mcg Charge
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
HCPCS J2469
|
| Hospital Charge Code |
2958937
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$174.14 |
| Rate for Payer: Aetna Commercial |
$170.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.78
|
| Rate for Payer: Aetna Managed Medicare |
$53.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$123.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$94.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$90.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.32
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$174.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.64
|
| Rate for Payer: Health EOS Commercial |
$168.46
|
| Rate for Payer: HFN Commercial |
$174.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$141.96
|
| Rate for Payer: Multiplan Commercial |
$151.42
|
| Rate for Payer: NAPHCARE Commercial |
$113.57
|
| Rate for Payer: Preferred Network Access Commercial |
$174.14
|
| Rate for Payer: Quartz Beloit One Network |
$92.75
|
| Rate for Payer: Quartz Commercial |
$123.03
|
| Rate for Payer: Quartz Medicare Advantage |
$113.57
|
| Rate for Payer: The Alliance Commercial |
$1.46
|
| Rate for Payer: WEA Trust Commercial |
$104.10
|
| Rate for Payer: WPS Commercial |
$3.10
|
|
|
Alpha-1-Antitrypsin
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
CPT 82103
|
| Hospital Charge Code |
977861
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$141.16 |
| Max. Negotiated Rate |
$265.03 |
| Rate for Payer: Aetna Commercial |
$259.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.68
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$265.03
|
| Rate for Payer: Health EOS Commercial |
$256.39
|
| Rate for Payer: HFN Commercial |
$265.03
|
| Rate for Payer: Multiplan Commercial |
$230.46
|
| Rate for Payer: Preferred Network Access Commercial |
$265.03
|
| Rate for Payer: Quartz Beloit One Network |
$141.16
|
| Rate for Payer: Quartz Commercial |
$172.85
|
| Rate for Payer: WEA Trust Commercial |
$158.44
|
| Rate for Payer: WPS Commercial |
$213.37
|
|
|
Alpha-1-Antitrypsin
|
Professional
|
Both
|
$277.00
|
|
|
Service Code
|
CPT 82103
|
| Hospital Charge Code |
977861
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.98 |
| Max. Negotiated Rate |
$273.68 |
| Rate for Payer: Aetna Commercial |
$273.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.75
|
| Rate for Payer: Aetna Managed Medicare |
$13.98
|
| Rate for Payer: Anthem Medicare Advantage |
$13.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.98
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$273.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$144.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.98
|
| Rate for Payer: Health EOS Commercial |
$262.15
|
| Rate for Payer: HFN Commercial |
$273.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.98
|
| Rate for Payer: Multiplan Commercial |
$230.46
|
| Rate for Payer: NAPHCARE Commercial |
$20.97
|
| Rate for Payer: Preferred Network Access Commercial |
$273.68
|
| Rate for Payer: Quartz Beloit One Network |
$126.76
|
| Rate for Payer: Quartz Commercial |
$164.21
|
| Rate for Payer: Quartz Medicare Advantage |
$13.98
|
| Rate for Payer: The Alliance Commercial |
$55.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.98
|
| Rate for Payer: WEA Trust Commercial |
$158.44
|
| Rate for Payer: WPS Commercial |
$61.50
|
|
|
Alpha-1-Antitrypsin
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
CPT 82103
|
| Hospital Charge Code |
977861
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.98 |
| Max. Negotiated Rate |
$265.03 |
| Rate for Payer: Aetna Commercial |
$259.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.75
|
| Rate for Payer: Aetna Managed Medicare |
$13.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.20
|
| Rate for Payer: Anthem Medicare Advantage |
$13.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.98
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$265.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$161.21
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.98
|
| Rate for Payer: Health EOS Commercial |
$256.39
|
| Rate for Payer: HFN Commercial |
$265.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.98
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.98
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.98
|
| Rate for Payer: Multiplan Commercial |
$230.46
|
| Rate for Payer: NAPHCARE Commercial |
$20.97
|
| Rate for Payer: Preferred Network Access Commercial |
$265.03
|
| Rate for Payer: Quartz Beloit One Network |
$141.16
|
| Rate for Payer: Quartz Commercial |
$187.25
|
| Rate for Payer: Quartz Medicare Advantage |
$13.98
|
| Rate for Payer: The Alliance Commercial |
$55.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.98
|
| Rate for Payer: United Healthcare PPO |
$216.06
|
| Rate for Payer: WEA Trust Commercial |
$158.44
|
| Rate for Payer: Wellcare Medicare |
$13.98
|
| Rate for Payer: WPS Commercial |
$213.37
|
|
