|
IMPLANT TOETAC XPRESS LARGE HAMMERTOE HT-00003
|
Facility
|
IP
|
$8,142.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5547499
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,149.16 |
| Max. Negotiated Rate |
$7,790.27 |
| Rate for Payer: Aetna Commercial |
$7,620.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,282.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,487.87
|
| Rate for Payer: Cash Price |
$2,442.60
|
| Rate for Payer: Cigna Commercial |
$7,790.27
|
| Rate for Payer: Health EOS Commercial |
$7,536.24
|
| Rate for Payer: HFN Commercial |
$7,790.27
|
| Rate for Payer: Multiplan Commercial |
$6,774.14
|
| Rate for Payer: Preferred Network Access Commercial |
$7,790.27
|
| Rate for Payer: Quartz Beloit One Network |
$4,149.16
|
| Rate for Payer: Quartz Commercial |
$5,080.61
|
| Rate for Payer: WEA Trust Commercial |
$4,657.22
|
| Rate for Payer: WPS Commercial |
$6,271.78
|
|
|
IMPLANT TOETAC XPRESS MEDIUM 10DEG HAMMERTOE HT-00005
|
Facility
|
IP
|
$2,239.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5414668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.99 |
| Max. Negotiated Rate |
$2,142.28 |
| Rate for Payer: Aetna Commercial |
$2,095.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,002.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,234.14
|
| Rate for Payer: Cash Price |
$671.70
|
| Rate for Payer: Cigna Commercial |
$2,142.28
|
| Rate for Payer: Health EOS Commercial |
$2,072.42
|
| Rate for Payer: HFN Commercial |
$2,142.28
|
| Rate for Payer: Multiplan Commercial |
$1,862.85
|
| Rate for Payer: Preferred Network Access Commercial |
$2,142.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,140.99
|
| Rate for Payer: Quartz Commercial |
$1,397.14
|
| Rate for Payer: WEA Trust Commercial |
$1,280.71
|
| Rate for Payer: WPS Commercial |
$1,724.70
|
|
|
IMPLANT TOETAC XPRESS MEDIUM 10DEG HAMMERTOE HT-00005
|
Facility
|
OP
|
$2,239.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5414668
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$652.00 |
| Max. Negotiated Rate |
$2,142.28 |
| Rate for Payer: Aetna Commercial |
$2,095.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,002.56
|
| Rate for Payer: Aetna Managed Medicare |
$652.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,513.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,164.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,117.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,234.14
|
| Rate for Payer: Cash Price |
$671.70
|
| Rate for Payer: Cigna Commercial |
$2,142.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,303.10
|
| Rate for Payer: Health EOS Commercial |
$2,072.42
|
| Rate for Payer: HFN Commercial |
$2,142.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,746.42
|
| Rate for Payer: Multiplan Commercial |
$1,862.85
|
| Rate for Payer: NAPHCARE Commercial |
$1,397.14
|
| Rate for Payer: Preferred Network Access Commercial |
$2,142.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,140.99
|
| Rate for Payer: Quartz Commercial |
$1,513.56
|
| Rate for Payer: Quartz Medicare Advantage |
$1,397.14
|
| Rate for Payer: The Alliance Commercial |
$1,164.28
|
| Rate for Payer: WEA Trust Commercial |
$1,280.71
|
| Rate for Payer: WPS Commercial |
$1,724.70
|
|
|
IMPLANT TOETAC XPRESS MEDIUM HAMMERTOE HT-00002
|
Facility
|
IP
|
$8,142.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5306927
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,149.16 |
| Max. Negotiated Rate |
$7,790.27 |
| Rate for Payer: Aetna Commercial |
$7,620.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,282.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,487.87
|
| Rate for Payer: Cash Price |
$2,442.60
|
| Rate for Payer: Cigna Commercial |
$7,790.27
|
| Rate for Payer: Health EOS Commercial |
$7,536.24
|
| Rate for Payer: HFN Commercial |
$7,790.27
|
| Rate for Payer: Multiplan Commercial |
$6,774.14
|
| Rate for Payer: Preferred Network Access Commercial |
$7,790.27
|
| Rate for Payer: Quartz Beloit One Network |
$4,149.16
|
| Rate for Payer: Quartz Commercial |
$5,080.61
|
| Rate for Payer: WEA Trust Commercial |
$4,657.22
|
| Rate for Payer: WPS Commercial |
$6,271.78
|
|
|
IMPLANT TOETAC XPRESS MEDIUM HAMMERTOE HT-00002
|
Facility
|
OP
|
$8,142.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5306927
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,370.95 |
| Max. Negotiated Rate |
$7,790.27 |
| Rate for Payer: The Alliance Commercial |
$4,233.84
|
| Rate for Payer: Aetna Commercial |
$7,620.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,282.20
|
| Rate for Payer: Aetna Managed Medicare |
$2,370.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,503.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,233.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,064.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,487.87
|
| Rate for Payer: Cash Price |
$2,442.60
|
| Rate for Payer: Cigna Commercial |
$7,790.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,738.64
|
| Rate for Payer: Health EOS Commercial |
$7,536.24
|
| Rate for Payer: HFN Commercial |
$7,790.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,350.76
|
| Rate for Payer: Multiplan Commercial |
$6,774.14
|
| Rate for Payer: NAPHCARE Commercial |
$5,080.61
|
| Rate for Payer: Preferred Network Access Commercial |
$7,790.27
|
| Rate for Payer: Quartz Beloit One Network |
$4,149.16
|
| Rate for Payer: Quartz Commercial |
$5,503.99
|
| Rate for Payer: Quartz Medicare Advantage |
$5,080.61
|
| Rate for Payer: WEA Trust Commercial |
$4,657.22
|
| Rate for Payer: WPS Commercial |
$6,271.78
|
|
|
IMPLANT TOETAC XPRESS SMALL HAMMERTOE HT-00001
|
Facility
|
OP
|
$1,278.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5265022
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$372.15 |
| Max. Negotiated Rate |
$1,222.79 |
| Rate for Payer: Aetna Commercial |
$1,196.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,143.04
|
| Rate for Payer: Aetna Managed Medicare |
$372.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$863.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$664.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$637.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$704.43
|
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cigna Commercial |
$1,222.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$743.80
|
| Rate for Payer: Health EOS Commercial |
$1,182.92
|
| Rate for Payer: HFN Commercial |
$1,222.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$996.84
|
| Rate for Payer: Multiplan Commercial |
$1,063.30
|
| Rate for Payer: NAPHCARE Commercial |
$797.47
|
| Rate for Payer: Preferred Network Access Commercial |
$1,222.79
|
| Rate for Payer: Quartz Beloit One Network |
$651.27
|
| Rate for Payer: Quartz Commercial |
$863.93
|
| Rate for Payer: Quartz Medicare Advantage |
$797.47
|
| Rate for Payer: The Alliance Commercial |
$664.56
|
| Rate for Payer: WEA Trust Commercial |
$731.02
|
| Rate for Payer: WPS Commercial |
$984.44
|
|
|
IMPLANT TOETAC XPRESS SMALL HAMMERTOE HT-00001
|
Facility
|
IP
|
$1,278.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5265022
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$651.27 |
| Max. Negotiated Rate |
$1,222.79 |
| Rate for Payer: Aetna Commercial |
$1,196.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,143.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$704.43
|
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cigna Commercial |
$1,222.79
|
| Rate for Payer: Health EOS Commercial |
$1,182.92
|
| Rate for Payer: HFN Commercial |
$1,222.79
|
| Rate for Payer: Multiplan Commercial |
$1,063.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,222.79
|
| Rate for Payer: Quartz Beloit One Network |
$651.27
|
| Rate for Payer: Quartz Commercial |
$797.47
|
| Rate for Payer: WEA Trust Commercial |
$731.02
|
| Rate for Payer: WPS Commercial |
$984.44
|
|
|
IMPLANT TRANSFIX 3x50
|
Facility
|
IP
|
$2,410.00
|
|
| Hospital Charge Code |
2964683
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,228.14 |
| Max. Negotiated Rate |
$2,305.89 |
| Rate for Payer: Aetna Commercial |
$2,255.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,155.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,328.39
|
| Rate for Payer: Cash Price |
$723.00
|
| Rate for Payer: Cigna Commercial |
$2,305.89
|
| Rate for Payer: Health EOS Commercial |
$2,230.70
|
| Rate for Payer: HFN Commercial |
$2,305.89
|
| Rate for Payer: Multiplan Commercial |
$2,005.12
|
| Rate for Payer: Preferred Network Access Commercial |
$2,305.89
|
| Rate for Payer: Quartz Beloit One Network |
$1,228.14
|
| Rate for Payer: Quartz Commercial |
$1,503.84
|
| Rate for Payer: WEA Trust Commercial |
$1,378.52
|
| Rate for Payer: WPS Commercial |
$1,856.42
|
|
|
IMPLANT TRANSFIX 3x50
|
Facility
|
OP
|
$2,410.00
|
|
| Hospital Charge Code |
2964683
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$701.79 |
| Max. Negotiated Rate |
$2,305.89 |
| Rate for Payer: Aetna Commercial |
$2,255.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,155.50
|
| Rate for Payer: Aetna Managed Medicare |
$701.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,629.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,253.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,203.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,328.39
|
| Rate for Payer: Cash Price |
$723.00
|
| Rate for Payer: Cigna Commercial |
$2,305.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,402.62
|
| Rate for Payer: Health EOS Commercial |
$2,230.70
|
| Rate for Payer: HFN Commercial |
$2,305.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,879.80
|
| Rate for Payer: Multiplan Commercial |
$2,005.12
|
| Rate for Payer: NAPHCARE Commercial |
$1,503.84
|
| Rate for Payer: Preferred Network Access Commercial |
$2,305.89
|
| Rate for Payer: Quartz Beloit One Network |
$1,228.14
|
| Rate for Payer: Quartz Commercial |
$1,629.16
|
| Rate for Payer: Quartz Medicare Advantage |
$1,503.84
|
| Rate for Payer: The Alliance Commercial |
$1,253.20
|
| Rate for Payer: WEA Trust Commercial |
$1,378.52
|
| Rate for Payer: WPS Commercial |
$1,856.42
|
|
|
IMPLANT X-FUSE 0 DEGREE
|
Facility
|
IP
|
$5,721.00
|
|
| Hospital Charge Code |
2965384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,915.42 |
| Max. Negotiated Rate |
$5,473.85 |
| Rate for Payer: Aetna Commercial |
$5,354.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,116.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,153.42
|
| Rate for Payer: Cash Price |
$1,716.30
|
| Rate for Payer: Cigna Commercial |
$5,473.85
|
| Rate for Payer: Health EOS Commercial |
$5,295.36
|
| Rate for Payer: HFN Commercial |
$5,473.85
|
| Rate for Payer: Multiplan Commercial |
$4,759.87
|
| Rate for Payer: Preferred Network Access Commercial |
$5,473.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,915.42
|
| Rate for Payer: Quartz Commercial |
$3,569.90
|
| Rate for Payer: WEA Trust Commercial |
$3,272.41
|
| Rate for Payer: WPS Commercial |
$4,406.89
|
|
|
IMPLANT X-FUSE 0 DEGREE
|
Facility
|
OP
|
$5,721.00
|
|
| Hospital Charge Code |
2965384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,665.96 |
| Max. Negotiated Rate |
$5,473.85 |
| Rate for Payer: Aetna Commercial |
$5,354.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,116.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,665.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,867.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,974.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,855.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,153.42
|
| Rate for Payer: Cash Price |
$1,716.30
|
| Rate for Payer: Cigna Commercial |
$5,473.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,329.62
|
| Rate for Payer: Health EOS Commercial |
$5,295.36
|
| Rate for Payer: HFN Commercial |
$5,473.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,462.38
|
| Rate for Payer: Multiplan Commercial |
$4,759.87
|
| Rate for Payer: NAPHCARE Commercial |
$3,569.90
|
| Rate for Payer: Preferred Network Access Commercial |
$5,473.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,915.42
|
| Rate for Payer: Quartz Commercial |
$3,867.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,569.90
|
| Rate for Payer: The Alliance Commercial |
$2,974.92
|
| Rate for Payer: WEA Trust Commercial |
$3,272.41
|
| Rate for Payer: WPS Commercial |
$4,406.89
|
|
|
IMPLANT X-FUSE 15 DEGREE
|
Facility
|
IP
|
$5,721.00
|
|
| Hospital Charge Code |
2965385
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,915.42 |
| Max. Negotiated Rate |
$5,473.85 |
| Rate for Payer: Aetna Commercial |
$5,354.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,116.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,153.42
|
| Rate for Payer: Cash Price |
$1,716.30
|
| Rate for Payer: Cigna Commercial |
$5,473.85
|
| Rate for Payer: Health EOS Commercial |
$5,295.36
|
| Rate for Payer: HFN Commercial |
$5,473.85
|
| Rate for Payer: Multiplan Commercial |
$4,759.87
|
| Rate for Payer: Preferred Network Access Commercial |
$5,473.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,915.42
|
| Rate for Payer: Quartz Commercial |
$3,569.90
|
| Rate for Payer: WEA Trust Commercial |
$3,272.41
|
| Rate for Payer: WPS Commercial |
$4,406.89
|
|
|
IMPLANT X-FUSE 15 DEGREE
|
Facility
|
OP
|
$5,721.00
|
|
| Hospital Charge Code |
2965385
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,665.96 |
| Max. Negotiated Rate |
$5,473.85 |
| Rate for Payer: Aetna Commercial |
$5,354.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,116.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,665.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,867.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,974.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,855.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,153.42
|
| Rate for Payer: Cash Price |
$1,716.30
|
| Rate for Payer: Cigna Commercial |
$5,473.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,329.62
|
| Rate for Payer: Health EOS Commercial |
$5,295.36
|
| Rate for Payer: HFN Commercial |
$5,473.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,462.38
|
| Rate for Payer: Multiplan Commercial |
$4,759.87
|
| Rate for Payer: NAPHCARE Commercial |
$3,569.90
|
| Rate for Payer: Preferred Network Access Commercial |
$5,473.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,915.42
|
| Rate for Payer: Quartz Commercial |
$3,867.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,569.90
|
| Rate for Payer: The Alliance Commercial |
$2,974.92
|
| Rate for Payer: WEA Trust Commercial |
$3,272.41
|
| Rate for Payer: WPS Commercial |
$4,406.89
|
|
|
Impression casting ft S0395
|
Professional
|
Both
|
$96.00
|
|
|
Service Code
|
HCPCS S0395
|
| Hospital Charge Code |
3133687
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$43.93 |
| Max. Negotiated Rate |
$94.85 |
| Rate for Payer: Aetna Commercial |
$94.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.86
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$94.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$49.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.90
|
| Rate for Payer: Health EOS Commercial |
$90.85
|
| Rate for Payer: HFN Commercial |
$94.85
|
| Rate for Payer: Multiplan Commercial |
$79.87
|
| Rate for Payer: Preferred Network Access Commercial |
$94.85
|
| Rate for Payer: Quartz Beloit One Network |
$43.93
|
| Rate for Payer: Quartz Commercial |
$56.91
|
| Rate for Payer: The Alliance Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$54.91
|
| Rate for Payer: WPS Commercial |
$73.95
|
|
|
Impression casting ft S0395
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
HCPCS S0395
|
| Hospital Charge Code |
3133687
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$48.92 |
| Max. Negotiated Rate |
$91.85 |
| Rate for Payer: Aetna Commercial |
$89.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$52.92
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$91.85
|
| Rate for Payer: Health EOS Commercial |
$88.86
|
| Rate for Payer: HFN Commercial |
$91.85
|
| Rate for Payer: Multiplan Commercial |
$79.87
|
| Rate for Payer: Preferred Network Access Commercial |
$91.85
|
| Rate for Payer: Quartz Beloit One Network |
$48.92
|
| Rate for Payer: Quartz Commercial |
$59.90
|
| Rate for Payer: WEA Trust Commercial |
$54.91
|
| Rate for Payer: WPS Commercial |
$73.95
|
|
|
Impression casting ft S0395
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
HCPCS S0395
|
| Hospital Charge Code |
3133687
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$27.96 |
| Max. Negotiated Rate |
$91.85 |
| Rate for Payer: Aetna Commercial |
$89.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.86
|
| Rate for Payer: Aetna Managed Medicare |
$27.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$52.92
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$91.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$55.87
|
| Rate for Payer: Health EOS Commercial |
$88.86
|
| Rate for Payer: HFN Commercial |
$91.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$74.88
|
| Rate for Payer: Multiplan Commercial |
$79.87
|
| Rate for Payer: NAPHCARE Commercial |
$59.90
|
| Rate for Payer: Preferred Network Access Commercial |
$91.85
|
| Rate for Payer: Quartz Beloit One Network |
$48.92
|
| Rate for Payer: Quartz Commercial |
$64.90
|
| Rate for Payer: Quartz Medicare Advantage |
$59.90
|
| Rate for Payer: The Alliance Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$54.91
|
| Rate for Payer: WPS Commercial |
$73.95
|
|
|
IMRT Radiotherapy Plan
|
Facility
|
IP
|
$11,981.00
|
|
|
Service Code
|
CPT 77301
|
| Hospital Charge Code |
3040380
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$6,105.52 |
| Max. Negotiated Rate |
$11,463.42 |
| Rate for Payer: Aetna Commercial |
$11,214.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,715.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,603.93
|
| Rate for Payer: Cash Price |
$3,594.30
|
| Rate for Payer: Cigna Commercial |
$11,463.42
|
| Rate for Payer: Health EOS Commercial |
$11,089.61
|
| Rate for Payer: HFN Commercial |
$11,463.42
|
| Rate for Payer: Multiplan Commercial |
$9,968.19
|
| Rate for Payer: Preferred Network Access Commercial |
$11,463.42
|
| Rate for Payer: Quartz Beloit One Network |
$6,105.52
|
| Rate for Payer: Quartz Commercial |
$7,476.14
|
| Rate for Payer: WEA Trust Commercial |
$6,853.13
|
| Rate for Payer: WPS Commercial |
$9,228.96
|
|
|
IMRT Radiotherapy Plan
|
Facility
|
OP
|
$11,981.00
|
|
|
Service Code
|
CPT 77301
|
| Hospital Charge Code |
3040380
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,456.64 |
| Max. Negotiated Rate |
$11,463.42 |
| Rate for Payer: Aetna Commercial |
$11,214.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,715.81
|
| Rate for Payer: Aetna Managed Medicare |
$1,456.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,341.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,273.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,059.38
|
| Rate for Payer: Anthem Medicare Advantage |
$1,456.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,603.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,456.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,456.64
|
| Rate for Payer: Cash Price |
$3,594.30
|
| Rate for Payer: Cash Price |
$3,594.30
|
| Rate for Payer: Cigna Commercial |
$11,463.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,456.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,972.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,456.64
|
| Rate for Payer: Health EOS Commercial |
$11,089.61
|
| Rate for Payer: HFN Commercial |
$11,463.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,418.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,456.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,456.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,456.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,456.64
|
| Rate for Payer: Multiplan Commercial |
$9,968.19
|
| Rate for Payer: NAPHCARE Commercial |
$2,184.97
|
| Rate for Payer: Preferred Network Access Commercial |
$11,463.42
|
| Rate for Payer: Quartz Beloit One Network |
$6,105.52
|
| Rate for Payer: Quartz Commercial |
$8,099.16
|
| Rate for Payer: Quartz Medicare Advantage |
$1,456.64
|
| Rate for Payer: The Alliance Commercial |
$5,826.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,456.64
|
| Rate for Payer: United Healthcare PPO |
$9,345.18
|
| Rate for Payer: WEA Trust Commercial |
$6,853.13
|
| Rate for Payer: Wellcare Medicare |
$1,456.64
|
| Rate for Payer: WPS Commercial |
$9,228.96
|
|
|
IMRT Treatment Complex (all other areas)
|
Facility
|
IP
|
$5,709.00
|
|
|
Service Code
|
CPT 77386
|
| Hospital Charge Code |
3040396
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$2,909.31 |
| Max. Negotiated Rate |
$5,462.37 |
| Rate for Payer: Aetna Commercial |
$5,343.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,106.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,146.80
|
| Rate for Payer: Cash Price |
$1,712.70
|
| Rate for Payer: Cigna Commercial |
$5,462.37
|
| Rate for Payer: Health EOS Commercial |
$5,284.25
|
| Rate for Payer: HFN Commercial |
$5,462.37
|
| Rate for Payer: Multiplan Commercial |
$4,749.89
|
| Rate for Payer: Preferred Network Access Commercial |
$5,462.37
|
| Rate for Payer: Quartz Beloit One Network |
$2,909.31
|
| Rate for Payer: Quartz Commercial |
$3,562.42
|
| Rate for Payer: WEA Trust Commercial |
$3,265.55
|
| Rate for Payer: WPS Commercial |
$4,397.64
|
|
|
IMRT Treatment Complex (all other areas)
|
Facility
|
OP
|
$5,709.00
|
|
|
Service Code
|
CPT 77386
|
| Hospital Charge Code |
3040396
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,662.46 |
| Max. Negotiated Rate |
$5,462.37 |
| Rate for Payer: Aetna Commercial |
$5,343.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,106.13
|
| Rate for Payer: Aetna Managed Medicare |
$1,662.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,269.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,815.34
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,724.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,146.80
|
| Rate for Payer: Cash Price |
$1,712.70
|
| Rate for Payer: Cash Price |
$1,712.70
|
| Rate for Payer: Cigna Commercial |
$5,462.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,322.64
|
| Rate for Payer: Health EOS Commercial |
$5,284.25
|
| Rate for Payer: HFN Commercial |
$5,462.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,453.02
|
| Rate for Payer: Multiplan Commercial |
$4,749.89
|
| Rate for Payer: NAPHCARE Commercial |
$3,562.42
|
| Rate for Payer: Preferred Network Access Commercial |
$5,462.37
|
| Rate for Payer: Quartz Beloit One Network |
$2,909.31
|
| Rate for Payer: Quartz Commercial |
$3,859.28
|
| Rate for Payer: Quartz Medicare Advantage |
$3,562.42
|
| Rate for Payer: The Alliance Commercial |
$2,968.68
|
| Rate for Payer: United Healthcare PPO |
$4,453.02
|
| Rate for Payer: WEA Trust Commercial |
$3,265.55
|
| Rate for Payer: WPS Commercial |
$4,397.64
|
|
|
IMRT Treatment Simplex (Breast & Prostate)
|
Facility
|
IP
|
$6,079.00
|
|
|
Service Code
|
CPT 77385
|
| Hospital Charge Code |
3040408
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$3,097.86 |
| Max. Negotiated Rate |
$5,816.39 |
| Rate for Payer: Aetna Commercial |
$5,689.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,437.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,350.74
|
| Rate for Payer: Cash Price |
$1,823.70
|
| Rate for Payer: Cigna Commercial |
$5,816.39
|
| Rate for Payer: Health EOS Commercial |
$5,626.72
|
| Rate for Payer: HFN Commercial |
$5,816.39
|
| Rate for Payer: Multiplan Commercial |
$5,057.73
|
| Rate for Payer: Preferred Network Access Commercial |
$5,816.39
|
| Rate for Payer: Quartz Beloit One Network |
$3,097.86
|
| Rate for Payer: Quartz Commercial |
$3,793.30
|
| Rate for Payer: WEA Trust Commercial |
$3,477.19
|
| Rate for Payer: WPS Commercial |
$4,682.65
|
|
|
IMRT Treatment Simplex (Breast & Prostate)
|
Facility
|
OP
|
$6,079.00
|
|
|
Service Code
|
CPT 77385
|
| Hospital Charge Code |
3040408
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,724.57 |
| Max. Negotiated Rate |
$5,816.39 |
| Rate for Payer: Aetna Commercial |
$5,689.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,437.06
|
| Rate for Payer: Aetna Managed Medicare |
$1,770.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,269.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,815.34
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,724.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,350.74
|
| Rate for Payer: Cash Price |
$1,823.70
|
| Rate for Payer: Cash Price |
$1,823.70
|
| Rate for Payer: Cigna Commercial |
$5,816.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,537.98
|
| Rate for Payer: Health EOS Commercial |
$5,626.72
|
| Rate for Payer: HFN Commercial |
$5,816.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,741.62
|
| Rate for Payer: Multiplan Commercial |
$5,057.73
|
| Rate for Payer: NAPHCARE Commercial |
$3,793.30
|
| Rate for Payer: Preferred Network Access Commercial |
$5,816.39
|
| Rate for Payer: Quartz Beloit One Network |
$3,097.86
|
| Rate for Payer: Quartz Commercial |
$4,109.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,793.30
|
| Rate for Payer: The Alliance Commercial |
$3,161.08
|
| Rate for Payer: United Healthcare PPO |
$4,741.62
|
| Rate for Payer: WEA Trust Commercial |
$3,477.19
|
| Rate for Payer: WPS Commercial |
$4,682.65
|
|
|
IM/Subsq Injection
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3040225
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$113.64 |
| Max. Negotiated Rate |
$213.37 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$139.15
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
IM/Subsq Injection
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3040225
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$75.77 |
| Max. Negotiated Rate |
$303.10 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$150.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$115.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$111.32
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.77
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$75.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$75.77
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: NAPHCARE Commercial |
$113.66
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$150.75
|
| Rate for Payer: Quartz Medicare Advantage |
$75.77
|
| Rate for Payer: The Alliance Commercial |
$303.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.77
|
| Rate for Payer: United Healthcare PPO |
$173.94
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: Wellcare Medicare |
$75.77
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
IM/Subsq Injection - 96372
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
5516709
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$75.77 |
| Max. Negotiated Rate |
$303.10 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$150.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$115.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$111.32
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.77
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$75.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$75.77
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: NAPHCARE Commercial |
$113.66
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$150.75
|
| Rate for Payer: Quartz Medicare Advantage |
$75.77
|
| Rate for Payer: The Alliance Commercial |
$303.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.77
|
| Rate for Payer: United Healthcare PPO |
$173.94
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: Wellcare Medicare |
$75.77
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
