|
KIT RESUS ADJ MSK42 10 #RD1340-10
|
Facility
|
OP
|
$293.00
|
|
| Hospital Charge Code |
2972716
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$82.04 |
| Max. Negotiated Rate |
$1,172.00 |
| Rate for Payer: Aetna Commercial |
$263.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$251.98
|
| Rate for Payer: Aetna Managed Medicare |
$82.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$190.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$146.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$140.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$155.29
|
| Rate for Payer: Cash Price |
$87.90
|
| Rate for Payer: Cigna Commercial |
$269.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$163.96
|
| Rate for Payer: Health EOS Commercial |
$260.77
|
| Rate for Payer: HFN Commercial |
$269.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$219.75
|
| Rate for Payer: Multiplan Commercial |
$234.40
|
| Rate for Payer: NAPHCARE Commercial |
$175.80
|
| Rate for Payer: Preferred Network Access Commercial |
$269.56
|
| Rate for Payer: Quartz Beloit One Network |
$143.57
|
| Rate for Payer: Quartz Commercial |
$190.45
|
| Rate for Payer: Quartz Medicare Advantage |
$175.80
|
| Rate for Payer: The Alliance Commercial |
$1,172.00
|
| Rate for Payer: WEA Trust Commercial |
$161.15
|
| Rate for Payer: WPS Commercial |
$217.03
|
|
|
KIT RESUS ADJ MSK50 10 #RD1350-10
|
Facility
|
IP
|
$261.00
|
|
| Hospital Charge Code |
2972426
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$127.89 |
| Max. Negotiated Rate |
$240.12 |
| Rate for Payer: Aetna Commercial |
$234.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.33
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$240.12
|
| Rate for Payer: Health EOS Commercial |
$232.29
|
| Rate for Payer: HFN Commercial |
$240.12
|
| Rate for Payer: Multiplan Commercial |
$208.80
|
| Rate for Payer: NAPHCARE Commercial |
$156.60
|
| Rate for Payer: Preferred Network Access Commercial |
$240.12
|
| Rate for Payer: Quartz Beloit One Network |
$127.89
|
| Rate for Payer: Quartz Commercial |
$156.60
|
| Rate for Payer: WEA Trust Commercial |
$143.55
|
| Rate for Payer: WPS Commercial |
$193.32
|
|
|
KIT RESUS ADJ MSK50 10 #RD1350-10
|
Facility
|
OP
|
$261.00
|
|
| Hospital Charge Code |
2972426
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$73.08 |
| Max. Negotiated Rate |
$1,044.00 |
| Rate for Payer: Aetna Commercial |
$234.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.46
|
| Rate for Payer: Aetna Managed Medicare |
$73.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$169.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$130.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$125.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.33
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$240.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.06
|
| Rate for Payer: Health EOS Commercial |
$232.29
|
| Rate for Payer: HFN Commercial |
$240.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$195.75
|
| Rate for Payer: Multiplan Commercial |
$208.80
|
| Rate for Payer: NAPHCARE Commercial |
$156.60
|
| Rate for Payer: Preferred Network Access Commercial |
$240.12
|
| Rate for Payer: Quartz Beloit One Network |
$127.89
|
| Rate for Payer: Quartz Commercial |
$169.65
|
| Rate for Payer: Quartz Medicare Advantage |
$156.60
|
| Rate for Payer: The Alliance Commercial |
$1,044.00
|
| Rate for Payer: WEA Trust Commercial |
$143.55
|
| Rate for Payer: WPS Commercial |
$193.32
|
|
|
KIT RESUS ADJ MSK60 10 #RD1360-10
|
Facility
|
OP
|
$261.00
|
|
| Hospital Charge Code |
2972427
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$73.08 |
| Max. Negotiated Rate |
$1,044.00 |
| Rate for Payer: Aetna Commercial |
$234.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.46
|
| Rate for Payer: Aetna Managed Medicare |
$73.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$169.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$130.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$125.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.33
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$240.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.06
|
| Rate for Payer: Health EOS Commercial |
$232.29
|
| Rate for Payer: HFN Commercial |
$240.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$195.75
|
| Rate for Payer: Multiplan Commercial |
$208.80
|
| Rate for Payer: NAPHCARE Commercial |
$156.60
|
| Rate for Payer: Preferred Network Access Commercial |
$240.12
|
| Rate for Payer: Quartz Beloit One Network |
$127.89
|
| Rate for Payer: Quartz Commercial |
$169.65
|
| Rate for Payer: Quartz Medicare Advantage |
$156.60
|
| Rate for Payer: The Alliance Commercial |
$1,044.00
|
| Rate for Payer: WEA Trust Commercial |
$143.55
|
| Rate for Payer: WPS Commercial |
$193.32
|
|
|
KIT RESUS ADJ MSK60 10 #RD1360-10
|
Facility
|
IP
|
$261.00
|
|
| Hospital Charge Code |
2972427
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$127.89 |
| Max. Negotiated Rate |
$240.12 |
| Rate for Payer: Aetna Commercial |
$234.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.33
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$240.12
|
| Rate for Payer: Health EOS Commercial |
$232.29
|
| Rate for Payer: HFN Commercial |
$240.12
|
| Rate for Payer: Multiplan Commercial |
$208.80
|
| Rate for Payer: NAPHCARE Commercial |
$156.60
|
| Rate for Payer: Preferred Network Access Commercial |
$240.12
|
| Rate for Payer: Quartz Beloit One Network |
$127.89
|
| Rate for Payer: Quartz Commercial |
$156.60
|
| Rate for Payer: WEA Trust Commercial |
$143.55
|
| Rate for Payer: WPS Commercial |
$193.32
|
|
|
KIT SCP FOOT & ANKLE 11GA 3CC 514.303
|
Facility
|
IP
|
$15,898.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5591319
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,790.02 |
| Max. Negotiated Rate |
$14,626.16 |
| Rate for Payer: Aetna Commercial |
$14,308.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,672.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,425.94
|
| Rate for Payer: Cash Price |
$4,769.40
|
| Rate for Payer: Cigna Commercial |
$14,626.16
|
| Rate for Payer: Health EOS Commercial |
$14,149.22
|
| Rate for Payer: HFN Commercial |
$14,626.16
|
| Rate for Payer: Multiplan Commercial |
$12,718.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,538.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,626.16
|
| Rate for Payer: Quartz Beloit One Network |
$7,790.02
|
| Rate for Payer: Quartz Commercial |
$9,538.80
|
| Rate for Payer: WEA Trust Commercial |
$8,743.90
|
| Rate for Payer: WPS Commercial |
$11,775.65
|
|
|
KIT SCP FOOT & ANKLE 11GA 3CC 514.303
|
Facility
|
OP
|
$15,898.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5591319
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,451.44 |
| Max. Negotiated Rate |
$63,592.00 |
| Rate for Payer: Aetna Commercial |
$14,308.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,672.28
|
| Rate for Payer: Aetna Managed Medicare |
$4,451.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,333.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,949.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,631.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,425.94
|
| Rate for Payer: Cash Price |
$4,769.40
|
| Rate for Payer: Cigna Commercial |
$14,626.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,896.52
|
| Rate for Payer: Health EOS Commercial |
$14,149.22
|
| Rate for Payer: HFN Commercial |
$14,626.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,923.50
|
| Rate for Payer: Multiplan Commercial |
$12,718.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,538.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,626.16
|
| Rate for Payer: Quartz Beloit One Network |
$7,790.02
|
| Rate for Payer: Quartz Commercial |
$10,333.70
|
| Rate for Payer: Quartz Medicare Advantage |
$9,538.80
|
| Rate for Payer: The Alliance Commercial |
$63,592.00
|
| Rate for Payer: WEA Trust Commercial |
$8,743.90
|
| Rate for Payer: WPS Commercial |
$11,775.65
|
|
|
KIT SCP KNEE WITH ACCUPORT SIDE DELIVERY CANNULA 414.502
|
Facility
|
IP
|
$20,842.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5206672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,212.58 |
| Max. Negotiated Rate |
$19,174.64 |
| Rate for Payer: Aetna Commercial |
$18,757.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,924.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,046.26
|
| Rate for Payer: Cash Price |
$6,252.60
|
| Rate for Payer: Cigna Commercial |
$19,174.64
|
| Rate for Payer: Health EOS Commercial |
$18,549.38
|
| Rate for Payer: HFN Commercial |
$19,174.64
|
| Rate for Payer: Multiplan Commercial |
$16,673.60
|
| Rate for Payer: NAPHCARE Commercial |
$12,505.20
|
| Rate for Payer: Preferred Network Access Commercial |
$19,174.64
|
| Rate for Payer: Quartz Beloit One Network |
$10,212.58
|
| Rate for Payer: Quartz Commercial |
$12,505.20
|
| Rate for Payer: WEA Trust Commercial |
$11,463.10
|
| Rate for Payer: WPS Commercial |
$15,437.67
|
|
|
KIT SCP KNEE WITH ACCUPORT SIDE DELIVERY CANNULA 414.502
|
Facility
|
OP
|
$20,842.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5206672
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,835.76 |
| Max. Negotiated Rate |
$83,368.00 |
| Rate for Payer: Aetna Commercial |
$18,757.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,924.12
|
| Rate for Payer: Aetna Managed Medicare |
$5,835.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,547.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,421.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,004.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,046.26
|
| Rate for Payer: Cash Price |
$6,252.60
|
| Rate for Payer: Cigna Commercial |
$19,174.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,663.18
|
| Rate for Payer: Health EOS Commercial |
$18,549.38
|
| Rate for Payer: HFN Commercial |
$19,174.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,631.50
|
| Rate for Payer: Multiplan Commercial |
$16,673.60
|
| Rate for Payer: NAPHCARE Commercial |
$12,505.20
|
| Rate for Payer: Preferred Network Access Commercial |
$19,174.64
|
| Rate for Payer: Quartz Beloit One Network |
$10,212.58
|
| Rate for Payer: Quartz Commercial |
$13,547.30
|
| Rate for Payer: Quartz Medicare Advantage |
$12,505.20
|
| Rate for Payer: The Alliance Commercial |
$83,368.00
|
| Rate for Payer: WEA Trust Commercial |
$11,463.10
|
| Rate for Payer: WPS Commercial |
$15,437.67
|
|
|
KIT SCP PF KNEE WITH ACCUPORT END DELIVERY CANNULA 11GAX120MM 464303
|
Facility
|
OP
|
$14,085.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685670
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,943.80 |
| Max. Negotiated Rate |
$56,340.00 |
| Rate for Payer: Aetna Commercial |
$12,676.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,113.10
|
| Rate for Payer: Aetna Managed Medicare |
$3,943.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,155.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,042.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,760.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,465.05
|
| Rate for Payer: Cash Price |
$4,225.50
|
| Rate for Payer: Cigna Commercial |
$12,958.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,881.97
|
| Rate for Payer: Health EOS Commercial |
$12,535.65
|
| Rate for Payer: HFN Commercial |
$12,958.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,563.75
|
| Rate for Payer: Multiplan Commercial |
$11,268.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,451.00
|
| Rate for Payer: Preferred Network Access Commercial |
$12,958.20
|
| Rate for Payer: Quartz Beloit One Network |
$6,901.65
|
| Rate for Payer: Quartz Commercial |
$9,155.25
|
| Rate for Payer: Quartz Medicare Advantage |
$8,451.00
|
| Rate for Payer: The Alliance Commercial |
$56,340.00
|
| Rate for Payer: WEA Trust Commercial |
$7,746.75
|
| Rate for Payer: WPS Commercial |
$10,432.76
|
|
|
KIT SCP PF KNEE WITH ACCUPORT END DELIVERY CANNULA 11GAX120MM 464303
|
Facility
|
IP
|
$14,085.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685670
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,901.65 |
| Max. Negotiated Rate |
$12,958.20 |
| Rate for Payer: Aetna Commercial |
$12,676.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,113.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,465.05
|
| Rate for Payer: Cash Price |
$4,225.50
|
| Rate for Payer: Cigna Commercial |
$12,958.20
|
| Rate for Payer: Health EOS Commercial |
$12,535.65
|
| Rate for Payer: HFN Commercial |
$12,958.20
|
| Rate for Payer: Multiplan Commercial |
$11,268.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,451.00
|
| Rate for Payer: Preferred Network Access Commercial |
$12,958.20
|
| Rate for Payer: Quartz Beloit One Network |
$6,901.65
|
| Rate for Payer: Quartz Commercial |
$8,451.00
|
| Rate for Payer: WEA Trust Commercial |
$7,746.75
|
| Rate for Payer: WPS Commercial |
$10,432.76
|
|
|
KIT SHEATH INTRODUCER 9FR AK-29903-CDC
|
Facility
|
OP
|
$707.00
|
|
| Hospital Charge Code |
2962970
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$197.96 |
| Max. Negotiated Rate |
$2,828.00 |
| Rate for Payer: Aetna Commercial |
$636.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$608.02
|
| Rate for Payer: Aetna Managed Medicare |
$197.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$459.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$353.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$339.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$374.71
|
| Rate for Payer: Cash Price |
$212.10
|
| Rate for Payer: Cigna Commercial |
$650.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$395.64
|
| Rate for Payer: Health EOS Commercial |
$629.23
|
| Rate for Payer: HFN Commercial |
$650.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$530.25
|
| Rate for Payer: Multiplan Commercial |
$565.60
|
| Rate for Payer: NAPHCARE Commercial |
$424.20
|
| Rate for Payer: Preferred Network Access Commercial |
$650.44
|
| Rate for Payer: Quartz Beloit One Network |
$346.43
|
| Rate for Payer: Quartz Commercial |
$459.55
|
| Rate for Payer: Quartz Medicare Advantage |
$424.20
|
| Rate for Payer: The Alliance Commercial |
$2,828.00
|
| Rate for Payer: WEA Trust Commercial |
$388.85
|
| Rate for Payer: WPS Commercial |
$523.67
|
|
|
KIT SHEATH INTRODUCER 9FR AK-29903-CDC
|
Facility
|
IP
|
$707.00
|
|
| Hospital Charge Code |
2962970
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$346.43 |
| Max. Negotiated Rate |
$650.44 |
| Rate for Payer: Aetna Commercial |
$636.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$608.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$374.71
|
| Rate for Payer: Cash Price |
$212.10
|
| Rate for Payer: Cigna Commercial |
$650.44
|
| Rate for Payer: Health EOS Commercial |
$629.23
|
| Rate for Payer: HFN Commercial |
$650.44
|
| Rate for Payer: Multiplan Commercial |
$565.60
|
| Rate for Payer: NAPHCARE Commercial |
$424.20
|
| Rate for Payer: Preferred Network Access Commercial |
$650.44
|
| Rate for Payer: Quartz Beloit One Network |
$346.43
|
| Rate for Payer: Quartz Commercial |
$424.20
|
| Rate for Payer: WEA Trust Commercial |
$388.85
|
| Rate for Payer: WPS Commercial |
$523.67
|
|
|
KIT SHOULDER SPACER SM 41MM SBS0121K
|
Facility
|
IP
|
$20,049.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5787626
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,824.01 |
| Max. Negotiated Rate |
$18,445.08 |
| Rate for Payer: Aetna Commercial |
$18,044.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,242.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,625.97
|
| Rate for Payer: Cash Price |
$6,014.70
|
| Rate for Payer: Cigna Commercial |
$18,445.08
|
| Rate for Payer: Health EOS Commercial |
$17,843.61
|
| Rate for Payer: HFN Commercial |
$18,445.08
|
| Rate for Payer: Multiplan Commercial |
$16,039.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,029.40
|
| Rate for Payer: Preferred Network Access Commercial |
$18,445.08
|
| Rate for Payer: Quartz Beloit One Network |
$9,824.01
|
| Rate for Payer: Quartz Commercial |
$12,029.40
|
| Rate for Payer: WEA Trust Commercial |
$11,026.95
|
| Rate for Payer: WPS Commercial |
$14,850.29
|
|
|
KIT SHOULDER SPACER SM 41MM SBS0121K
|
Facility
|
OP
|
$20,049.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5787626
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,613.72 |
| Max. Negotiated Rate |
$80,196.00 |
| Rate for Payer: Aetna Commercial |
$18,044.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,242.14
|
| Rate for Payer: Aetna Managed Medicare |
$5,613.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,031.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,024.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,623.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,625.97
|
| Rate for Payer: Cash Price |
$6,014.70
|
| Rate for Payer: Cigna Commercial |
$18,445.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,219.42
|
| Rate for Payer: Health EOS Commercial |
$17,843.61
|
| Rate for Payer: HFN Commercial |
$18,445.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,036.75
|
| Rate for Payer: Multiplan Commercial |
$16,039.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,029.40
|
| Rate for Payer: Preferred Network Access Commercial |
$18,445.08
|
| Rate for Payer: Quartz Beloit One Network |
$9,824.01
|
| Rate for Payer: Quartz Commercial |
$13,031.85
|
| Rate for Payer: Quartz Medicare Advantage |
$12,029.40
|
| Rate for Payer: The Alliance Commercial |
$80,196.00
|
| Rate for Payer: WEA Trust Commercial |
$11,026.95
|
| Rate for Payer: WPS Commercial |
$14,850.29
|
|
|
KIT SHOULDER STABILIZER (SPIDER S&N) 7210573
|
Facility
|
IP
|
$1,380.00
|
|
| Hospital Charge Code |
6214966
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$676.20 |
| Max. Negotiated Rate |
$1,269.60 |
| Rate for Payer: Aetna Commercial |
$1,242.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,186.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$731.40
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cigna Commercial |
$1,269.60
|
| Rate for Payer: Health EOS Commercial |
$1,228.20
|
| Rate for Payer: HFN Commercial |
$1,269.60
|
| Rate for Payer: Multiplan Commercial |
$1,104.00
|
| Rate for Payer: NAPHCARE Commercial |
$828.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,269.60
|
| Rate for Payer: Quartz Beloit One Network |
$676.20
|
| Rate for Payer: Quartz Commercial |
$828.00
|
| Rate for Payer: WEA Trust Commercial |
$759.00
|
| Rate for Payer: WPS Commercial |
$1,022.17
|
|
|
KIT SHOULDER STABILIZER (SPIDER S&N) 7210573
|
Facility
|
OP
|
$1,380.00
|
|
| Hospital Charge Code |
6214966
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$386.40 |
| Max. Negotiated Rate |
$5,520.00 |
| Rate for Payer: Aetna Commercial |
$1,242.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,186.80
|
| Rate for Payer: Aetna Managed Medicare |
$386.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$897.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$690.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$662.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$731.40
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cigna Commercial |
$1,269.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$772.25
|
| Rate for Payer: Health EOS Commercial |
$1,228.20
|
| Rate for Payer: HFN Commercial |
$1,269.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,035.00
|
| Rate for Payer: Multiplan Commercial |
$1,104.00
|
| Rate for Payer: NAPHCARE Commercial |
$828.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,269.60
|
| Rate for Payer: Quartz Beloit One Network |
$676.20
|
| Rate for Payer: Quartz Commercial |
$897.00
|
| Rate for Payer: Quartz Medicare Advantage |
$828.00
|
| Rate for Payer: The Alliance Commercial |
$5,520.00
|
| Rate for Payer: WEA Trust Commercial |
$759.00
|
| Rate for Payer: WPS Commercial |
$1,022.17
|
|
|
KIT SHOULDER SUSPENSION (DYONICS) 72200195
|
Facility
|
OP
|
$1,822.00
|
|
| Hospital Charge Code |
6214967
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$510.16 |
| Max. Negotiated Rate |
$7,288.00 |
| Rate for Payer: Aetna Commercial |
$1,639.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,566.92
|
| Rate for Payer: Aetna Managed Medicare |
$510.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,184.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$911.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$874.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$965.66
|
| Rate for Payer: Cash Price |
$546.60
|
| Rate for Payer: Cigna Commercial |
$1,676.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,019.59
|
| Rate for Payer: Health EOS Commercial |
$1,621.58
|
| Rate for Payer: HFN Commercial |
$1,676.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,366.50
|
| Rate for Payer: Multiplan Commercial |
$1,457.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,093.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,676.24
|
| Rate for Payer: Quartz Beloit One Network |
$892.78
|
| Rate for Payer: Quartz Commercial |
$1,184.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,093.20
|
| Rate for Payer: The Alliance Commercial |
$7,288.00
|
| Rate for Payer: WEA Trust Commercial |
$1,002.10
|
| Rate for Payer: WPS Commercial |
$1,349.56
|
|
|
KIT SHOULDER SUSPENSION (DYONICS) 72200195
|
Facility
|
IP
|
$1,822.00
|
|
| Hospital Charge Code |
6214967
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$892.78 |
| Max. Negotiated Rate |
$1,676.24 |
| Rate for Payer: Aetna Commercial |
$1,639.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,566.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$965.66
|
| Rate for Payer: Cash Price |
$546.60
|
| Rate for Payer: Cigna Commercial |
$1,676.24
|
| Rate for Payer: Health EOS Commercial |
$1,621.58
|
| Rate for Payer: HFN Commercial |
$1,676.24
|
| Rate for Payer: Multiplan Commercial |
$1,457.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,093.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,676.24
|
| Rate for Payer: Quartz Beloit One Network |
$892.78
|
| Rate for Payer: Quartz Commercial |
$1,093.20
|
| Rate for Payer: WEA Trust Commercial |
$1,002.10
|
| Rate for Payer: WPS Commercial |
$1,349.56
|
|
|
KIT SUTURE LACERATION
|
Facility
|
OP
|
$83.00
|
|
| Hospital Charge Code |
2963040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.24 |
| Max. Negotiated Rate |
$332.00 |
| Rate for Payer: Aetna Commercial |
$74.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Aetna Managed Medicare |
$23.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.99
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.45
|
| Rate for Payer: Health EOS Commercial |
$73.87
|
| Rate for Payer: HFN Commercial |
$76.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.25
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: NAPHCARE Commercial |
$49.80
|
| Rate for Payer: Preferred Network Access Commercial |
$76.36
|
| Rate for Payer: Quartz Beloit One Network |
$40.67
|
| Rate for Payer: Quartz Commercial |
$53.95
|
| Rate for Payer: Quartz Medicare Advantage |
$49.80
|
| Rate for Payer: The Alliance Commercial |
$332.00
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
KIT SUTURE LACERATION
|
Facility
|
IP
|
$83.00
|
|
| Hospital Charge Code |
2963040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.67 |
| Max. Negotiated Rate |
$76.36 |
| Rate for Payer: Aetna Commercial |
$74.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.99
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: Health EOS Commercial |
$73.87
|
| Rate for Payer: HFN Commercial |
$76.36
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: NAPHCARE Commercial |
$49.80
|
| Rate for Payer: Preferred Network Access Commercial |
$76.36
|
| Rate for Payer: Quartz Beloit One Network |
$40.67
|
| Rate for Payer: Quartz Commercial |
$49.80
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
KIT SUTURETAK PERC INSERTION AR-1934PI
|
Facility
|
IP
|
$3,404.00
|
|
| Hospital Charge Code |
2964686
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,667.96 |
| Max. Negotiated Rate |
$3,131.68 |
| Rate for Payer: Aetna Commercial |
$3,063.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,927.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,804.12
|
| Rate for Payer: Cash Price |
$1,021.20
|
| Rate for Payer: Cigna Commercial |
$3,131.68
|
| Rate for Payer: Health EOS Commercial |
$3,029.56
|
| Rate for Payer: HFN Commercial |
$3,131.68
|
| Rate for Payer: Multiplan Commercial |
$2,723.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,042.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,131.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,667.96
|
| Rate for Payer: Quartz Commercial |
$2,042.40
|
| Rate for Payer: WEA Trust Commercial |
$1,872.20
|
| Rate for Payer: WPS Commercial |
$2,521.34
|
|
|
KIT SUTURETAK PERC INSERTION AR-1934PI
|
Facility
|
OP
|
$3,404.00
|
|
| Hospital Charge Code |
2964686
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$953.12 |
| Max. Negotiated Rate |
$13,616.00 |
| Rate for Payer: Aetna Commercial |
$3,063.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,927.44
|
| Rate for Payer: Aetna Managed Medicare |
$953.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,212.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,702.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,633.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,804.12
|
| Rate for Payer: Cash Price |
$1,021.20
|
| Rate for Payer: Cigna Commercial |
$3,131.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,904.88
|
| Rate for Payer: Health EOS Commercial |
$3,029.56
|
| Rate for Payer: HFN Commercial |
$3,131.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,553.00
|
| Rate for Payer: Multiplan Commercial |
$2,723.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,042.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,131.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,667.96
|
| Rate for Payer: Quartz Commercial |
$2,212.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,042.40
|
| Rate for Payer: The Alliance Commercial |
$13,616.00
|
| Rate for Payer: WEA Trust Commercial |
$1,872.20
|
| Rate for Payer: WPS Commercial |
$2,521.34
|
|
|
KIT SYSTEM INTERNAL BRACE HAND/WRIST LIGAMENT AUGMENT REPAIR AR-8978-CP
|
Facility
|
IP
|
$11,361.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5414870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,566.89 |
| Max. Negotiated Rate |
$10,452.12 |
| Rate for Payer: Aetna Commercial |
$10,224.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,770.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,021.33
|
| Rate for Payer: Cash Price |
$3,408.30
|
| Rate for Payer: Cigna Commercial |
$10,452.12
|
| Rate for Payer: Health EOS Commercial |
$10,111.29
|
| Rate for Payer: HFN Commercial |
$10,452.12
|
| Rate for Payer: Multiplan Commercial |
$9,088.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,816.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,452.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,566.89
|
| Rate for Payer: Quartz Commercial |
$6,816.60
|
| Rate for Payer: WEA Trust Commercial |
$6,248.55
|
| Rate for Payer: WPS Commercial |
$8,415.09
|
|
|
KIT SYSTEM INTERNAL BRACE HAND/WRIST LIGAMENT AUGMENT REPAIR AR-8978-CP
|
Facility
|
OP
|
$11,361.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5414870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,181.08 |
| Max. Negotiated Rate |
$45,444.00 |
| Rate for Payer: Aetna Commercial |
$10,224.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,770.46
|
| Rate for Payer: Aetna Managed Medicare |
$3,181.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,384.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,680.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,453.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,021.33
|
| Rate for Payer: Cash Price |
$3,408.30
|
| Rate for Payer: Cigna Commercial |
$10,452.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,357.62
|
| Rate for Payer: Health EOS Commercial |
$10,111.29
|
| Rate for Payer: HFN Commercial |
$10,452.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,520.75
|
| Rate for Payer: Multiplan Commercial |
$9,088.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,816.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10,452.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,566.89
|
| Rate for Payer: Quartz Commercial |
$7,384.65
|
| Rate for Payer: Quartz Medicare Advantage |
$6,816.60
|
| Rate for Payer: The Alliance Commercial |
$45,444.00
|
| Rate for Payer: WEA Trust Commercial |
$6,248.55
|
| Rate for Payer: WPS Commercial |
$8,415.09
|
|
