|
Micromewi Infusion 10cm
|
Facility
|
OP
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549124
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$706.72 |
| Max. Negotiated Rate |
$10,096.00 |
| Rate for Payer: Aetna Commercial |
$2,271.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Aetna Managed Medicare |
$706.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,640.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,262.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,211.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,337.72
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,322.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,412.43
|
| Rate for Payer: Health EOS Commercial |
$2,246.36
|
| Rate for Payer: HFN Commercial |
$2,322.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,893.00
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,322.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,236.76
|
| Rate for Payer: Quartz Commercial |
$1,640.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,514.40
|
| Rate for Payer: The Alliance Commercial |
$10,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
Micromewi Infusion 10cm
|
Professional
|
Both
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549124
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,110.56 |
| Max. Negotiated Rate |
$2,397.80 |
| Rate for Payer: Aetna Commercial |
$2,397.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,397.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,262.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,514.40
|
| Rate for Payer: Health EOS Commercial |
$2,296.84
|
| Rate for Payer: HFN Commercial |
$2,397.80
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,397.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,110.56
|
| Rate for Payer: Quartz Commercial |
$1,438.68
|
| Rate for Payer: The Alliance Commercial |
$1,262.00
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
Micromewi Infusion 10cm
|
Facility
|
IP
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549124
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,236.76 |
| Max. Negotiated Rate |
$2,322.08 |
| Rate for Payer: Aetna Commercial |
$2,271.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,337.72
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,322.08
|
| Rate for Payer: Health EOS Commercial |
$2,246.36
|
| Rate for Payer: HFN Commercial |
$2,322.08
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,322.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,236.76
|
| Rate for Payer: Quartz Commercial |
$1,514.40
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
Micromewi Infusion 5cm
|
Facility
|
IP
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549122
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,236.76 |
| Max. Negotiated Rate |
$2,322.08 |
| Rate for Payer: Aetna Commercial |
$2,271.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,337.72
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,322.08
|
| Rate for Payer: Health EOS Commercial |
$2,246.36
|
| Rate for Payer: HFN Commercial |
$2,322.08
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,322.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,236.76
|
| Rate for Payer: Quartz Commercial |
$1,514.40
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
Micromewi Infusion 5cm
|
Professional
|
Both
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549122
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,110.56 |
| Max. Negotiated Rate |
$2,397.80 |
| Rate for Payer: Aetna Commercial |
$2,397.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,397.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,262.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,514.40
|
| Rate for Payer: Health EOS Commercial |
$2,296.84
|
| Rate for Payer: HFN Commercial |
$2,397.80
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,397.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,110.56
|
| Rate for Payer: Quartz Commercial |
$1,438.68
|
| Rate for Payer: The Alliance Commercial |
$1,262.00
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
Micromewi Infusion 5cm
|
Facility
|
OP
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549122
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$706.72 |
| Max. Negotiated Rate |
$10,096.00 |
| Rate for Payer: Aetna Commercial |
$2,271.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Aetna Managed Medicare |
$706.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,640.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,262.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,211.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,337.72
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,322.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,412.43
|
| Rate for Payer: Health EOS Commercial |
$2,246.36
|
| Rate for Payer: HFN Commercial |
$2,322.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,893.00
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,322.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,236.76
|
| Rate for Payer: Quartz Commercial |
$1,640.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,514.40
|
| Rate for Payer: The Alliance Commercial |
$10,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
Micropolyspora faeni
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
CPT 86609
|
| Hospital Charge Code |
2942918
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.45 |
| Max. Negotiated Rate |
$96.60 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$63.00
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$63.00
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
Micropolyspora faeni
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
CPT 86609
|
| Hospital Charge Code |
2942918
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$96.60 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Aetna Managed Medicare |
$12.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.54
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.38
|
| Rate for Payer: Anthem Medicaid |
$8.17
|
| Rate for Payer: Anthem Medicare Advantage |
$12.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.88
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$96.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.76
|
| Rate for Payer: Dean Health Medicaid |
$8.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.88
|
| Rate for Payer: Health EOS Commercial |
$93.45
|
| Rate for Payer: HFN Commercial |
$96.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.88
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.88
|
| Rate for Payer: Managed Health Services Medicaid |
$8.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.88
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.88
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: NAPHCARE Commercial |
$19.32
|
| Rate for Payer: Preferred Network Access Commercial |
$96.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.17
|
| Rate for Payer: Quartz Beloit One Network |
$51.45
|
| Rate for Payer: Quartz Commercial |
$68.25
|
| Rate for Payer: Quartz Medicare Advantage |
$12.88
|
| Rate for Payer: The Alliance Commercial |
$51.52
|
| Rate for Payer: United Healthcare Medicaid |
$8.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.88
|
| Rate for Payer: United Healthcare PPO |
$78.75
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: Wellcare Medicare |
$12.88
|
| Rate for Payer: WMAP Medicaid |
$8.17
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
Micropolyspora faeni
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
CPT 86609
|
| Hospital Charge Code |
2942918
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$45.47 |
| Max. Negotiated Rate |
$99.75 |
| Rate for Payer: Aetna Commercial |
$99.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$99.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.00
|
| Rate for Payer: Health EOS Commercial |
$95.55
|
| Rate for Payer: HFN Commercial |
$99.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$45.47
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Preferred Network Access Commercial |
$99.75
|
| Rate for Payer: Quartz Beloit One Network |
$46.20
|
| Rate for Payer: Quartz Commercial |
$59.85
|
| Rate for Payer: The Alliance Commercial |
$52.50
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
MICROPULSE P3 PROBES 15522
|
Facility
|
IP
|
$2,601.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
6175698
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,274.49 |
| Max. Negotiated Rate |
$2,392.92 |
| Rate for Payer: Aetna Commercial |
$2,340.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,236.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,378.53
|
| Rate for Payer: Cash Price |
$780.30
|
| Rate for Payer: Cigna Commercial |
$2,392.92
|
| Rate for Payer: Health EOS Commercial |
$2,314.89
|
| Rate for Payer: HFN Commercial |
$2,392.92
|
| Rate for Payer: Multiplan Commercial |
$2,080.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,560.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,392.92
|
| Rate for Payer: Quartz Beloit One Network |
$1,274.49
|
| Rate for Payer: Quartz Commercial |
$1,560.60
|
| Rate for Payer: WEA Trust Commercial |
$1,430.55
|
| Rate for Payer: WPS Commercial |
$1,926.56
|
|
|
MICROPULSE P3 PROBES 15522
|
Facility
|
OP
|
$2,601.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
6175698
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$728.28 |
| Max. Negotiated Rate |
$10,404.00 |
| Rate for Payer: Aetna Commercial |
$2,340.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,236.86
|
| Rate for Payer: Aetna Managed Medicare |
$728.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,690.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,300.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,248.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,378.53
|
| Rate for Payer: Cash Price |
$780.30
|
| Rate for Payer: Cigna Commercial |
$2,392.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,455.52
|
| Rate for Payer: Health EOS Commercial |
$2,314.89
|
| Rate for Payer: HFN Commercial |
$2,392.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,950.75
|
| Rate for Payer: Multiplan Commercial |
$2,080.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,560.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,392.92
|
| Rate for Payer: Quartz Beloit One Network |
$1,274.49
|
| Rate for Payer: Quartz Commercial |
$1,690.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,560.60
|
| Rate for Payer: The Alliance Commercial |
$10,404.00
|
| Rate for Payer: WEA Trust Commercial |
$1,430.55
|
| Rate for Payer: WPS Commercial |
$1,926.56
|
|
|
Micropuncture 4Fr
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2549132
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.24 |
| Max. Negotiated Rate |
$304.95 |
| Rate for Payer: Aetna Commercial |
$304.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$304.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$160.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.60
|
| Rate for Payer: Health EOS Commercial |
$292.11
|
| Rate for Payer: HFN Commercial |
$304.95
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: Preferred Network Access Commercial |
$304.95
|
| Rate for Payer: Quartz Beloit One Network |
$141.24
|
| Rate for Payer: Quartz Commercial |
$182.97
|
| Rate for Payer: The Alliance Commercial |
$160.50
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
Micropuncture 4Fr
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2549132
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$157.29 |
| Max. Negotiated Rate |
$295.32 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$192.60
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$192.60
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
Micropuncture 4Fr
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2549132
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$89.88 |
| Max. Negotiated Rate |
$1,284.00 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Aetna Managed Medicare |
$89.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$208.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$160.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$154.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$179.63
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$240.75
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$192.60
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$208.65
|
| Rate for Payer: Quartz Medicare Advantage |
$192.60
|
| Rate for Payer: The Alliance Commercial |
$1,284.00
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
Micropuncture 4Fr Ped
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2549134
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.24 |
| Max. Negotiated Rate |
$304.95 |
| Rate for Payer: Aetna Commercial |
$304.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$304.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$160.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.60
|
| Rate for Payer: Health EOS Commercial |
$292.11
|
| Rate for Payer: HFN Commercial |
$304.95
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: Preferred Network Access Commercial |
$304.95
|
| Rate for Payer: Quartz Beloit One Network |
$141.24
|
| Rate for Payer: Quartz Commercial |
$182.97
|
| Rate for Payer: The Alliance Commercial |
$160.50
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
Micropuncture 4Fr Ped
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2549134
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$157.29 |
| Max. Negotiated Rate |
$295.32 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$192.60
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$192.60
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
Micropuncture 4Fr Ped
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2549134
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$89.88 |
| Max. Negotiated Rate |
$1,284.00 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Aetna Managed Medicare |
$89.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$208.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$160.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$154.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$179.63
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$240.75
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$192.60
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$208.65
|
| Rate for Payer: Quartz Medicare Advantage |
$192.60
|
| Rate for Payer: The Alliance Commercial |
$1,284.00
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
Micropuncture 5Fr
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2549136
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$157.29 |
| Max. Negotiated Rate |
$295.32 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$192.60
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$192.60
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
Micropuncture 5Fr
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2549136
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$89.88 |
| Max. Negotiated Rate |
$1,284.00 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Aetna Managed Medicare |
$89.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$208.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$160.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$154.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$179.63
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$240.75
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$192.60
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$208.65
|
| Rate for Payer: Quartz Medicare Advantage |
$192.60
|
| Rate for Payer: The Alliance Commercial |
$1,284.00
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
Micropuncture 5Fr
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2549136
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.24 |
| Max. Negotiated Rate |
$304.95 |
| Rate for Payer: Aetna Commercial |
$304.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$304.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$160.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.60
|
| Rate for Payer: Health EOS Commercial |
$292.11
|
| Rate for Payer: HFN Commercial |
$304.95
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: Preferred Network Access Commercial |
$304.95
|
| Rate for Payer: Quartz Beloit One Network |
$141.24
|
| Rate for Payer: Quartz Commercial |
$182.97
|
| Rate for Payer: The Alliance Commercial |
$160.50
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
MICROSCOPE DRAPE DRAPETECH LEICA DR650
|
Facility
|
OP
|
$705.08
|
|
| Hospital Charge Code |
6246182
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$197.42 |
| Max. Negotiated Rate |
$2,820.32 |
| Rate for Payer: Aetna Commercial |
$634.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$606.37
|
| Rate for Payer: Aetna Managed Medicare |
$197.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$458.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$352.54
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$338.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$373.69
|
| Rate for Payer: Cash Price |
$211.52
|
| Rate for Payer: Cigna Commercial |
$648.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$394.56
|
| Rate for Payer: Health EOS Commercial |
$627.52
|
| Rate for Payer: HFN Commercial |
$648.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$528.81
|
| Rate for Payer: Multiplan Commercial |
$564.06
|
| Rate for Payer: NAPHCARE Commercial |
$423.05
|
| Rate for Payer: Preferred Network Access Commercial |
$648.67
|
| Rate for Payer: Quartz Beloit One Network |
$345.49
|
| Rate for Payer: Quartz Commercial |
$458.30
|
| Rate for Payer: Quartz Medicare Advantage |
$423.05
|
| Rate for Payer: The Alliance Commercial |
$2,820.32
|
| Rate for Payer: WEA Trust Commercial |
$387.79
|
| Rate for Payer: WPS Commercial |
$522.25
|
|
|
MICROSCOPE DRAPE DRAPETECH LEICA DR650
|
Facility
|
IP
|
$705.08
|
|
| Hospital Charge Code |
6246182
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$345.49 |
| Max. Negotiated Rate |
$648.67 |
| Rate for Payer: Aetna Commercial |
$634.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$606.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$373.69
|
| Rate for Payer: Cash Price |
$211.52
|
| Rate for Payer: Cigna Commercial |
$648.67
|
| Rate for Payer: Health EOS Commercial |
$627.52
|
| Rate for Payer: HFN Commercial |
$648.67
|
| Rate for Payer: Multiplan Commercial |
$564.06
|
| Rate for Payer: NAPHCARE Commercial |
$423.05
|
| Rate for Payer: Preferred Network Access Commercial |
$648.67
|
| Rate for Payer: Quartz Beloit One Network |
$345.49
|
| Rate for Payer: Quartz Commercial |
$423.05
|
| Rate for Payer: WEA Trust Commercial |
$387.79
|
| Rate for Payer: WPS Commercial |
$522.25
|
|
|
Microsporidia Stool
|
Professional
|
Both
|
$81.00
|
|
|
Service Code
|
CPT 87207
|
| Hospital Charge Code |
4592792
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$76.95 |
| Rate for Payer: Aetna Commercial |
$76.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Anthem Commercial |
$16.61
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$76.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$40.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.60
|
| Rate for Payer: Health EOS Commercial |
$73.71
|
| Rate for Payer: HFN Commercial |
$76.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.14
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: Preferred Network Access Commercial |
$76.95
|
| Rate for Payer: Quartz Beloit One Network |
$35.64
|
| Rate for Payer: Quartz Commercial |
$46.17
|
| Rate for Payer: The Alliance Commercial |
$40.50
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Microsporidia Stool
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
CPT 87207
|
| Hospital Charge Code |
4592792
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.99 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Aetna Managed Medicare |
$5.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.94
|
| Rate for Payer: Anthem Medicaid |
$6.19
|
| Rate for Payer: Anthem Medicare Advantage |
$5.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.99
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.33
|
| Rate for Payer: Dean Health Medicaid |
$6.19
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.99
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.99
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$6.19
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.99
|
| Rate for Payer: Managed Health Services Medicaid |
$6.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.99
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$8.98
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6.19
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$52.65
|
| Rate for Payer: Quartz Medicare Advantage |
$5.99
|
| Rate for Payer: The Alliance Commercial |
$23.96
|
| Rate for Payer: United Healthcare Medicaid |
$6.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.99
|
| Rate for Payer: United Healthcare PPO |
$60.75
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: Wellcare Medicare |
$5.99
|
| Rate for Payer: WMAP Medicaid |
$6.19
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Microsporidia Stool
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
CPT 87207
|
| Hospital Charge Code |
4592792
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$48.60
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
