|
Microstrep Plus Panel Type 1
|
Facility
|
IP
|
$409.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
1562933
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$200.41 |
| Max. Negotiated Rate |
$376.28 |
| Rate for Payer: Aetna Commercial |
$368.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$216.77
|
| Rate for Payer: Cash Price |
$122.70
|
| Rate for Payer: Cigna Commercial |
$376.28
|
| Rate for Payer: Health EOS Commercial |
$364.01
|
| Rate for Payer: HFN Commercial |
$376.28
|
| Rate for Payer: Multiplan Commercial |
$327.20
|
| Rate for Payer: NAPHCARE Commercial |
$245.40
|
| Rate for Payer: Preferred Network Access Commercial |
$376.28
|
| Rate for Payer: Quartz Beloit One Network |
$200.41
|
| Rate for Payer: Quartz Commercial |
$245.40
|
| Rate for Payer: WEA Trust Commercial |
$224.95
|
| Rate for Payer: WPS Commercial |
$302.95
|
|
|
Microstrep Plus Panel Type 1
|
Facility
|
OP
|
$409.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
1562933
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$376.28 |
| Rate for Payer: Aetna Commercial |
$368.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.74
|
| Rate for Payer: Aetna Managed Medicare |
$8.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.36
|
| Rate for Payer: Anthem Medicaid |
$8.94
|
| Rate for Payer: Anthem Medicare Advantage |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$216.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.65
|
| Rate for Payer: Cash Price |
$122.70
|
| Rate for Payer: Cash Price |
$122.70
|
| Rate for Payer: Cigna Commercial |
$376.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$228.88
|
| Rate for Payer: Dean Health Medicaid |
$8.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.65
|
| Rate for Payer: Health EOS Commercial |
$364.01
|
| Rate for Payer: HFN Commercial |
$376.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.65
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.65
|
| Rate for Payer: Managed Health Services Medicaid |
$9.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.65
|
| Rate for Payer: Multiplan Commercial |
$327.20
|
| Rate for Payer: NAPHCARE Commercial |
$12.98
|
| Rate for Payer: Preferred Network Access Commercial |
$376.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.94
|
| Rate for Payer: Quartz Beloit One Network |
$200.41
|
| Rate for Payer: Quartz Commercial |
$265.85
|
| Rate for Payer: Quartz Medicare Advantage |
$8.65
|
| Rate for Payer: The Alliance Commercial |
$34.60
|
| Rate for Payer: United Healthcare Medicaid |
$8.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.65
|
| Rate for Payer: United Healthcare PPO |
$306.75
|
| Rate for Payer: WEA Trust Commercial |
$224.95
|
| Rate for Payer: Wellcare Medicare |
$8.65
|
| Rate for Payer: WMAP Medicaid |
$8.94
|
| Rate for Payer: WPS Commercial |
$302.95
|
|
|
Microstrep Plus Panel Type 1
|
Professional
|
Both
|
$409.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
1562933
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.53 |
| Max. Negotiated Rate |
$388.55 |
| Rate for Payer: Aetna Commercial |
$388.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.74
|
| Rate for Payer: Cash Price |
$122.70
|
| Rate for Payer: Cash Price |
$122.70
|
| Rate for Payer: Cigna Commercial |
$388.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$204.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$245.40
|
| Rate for Payer: Health EOS Commercial |
$372.19
|
| Rate for Payer: HFN Commercial |
$388.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.53
|
| Rate for Payer: Multiplan Commercial |
$327.20
|
| Rate for Payer: Preferred Network Access Commercial |
$388.55
|
| Rate for Payer: Quartz Beloit One Network |
$179.96
|
| Rate for Payer: Quartz Commercial |
$233.13
|
| Rate for Payer: The Alliance Commercial |
$204.50
|
| Rate for Payer: WEA Trust Commercial |
$224.95
|
| Rate for Payer: WPS Commercial |
$302.95
|
|
|
midazolam 1 mg/mL 2 ml [MED]
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
5286880
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.93 |
| Max. Negotiated Rate |
$52.44 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.21
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$52.44
|
| Rate for Payer: Health EOS Commercial |
$50.73
|
| Rate for Payer: HFN Commercial |
$52.44
|
| Rate for Payer: Multiplan Commercial |
$45.60
|
| Rate for Payer: NAPHCARE Commercial |
$34.20
|
| Rate for Payer: Preferred Network Access Commercial |
$52.44
|
| Rate for Payer: Quartz Beloit One Network |
$27.93
|
| Rate for Payer: Quartz Commercial |
$34.20
|
| Rate for Payer: WEA Trust Commercial |
$31.35
|
| Rate for Payer: WPS Commercial |
$42.22
|
|
|
midazolam 1 mg/mL 2 ml [MED]
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
5286880
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$228.00 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.02
|
| Rate for Payer: Aetna Managed Medicare |
$15.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.21
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$52.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.18
|
| Rate for Payer: Health EOS Commercial |
$50.73
|
| Rate for Payer: HFN Commercial |
$52.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.75
|
| Rate for Payer: Multiplan Commercial |
$45.60
|
| Rate for Payer: NAPHCARE Commercial |
$34.20
|
| Rate for Payer: Preferred Network Access Commercial |
$52.44
|
| Rate for Payer: Quartz Beloit One Network |
$27.93
|
| Rate for Payer: Quartz Commercial |
$37.05
|
| Rate for Payer: Quartz Medicare Advantage |
$34.20
|
| Rate for Payer: The Alliance Commercial |
$228.00
|
| Rate for Payer: WEA Trust Commercial |
$31.35
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
midazolam 1 mg/mL Inj 5 ml [MED]
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
2983100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
midazolam 1 mg/mL Inj 5 ml [MED]
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
2983100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.18
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$42.00
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
MIDAZOLAM 2mg/2ml SDV (MED)
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
6172483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$5.52 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.60
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
MIDAZOLAM 2mg/2ml SDV (MED)
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
6172483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Aetna Managed Medicare |
$1.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.18
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3.60
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
MIDGUT MALROTATION REPAIR, PEDIATRIC
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2950479
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,928.15 |
| Max. Negotiated Rate |
$3,620.20 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,361.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
MIDGUT MALROTATION REPAIR, PEDIATRIC
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2950479
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
miLOOP 303071-9090-000
|
Facility
|
OP
|
$1,868.00
|
|
| Hospital Charge Code |
5415879
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$523.04 |
| Max. Negotiated Rate |
$7,472.00 |
| Rate for Payer: Aetna Commercial |
$1,681.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,606.48
|
| Rate for Payer: Aetna Managed Medicare |
$523.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,214.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$934.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$896.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$990.04
|
| Rate for Payer: Cash Price |
$560.40
|
| Rate for Payer: Cigna Commercial |
$1,718.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,045.33
|
| Rate for Payer: Health EOS Commercial |
$1,662.52
|
| Rate for Payer: HFN Commercial |
$1,718.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,401.00
|
| Rate for Payer: Multiplan Commercial |
$1,494.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,120.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,718.56
|
| Rate for Payer: Quartz Beloit One Network |
$915.32
|
| Rate for Payer: Quartz Commercial |
$1,214.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,120.80
|
| Rate for Payer: The Alliance Commercial |
$7,472.00
|
| Rate for Payer: WEA Trust Commercial |
$1,027.40
|
| Rate for Payer: WPS Commercial |
$1,383.63
|
|
|
miLOOP 303071-9090-000
|
Facility
|
IP
|
$1,868.00
|
|
| Hospital Charge Code |
5415879
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$915.32 |
| Max. Negotiated Rate |
$1,718.56 |
| Rate for Payer: Aetna Commercial |
$1,681.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,606.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$990.04
|
| Rate for Payer: Cash Price |
$560.40
|
| Rate for Payer: Cigna Commercial |
$1,718.56
|
| Rate for Payer: Health EOS Commercial |
$1,662.52
|
| Rate for Payer: HFN Commercial |
$1,718.56
|
| Rate for Payer: Multiplan Commercial |
$1,494.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,120.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,718.56
|
| Rate for Payer: Quartz Beloit One Network |
$915.32
|
| Rate for Payer: Quartz Commercial |
$1,120.80
|
| Rate for Payer: WEA Trust Commercial |
$1,027.40
|
| Rate for Payer: WPS Commercial |
$1,383.63
|
|
|
MIMI PLATE TENSION BAND MATRIX MANDIBLE 1.0MM 2HL X 2HL BROAD MALLEABLE 04.503.750
|
Facility
|
IP
|
$6,263.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6192962
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,068.87 |
| Max. Negotiated Rate |
$5,761.96 |
| Rate for Payer: Aetna Commercial |
$5,636.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,386.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,319.39
|
| Rate for Payer: Cash Price |
$1,878.90
|
| Rate for Payer: Cigna Commercial |
$5,761.96
|
| Rate for Payer: Health EOS Commercial |
$5,574.07
|
| Rate for Payer: HFN Commercial |
$5,761.96
|
| Rate for Payer: Multiplan Commercial |
$5,010.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,757.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,761.96
|
| Rate for Payer: Quartz Beloit One Network |
$3,068.87
|
| Rate for Payer: Quartz Commercial |
$3,757.80
|
| Rate for Payer: WEA Trust Commercial |
$3,444.65
|
| Rate for Payer: WPS Commercial |
$4,639.00
|
|
|
MIMI PLATE TENSION BAND MATRIX MANDIBLE 1.0MM 2HL X 2HL BROAD MALLEABLE 04.503.750
|
Facility
|
OP
|
$6,263.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6192962
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,753.64 |
| Max. Negotiated Rate |
$25,052.00 |
| Rate for Payer: Aetna Commercial |
$5,636.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,386.18
|
| Rate for Payer: Aetna Managed Medicare |
$1,753.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,070.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,131.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,006.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,319.39
|
| Rate for Payer: Cash Price |
$1,878.90
|
| Rate for Payer: Cigna Commercial |
$5,761.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,504.77
|
| Rate for Payer: Health EOS Commercial |
$5,574.07
|
| Rate for Payer: HFN Commercial |
$5,761.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,697.25
|
| Rate for Payer: Multiplan Commercial |
$5,010.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,757.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,761.96
|
| Rate for Payer: Quartz Beloit One Network |
$3,068.87
|
| Rate for Payer: Quartz Commercial |
$4,070.95
|
| Rate for Payer: Quartz Medicare Advantage |
$3,757.80
|
| Rate for Payer: The Alliance Commercial |
$25,052.00
|
| Rate for Payer: WEA Trust Commercial |
$3,444.65
|
| Rate for Payer: WPS Commercial |
$4,639.00
|
|
|
MIMI PLATE TENSION BAND MATRIX MANDIBLE 1.0MM 2HL X 2HL NARROW 04.503.702
|
Facility
|
OP
|
$4,572.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831670
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,280.16 |
| Max. Negotiated Rate |
$18,288.00 |
| Rate for Payer: Aetna Commercial |
$4,114.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,931.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,280.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,971.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,286.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,194.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,423.16
|
| Rate for Payer: Cash Price |
$1,371.60
|
| Rate for Payer: Cigna Commercial |
$4,206.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,558.49
|
| Rate for Payer: Health EOS Commercial |
$4,069.08
|
| Rate for Payer: HFN Commercial |
$4,206.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,429.00
|
| Rate for Payer: Multiplan Commercial |
$3,657.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,743.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,206.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,240.28
|
| Rate for Payer: Quartz Commercial |
$2,971.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,743.20
|
| Rate for Payer: The Alliance Commercial |
$18,288.00
|
| Rate for Payer: WEA Trust Commercial |
$2,514.60
|
| Rate for Payer: WPS Commercial |
$3,386.48
|
|
|
MIMI PLATE TENSION BAND MATRIX MANDIBLE 1.0MM 2HL X 2HL NARROW 04.503.702
|
Facility
|
IP
|
$4,572.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831670
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,240.28 |
| Max. Negotiated Rate |
$4,206.24 |
| Rate for Payer: Aetna Commercial |
$4,114.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,931.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,423.16
|
| Rate for Payer: Cash Price |
$1,371.60
|
| Rate for Payer: Cigna Commercial |
$4,206.24
|
| Rate for Payer: Health EOS Commercial |
$4,069.08
|
| Rate for Payer: HFN Commercial |
$4,206.24
|
| Rate for Payer: Multiplan Commercial |
$3,657.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,743.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,206.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,240.28
|
| Rate for Payer: Quartz Commercial |
$2,743.20
|
| Rate for Payer: WEA Trust Commercial |
$2,514.60
|
| Rate for Payer: WPS Commercial |
$3,386.48
|
|
|
MIMI PLATE TENSION BAND MATRIX MANDIBLE 1.0MM 2HL X 2HL PRE-BENT RT 04.503.780
|
Facility
|
OP
|
$4,684.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4038109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,311.52 |
| Max. Negotiated Rate |
$18,736.00 |
| Rate for Payer: Aetna Commercial |
$4,215.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,028.24
|
| Rate for Payer: Aetna Managed Medicare |
$1,311.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,044.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,342.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,248.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,482.52
|
| Rate for Payer: Cash Price |
$1,405.20
|
| Rate for Payer: Cigna Commercial |
$4,309.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,621.17
|
| Rate for Payer: Health EOS Commercial |
$4,168.76
|
| Rate for Payer: HFN Commercial |
$4,309.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,513.00
|
| Rate for Payer: Multiplan Commercial |
$3,747.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,810.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,309.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,295.16
|
| Rate for Payer: Quartz Commercial |
$3,044.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,810.40
|
| Rate for Payer: The Alliance Commercial |
$18,736.00
|
| Rate for Payer: WEA Trust Commercial |
$2,576.20
|
| Rate for Payer: WPS Commercial |
$3,469.44
|
|
|
MIMI PLATE TENSION BAND MATRIX MANDIBLE 1.0MM 2HL X 2HL PRE-BENT RT 04.503.780
|
Facility
|
IP
|
$4,684.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4038109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,295.16 |
| Max. Negotiated Rate |
$4,309.28 |
| Rate for Payer: Aetna Commercial |
$4,215.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,028.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,482.52
|
| Rate for Payer: Cash Price |
$1,405.20
|
| Rate for Payer: Cigna Commercial |
$4,309.28
|
| Rate for Payer: Health EOS Commercial |
$4,168.76
|
| Rate for Payer: HFN Commercial |
$4,309.28
|
| Rate for Payer: Multiplan Commercial |
$3,747.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,810.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,309.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,295.16
|
| Rate for Payer: Quartz Commercial |
$2,810.40
|
| Rate for Payer: WEA Trust Commercial |
$2,576.20
|
| Rate for Payer: WPS Commercial |
$3,469.44
|
|
|
MIMI PLATE TENSION BAND MATRIX MANDIBLE 1.0MM 3HL X 3HL NARROW 04.503.704
|
Facility
|
IP
|
$4,978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,439.22 |
| Max. Negotiated Rate |
$4,579.76 |
| Rate for Payer: Aetna Commercial |
$4,480.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.34
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,579.76
|
| Rate for Payer: Health EOS Commercial |
$4,430.42
|
| Rate for Payer: HFN Commercial |
$4,579.76
|
| Rate for Payer: Multiplan Commercial |
$3,982.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,986.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,579.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.22
|
| Rate for Payer: Quartz Commercial |
$2,986.80
|
| Rate for Payer: WEA Trust Commercial |
$2,737.90
|
| Rate for Payer: WPS Commercial |
$3,687.20
|
|
|
MIMI PLATE TENSION BAND MATRIX MANDIBLE 1.0MM 3HL X 3HL NARROW 04.503.704
|
Facility
|
OP
|
$4,978.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5831671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,393.84 |
| Max. Negotiated Rate |
$19,912.00 |
| Rate for Payer: Aetna Commercial |
$4,480.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,281.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,393.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,235.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,489.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,389.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,638.34
|
| Rate for Payer: Cash Price |
$1,493.40
|
| Rate for Payer: Cigna Commercial |
$4,579.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,785.69
|
| Rate for Payer: Health EOS Commercial |
$4,430.42
|
| Rate for Payer: HFN Commercial |
$4,579.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,733.50
|
| Rate for Payer: Multiplan Commercial |
$3,982.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,986.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,579.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,439.22
|
| Rate for Payer: Quartz Commercial |
$3,235.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,986.80
|
| Rate for Payer: The Alliance Commercial |
$19,912.00
|
| Rate for Payer: WEA Trust Commercial |
$2,737.90
|
| Rate for Payer: WPS Commercial |
$3,687.20
|
|
|
Mineral Oil 25ml (sterile) [Med]
|
Facility
|
OP
|
$34.00
|
|
| Hospital Charge Code |
2974964
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.52 |
| Max. Negotiated Rate |
$136.00 |
| Rate for Payer: Aetna Commercial |
$30.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.24
|
| Rate for Payer: Aetna Managed Medicare |
$9.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.02
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$31.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.03
|
| Rate for Payer: Health EOS Commercial |
$30.26
|
| Rate for Payer: HFN Commercial |
$31.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.50
|
| Rate for Payer: Multiplan Commercial |
$27.20
|
| Rate for Payer: NAPHCARE Commercial |
$20.40
|
| Rate for Payer: Preferred Network Access Commercial |
$31.28
|
| Rate for Payer: Quartz Beloit One Network |
$16.66
|
| Rate for Payer: Quartz Commercial |
$22.10
|
| Rate for Payer: Quartz Medicare Advantage |
$20.40
|
| Rate for Payer: The Alliance Commercial |
$136.00
|
| Rate for Payer: WEA Trust Commercial |
$18.70
|
| Rate for Payer: WPS Commercial |
$25.18
|
|
|
Mineral Oil 25ml (sterile) [Med]
|
Facility
|
IP
|
$34.00
|
|
| Hospital Charge Code |
2974964
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.66 |
| Max. Negotiated Rate |
$31.28 |
| Rate for Payer: Aetna Commercial |
$30.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.02
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$31.28
|
| Rate for Payer: Health EOS Commercial |
$30.26
|
| Rate for Payer: HFN Commercial |
$31.28
|
| Rate for Payer: Multiplan Commercial |
$27.20
|
| Rate for Payer: NAPHCARE Commercial |
$20.40
|
| Rate for Payer: Preferred Network Access Commercial |
$31.28
|
| Rate for Payer: Quartz Beloit One Network |
$16.66
|
| Rate for Payer: Quartz Commercial |
$20.40
|
| Rate for Payer: WEA Trust Commercial |
$18.70
|
| Rate for Payer: WPS Commercial |
$25.18
|
|
|
MINOR BLADDER PROCEDURES WITH CC
|
Facility
|
IP
|
$39,109.00
|
|
|
Service Code
|
MSDRG 663
|
| Min. Negotiated Rate |
$14,068.11 |
| Max. Negotiated Rate |
$39,109.00 |
| Rate for Payer: Aetna Managed Medicare |
$14,068.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30,630.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23,478.26
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22,305.88
|
| Rate for Payer: Anthem Medicare Advantage |
$14,068.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14,068.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14,068.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14,068.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24,761.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14,068.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,450.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14,068.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14,068.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14,068.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14,068.11
|
| Rate for Payer: NAPHCARE Commercial |
$21,102.16
|
| Rate for Payer: Quartz Medicare Advantage |
$14,068.11
|
| Rate for Payer: The Alliance Commercial |
$39,109.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14,068.11
|
| Rate for Payer: United Healthcare PPO |
$22,149.08
|
| Rate for Payer: Wellcare Medicare |
$14,068.11
|
|
|
MINOR BLADDER PROCEDURES WITH MCC
|
Facility
|
IP
|
$79,991.00
|
|
|
Service Code
|
MSDRG 662
|
| Min. Negotiated Rate |
$28,773.59 |
| Max. Negotiated Rate |
$79,991.00 |
| Rate for Payer: Aetna Managed Medicare |
$28,773.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62,940.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48,243.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$45,834.00
|
| Rate for Payer: Anthem Medicare Advantage |
$28,773.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28,773.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28,773.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$28,773.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50,879.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$28,773.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58,435.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28,773.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28,773.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$28,773.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$28,773.59
|
| Rate for Payer: NAPHCARE Commercial |
$43,160.38
|
| Rate for Payer: Quartz Medicare Advantage |
$28,773.59
|
| Rate for Payer: The Alliance Commercial |
$79,991.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28,773.59
|
| Rate for Payer: United Healthcare PPO |
$45,492.90
|
| Rate for Payer: Wellcare Medicare |
$28,773.59
|
|
