|
AORTOFEMORAL BYPASS GRAFT
|
Facility
|
IP
|
$16,069.00
|
|
| Hospital Charge Code |
2959809
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$8,188.76 |
| Max. Negotiated Rate |
$15,374.82 |
| Rate for Payer: Aetna Commercial |
$15,040.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,372.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,857.23
|
| Rate for Payer: Cash Price |
$4,820.70
|
| Rate for Payer: Cigna Commercial |
$15,374.82
|
| Rate for Payer: Health EOS Commercial |
$14,873.47
|
| Rate for Payer: HFN Commercial |
$15,374.82
|
| Rate for Payer: Multiplan Commercial |
$13,369.41
|
| Rate for Payer: Preferred Network Access Commercial |
$15,374.82
|
| Rate for Payer: Quartz Beloit One Network |
$8,188.76
|
| Rate for Payer: Quartz Commercial |
$10,027.06
|
| Rate for Payer: WEA Trust Commercial |
$9,191.47
|
| Rate for Payer: WPS Commercial |
$12,377.95
|
|
|
AORTOFEMORAL BYPASS GRAFT
|
Facility
|
OP
|
$16,069.00
|
|
| Hospital Charge Code |
2959809
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,679.29 |
| Max. Negotiated Rate |
$15,374.82 |
| Rate for Payer: Aetna Commercial |
$15,040.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,372.11
|
| Rate for Payer: Aetna Managed Medicare |
$4,679.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,862.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,355.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,021.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,857.23
|
| Rate for Payer: Cash Price |
$4,820.70
|
| Rate for Payer: Cigna Commercial |
$15,374.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,352.16
|
| Rate for Payer: Health EOS Commercial |
$14,873.47
|
| Rate for Payer: HFN Commercial |
$15,374.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,533.82
|
| Rate for Payer: Multiplan Commercial |
$13,369.41
|
| Rate for Payer: NAPHCARE Commercial |
$10,027.06
|
| Rate for Payer: Preferred Network Access Commercial |
$15,374.82
|
| Rate for Payer: Quartz Beloit One Network |
$8,188.76
|
| Rate for Payer: Quartz Commercial |
$10,862.64
|
| Rate for Payer: Quartz Medicare Advantage |
$10,027.06
|
| Rate for Payer: The Alliance Commercial |
$8,355.88
|
| Rate for Payer: WEA Trust Commercial |
$9,191.47
|
| Rate for Payer: WPS Commercial |
$12,377.95
|
|
|
AORTORENAL BYPASS GRAFT
|
Facility
|
IP
|
$16,069.00
|
|
| Hospital Charge Code |
2959810
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$8,188.76 |
| Max. Negotiated Rate |
$15,374.82 |
| Rate for Payer: Aetna Commercial |
$15,040.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,372.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,857.23
|
| Rate for Payer: Cash Price |
$4,820.70
|
| Rate for Payer: Cigna Commercial |
$15,374.82
|
| Rate for Payer: Health EOS Commercial |
$14,873.47
|
| Rate for Payer: HFN Commercial |
$15,374.82
|
| Rate for Payer: Multiplan Commercial |
$13,369.41
|
| Rate for Payer: Preferred Network Access Commercial |
$15,374.82
|
| Rate for Payer: Quartz Beloit One Network |
$8,188.76
|
| Rate for Payer: Quartz Commercial |
$10,027.06
|
| Rate for Payer: WEA Trust Commercial |
$9,191.47
|
| Rate for Payer: WPS Commercial |
$12,377.95
|
|
|
AORTORENAL BYPASS GRAFT
|
Facility
|
OP
|
$16,069.00
|
|
| Hospital Charge Code |
2959810
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,679.29 |
| Max. Negotiated Rate |
$15,374.82 |
| Rate for Payer: Aetna Commercial |
$15,040.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,372.11
|
| Rate for Payer: Aetna Managed Medicare |
$4,679.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,862.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,355.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,021.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,857.23
|
| Rate for Payer: Cash Price |
$4,820.70
|
| Rate for Payer: Cigna Commercial |
$15,374.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,352.16
|
| Rate for Payer: Health EOS Commercial |
$14,873.47
|
| Rate for Payer: HFN Commercial |
$15,374.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,533.82
|
| Rate for Payer: Multiplan Commercial |
$13,369.41
|
| Rate for Payer: NAPHCARE Commercial |
$10,027.06
|
| Rate for Payer: Preferred Network Access Commercial |
$15,374.82
|
| Rate for Payer: Quartz Beloit One Network |
$8,188.76
|
| Rate for Payer: Quartz Commercial |
$10,862.64
|
| Rate for Payer: Quartz Medicare Advantage |
$10,027.06
|
| Rate for Payer: The Alliance Commercial |
$8,355.88
|
| Rate for Payer: WEA Trust Commercial |
$9,191.47
|
| Rate for Payer: WPS Commercial |
$12,377.95
|
|
|
APC Gene Sequencing and Deletion/Duplication
|
Professional
|
Both
|
$2,669.00
|
|
|
Service Code
|
CPT 81201
|
| Hospital Charge Code |
4602758
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$811.20 |
| Max. Negotiated Rate |
$3,569.28 |
| Rate for Payer: Aetna Commercial |
$2,636.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,387.15
|
| Rate for Payer: Aetna Managed Medicare |
$811.20
|
| Rate for Payer: Anthem Medicare Advantage |
$811.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$811.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$811.20
|
| Rate for Payer: Cash Price |
$800.70
|
| Rate for Payer: Cash Price |
$800.70
|
| Rate for Payer: Cigna Commercial |
$2,636.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,387.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$811.20
|
| Rate for Payer: Health EOS Commercial |
$2,525.94
|
| Rate for Payer: HFN Commercial |
$2,636.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,863.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,863.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$811.20
|
| Rate for Payer: Multiplan Commercial |
$2,220.61
|
| Rate for Payer: NAPHCARE Commercial |
$1,216.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,636.97
|
| Rate for Payer: Quartz Beloit One Network |
$1,221.33
|
| Rate for Payer: Quartz Commercial |
$1,582.18
|
| Rate for Payer: Quartz Medicare Advantage |
$811.20
|
| Rate for Payer: The Alliance Commercial |
$3,204.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$811.20
|
| Rate for Payer: WEA Trust Commercial |
$1,526.67
|
| Rate for Payer: WPS Commercial |
$3,569.28
|
|
|
APC Gene Sequencing and Deletion/Duplication
|
Facility
|
IP
|
$2,669.00
|
|
|
Service Code
|
CPT 81201
|
| Hospital Charge Code |
4602758
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,360.12 |
| Max. Negotiated Rate |
$2,553.70 |
| Rate for Payer: Aetna Commercial |
$2,498.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,387.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,471.15
|
| Rate for Payer: Cash Price |
$800.70
|
| Rate for Payer: Cigna Commercial |
$2,553.70
|
| Rate for Payer: Health EOS Commercial |
$2,470.43
|
| Rate for Payer: HFN Commercial |
$2,553.70
|
| Rate for Payer: Multiplan Commercial |
$2,220.61
|
| Rate for Payer: Preferred Network Access Commercial |
$2,553.70
|
| Rate for Payer: Quartz Beloit One Network |
$1,360.12
|
| Rate for Payer: Quartz Commercial |
$1,665.46
|
| Rate for Payer: WEA Trust Commercial |
$1,526.67
|
| Rate for Payer: WPS Commercial |
$2,055.93
|
|
|
APC Gene Sequencing and Deletion/Duplication
|
Facility
|
OP
|
$2,669.00
|
|
|
Service Code
|
CPT 81201
|
| Hospital Charge Code |
4602758
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$811.20 |
| Max. Negotiated Rate |
$3,244.80 |
| Rate for Payer: Aetna Commercial |
$2,498.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,387.15
|
| Rate for Payer: Aetna Managed Medicare |
$811.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,042.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,419.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,346.59
|
| Rate for Payer: Anthem Medicare Advantage |
$811.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,471.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$811.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$811.20
|
| Rate for Payer: Cash Price |
$800.70
|
| Rate for Payer: Cash Price |
$800.70
|
| Rate for Payer: Cigna Commercial |
$2,553.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$811.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,553.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$811.20
|
| Rate for Payer: Health EOS Commercial |
$2,470.43
|
| Rate for Payer: HFN Commercial |
$2,553.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,017.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$811.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$811.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$811.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$811.20
|
| Rate for Payer: Multiplan Commercial |
$2,220.61
|
| Rate for Payer: NAPHCARE Commercial |
$1,216.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,553.70
|
| Rate for Payer: Quartz Beloit One Network |
$1,360.12
|
| Rate for Payer: Quartz Commercial |
$1,804.24
|
| Rate for Payer: Quartz Medicare Advantage |
$811.20
|
| Rate for Payer: The Alliance Commercial |
$3,244.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$811.20
|
| Rate for Payer: United Healthcare PPO |
$2,081.82
|
| Rate for Payer: WEA Trust Commercial |
$1,526.67
|
| Rate for Payer: Wellcare Medicare |
$811.20
|
| Rate for Payer: WPS Commercial |
$2,055.93
|
|
|
APC PROBE HOOK UP
|
Facility
|
OP
|
$2,578.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973060
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$750.71 |
| Max. Negotiated Rate |
$2,466.63 |
| Rate for Payer: Aetna Commercial |
$2,413.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,305.76
|
| Rate for Payer: Aetna Managed Medicare |
$750.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,742.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,340.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,286.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,420.99
|
| Rate for Payer: Cash Price |
$773.40
|
| Rate for Payer: Cigna Commercial |
$2,466.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,500.40
|
| Rate for Payer: Health EOS Commercial |
$2,386.20
|
| Rate for Payer: HFN Commercial |
$2,466.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,010.84
|
| Rate for Payer: Multiplan Commercial |
$2,144.90
|
| Rate for Payer: NAPHCARE Commercial |
$1,608.67
|
| Rate for Payer: Preferred Network Access Commercial |
$2,466.63
|
| Rate for Payer: Quartz Beloit One Network |
$1,313.75
|
| Rate for Payer: Quartz Commercial |
$1,742.73
|
| Rate for Payer: Quartz Medicare Advantage |
$1,608.67
|
| Rate for Payer: The Alliance Commercial |
$1,340.56
|
| Rate for Payer: WEA Trust Commercial |
$1,474.62
|
| Rate for Payer: WPS Commercial |
$1,985.83
|
|
|
APC PROBE HOOK UP
|
Facility
|
IP
|
$2,578.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2973060
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,313.75 |
| Max. Negotiated Rate |
$2,466.63 |
| Rate for Payer: Aetna Commercial |
$2,413.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,305.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,420.99
|
| Rate for Payer: Cash Price |
$773.40
|
| Rate for Payer: Cigna Commercial |
$2,466.63
|
| Rate for Payer: Health EOS Commercial |
$2,386.20
|
| Rate for Payer: HFN Commercial |
$2,466.63
|
| Rate for Payer: Multiplan Commercial |
$2,144.90
|
| Rate for Payer: Preferred Network Access Commercial |
$2,466.63
|
| Rate for Payer: Quartz Beloit One Network |
$1,313.75
|
| Rate for Payer: Quartz Commercial |
$1,608.67
|
| Rate for Payer: WEA Trust Commercial |
$1,474.62
|
| Rate for Payer: WPS Commercial |
$1,985.83
|
|
|
Apex 1.5mm x 15mm
|
Professional
|
Both
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1158990
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$871.27 |
| Max. Negotiated Rate |
$1,881.15 |
| Rate for Payer: Aetna Commercial |
$1,881.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,881.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$990.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,188.10
|
| Rate for Payer: Health EOS Commercial |
$1,801.95
|
| Rate for Payer: HFN Commercial |
$1,881.15
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,881.15
|
| Rate for Payer: Quartz Beloit One Network |
$871.27
|
| Rate for Payer: Quartz Commercial |
$1,128.69
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
Apex 1.5mm x 15mm
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1158990
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$554.44 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Aetna Managed Medicare |
$554.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,287.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$990.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$950.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,108.13
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,485.12
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: NAPHCARE Commercial |
$1,188.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,287.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,188.10
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
Apex 1.5mm x 15mm
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1158990
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$970.28 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,188.10
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
Apex 2.0mm x 15mm
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1158994
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$970.28 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,188.10
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
Apex 2.0mm x 15mm
|
Professional
|
Both
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1158994
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$871.27 |
| Max. Negotiated Rate |
$1,881.15 |
| Rate for Payer: Aetna Commercial |
$1,881.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,881.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$990.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,188.10
|
| Rate for Payer: Health EOS Commercial |
$1,801.95
|
| Rate for Payer: HFN Commercial |
$1,881.15
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,881.15
|
| Rate for Payer: Quartz Beloit One Network |
$871.27
|
| Rate for Payer: Quartz Commercial |
$1,128.69
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
Apex 2.0mm x 15mm
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1158994
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$554.44 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Aetna Managed Medicare |
$554.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,287.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$990.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$950.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,108.13
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,485.12
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: NAPHCARE Commercial |
$1,188.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,287.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,188.10
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
Apex 2.0mm x 20mm
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1158996
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$554.44 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Aetna Managed Medicare |
$554.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,287.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$990.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$950.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,108.13
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,485.12
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: NAPHCARE Commercial |
$1,188.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,287.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,188.10
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
Apex 2.0mm x 20mm
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1158996
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$970.28 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,188.10
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
Apex 2.0mm x 20mm
|
Professional
|
Both
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1158996
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$871.27 |
| Max. Negotiated Rate |
$1,881.15 |
| Rate for Payer: Aetna Commercial |
$1,881.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,881.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$990.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,188.10
|
| Rate for Payer: Health EOS Commercial |
$1,801.95
|
| Rate for Payer: HFN Commercial |
$1,881.15
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,881.15
|
| Rate for Payer: Quartz Beloit One Network |
$871.27
|
| Rate for Payer: Quartz Commercial |
$1,128.69
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
Apex 2.5mm x 15mm
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1158998
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$554.44 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Aetna Managed Medicare |
$554.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,287.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$990.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$950.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,108.13
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,485.12
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: NAPHCARE Commercial |
$1,188.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,287.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,188.10
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
Apex 2.5mm x 15mm
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1158998
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$970.28 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,188.10
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
Apex 2.5mm x 15mm
|
Professional
|
Both
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1158998
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$871.27 |
| Max. Negotiated Rate |
$1,881.15 |
| Rate for Payer: Aetna Commercial |
$1,881.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,881.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$990.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,188.10
|
| Rate for Payer: Health EOS Commercial |
$1,801.95
|
| Rate for Payer: HFN Commercial |
$1,881.15
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,881.15
|
| Rate for Payer: Quartz Beloit One Network |
$871.27
|
| Rate for Payer: Quartz Commercial |
$1,128.69
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
Apex 2.5mm x 20mm
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159000
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$970.28 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,188.10
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
Apex 2.5mm x 20mm
|
Professional
|
Both
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159000
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$871.27 |
| Max. Negotiated Rate |
$1,881.15 |
| Rate for Payer: Aetna Commercial |
$1,881.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,881.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$990.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,188.10
|
| Rate for Payer: Health EOS Commercial |
$1,801.95
|
| Rate for Payer: HFN Commercial |
$1,881.15
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,881.15
|
| Rate for Payer: Quartz Beloit One Network |
$871.27
|
| Rate for Payer: Quartz Commercial |
$1,128.69
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
Apex 2.5mm x 20mm
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159000
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$554.44 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Aetna Managed Medicare |
$554.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,287.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$990.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$950.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,108.13
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,485.12
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: NAPHCARE Commercial |
$1,188.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,287.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,188.10
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
Apex 2.5mm x 30mm
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
1159002
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$554.44 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Aetna Managed Medicare |
$554.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,287.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$990.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$950.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,108.13
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,485.12
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: NAPHCARE Commercial |
$1,188.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,287.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,188.10
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
