|
Nano 4.0mm x 40mm 150cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547016
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Nano 4.0mm x 40mm 150cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547016
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$751.52 |
| Max. Negotiated Rate |
$1,622.60 |
| Rate for Payer: Aetna Commercial |
$1,622.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,622.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$854.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,024.80
|
| Rate for Payer: Health EOS Commercial |
$1,554.28
|
| Rate for Payer: HFN Commercial |
$1,622.60
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.60
|
| Rate for Payer: Quartz Beloit One Network |
$751.52
|
| Rate for Payer: Quartz Commercial |
$973.56
|
| Rate for Payer: The Alliance Commercial |
$854.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Nano 4.0mm x 40mm 150cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547016
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Nano 4.0mm x 80mm 150cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547018
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$751.52 |
| Max. Negotiated Rate |
$1,622.60 |
| Rate for Payer: Aetna Commercial |
$1,622.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,622.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$854.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,024.80
|
| Rate for Payer: Health EOS Commercial |
$1,554.28
|
| Rate for Payer: HFN Commercial |
$1,622.60
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.60
|
| Rate for Payer: Quartz Beloit One Network |
$751.52
|
| Rate for Payer: Quartz Commercial |
$973.56
|
| Rate for Payer: The Alliance Commercial |
$854.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Nano 4.0mm x 80mm 150cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547018
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$1,571.36 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,024.80
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Nano 4.0mm x 80mm 150cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547018
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.24 |
| Max. Negotiated Rate |
$6,832.00 |
| Rate for Payer: Aetna Commercial |
$1,537.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Aetna Managed Medicare |
$478.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.24
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,571.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.80
|
| Rate for Payer: Health EOS Commercial |
$1,520.12
|
| Rate for Payer: HFN Commercial |
$1,571.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.00
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.36
|
| Rate for Payer: Quartz Beloit One Network |
$836.92
|
| Rate for Payer: Quartz Commercial |
$1,110.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.80
|
| Rate for Payer: The Alliance Commercial |
$6,832.00
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Narcan 4mg/0.1ML Nasal Spray - Narcan Med Charge
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
6222279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$142.50 |
| Rate for Payer: Aetna Commercial |
$142.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$142.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.00
|
| Rate for Payer: Health EOS Commercial |
$136.50
|
| Rate for Payer: HFN Commercial |
$142.50
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: Preferred Network Access Commercial |
$142.50
|
| Rate for Payer: Quartz Beloit One Network |
$66.00
|
| Rate for Payer: Quartz Commercial |
$85.50
|
| Rate for Payer: The Alliance Commercial |
$75.00
|
| Rate for Payer: WEA Trust Commercial |
$82.50
|
| Rate for Payer: WPS Commercial |
$111.10
|
|
|
Narcan 4mg/0.1ML Nasal Spray - Narcan Med Charge
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
6222279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$135.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.00
|
| Rate for Payer: Aetna Managed Medicare |
$42.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$97.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.50
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$138.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$83.94
|
| Rate for Payer: Health EOS Commercial |
$133.50
|
| Rate for Payer: HFN Commercial |
$138.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.50
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: NAPHCARE Commercial |
$90.00
|
| Rate for Payer: Preferred Network Access Commercial |
$138.00
|
| Rate for Payer: Quartz Beloit One Network |
$73.50
|
| Rate for Payer: Quartz Commercial |
$97.50
|
| Rate for Payer: Quartz Medicare Advantage |
$90.00
|
| Rate for Payer: The Alliance Commercial |
$600.00
|
| Rate for Payer: WEA Trust Commercial |
$82.50
|
| Rate for Payer: WPS Commercial |
$111.10
|
|
|
Narcan 4mg/0.1ML Nasal Spray - Narcan Med Charge
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
6222279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$138.00 |
| Rate for Payer: Aetna Commercial |
$135.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.50
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$138.00
|
| Rate for Payer: Health EOS Commercial |
$133.50
|
| Rate for Payer: HFN Commercial |
$138.00
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: NAPHCARE Commercial |
$90.00
|
| Rate for Payer: Preferred Network Access Commercial |
$138.00
|
| Rate for Payer: Quartz Beloit One Network |
$73.50
|
| Rate for Payer: Quartz Commercial |
$90.00
|
| Rate for Payer: WEA Trust Commercial |
$82.50
|
| Rate for Payer: WPS Commercial |
$111.10
|
|
|
Naropin (Ropivicaine) 0.5% 20mL vial [Med]
|
Facility
|
IP
|
$111.00
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
5591330
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.39 |
| Max. Negotiated Rate |
$102.12 |
| Rate for Payer: Aetna Commercial |
$99.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.83
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$102.12
|
| Rate for Payer: Health EOS Commercial |
$98.79
|
| Rate for Payer: HFN Commercial |
$102.12
|
| Rate for Payer: Multiplan Commercial |
$88.80
|
| Rate for Payer: NAPHCARE Commercial |
$66.60
|
| Rate for Payer: Preferred Network Access Commercial |
$102.12
|
| Rate for Payer: Quartz Beloit One Network |
$54.39
|
| Rate for Payer: Quartz Commercial |
$66.60
|
| Rate for Payer: WEA Trust Commercial |
$61.05
|
| Rate for Payer: WPS Commercial |
$82.22
|
|
|
Naropin (Ropivicaine) 0.5% 20mL vial [Med]
|
Facility
|
OP
|
$111.00
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
5591330
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$444.00 |
| Rate for Payer: Aetna Commercial |
$99.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.46
|
| Rate for Payer: Aetna Managed Medicare |
$31.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$55.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$53.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.83
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$102.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.09
|
| Rate for Payer: Health EOS Commercial |
$98.79
|
| Rate for Payer: HFN Commercial |
$102.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.25
|
| Rate for Payer: Multiplan Commercial |
$88.80
|
| Rate for Payer: NAPHCARE Commercial |
$66.60
|
| Rate for Payer: Preferred Network Access Commercial |
$102.12
|
| Rate for Payer: Quartz Beloit One Network |
$54.39
|
| Rate for Payer: Quartz Commercial |
$72.15
|
| Rate for Payer: Quartz Medicare Advantage |
$66.60
|
| Rate for Payer: The Alliance Commercial |
$444.00
|
| Rate for Payer: WEA Trust Commercial |
$61.05
|
| Rate for Payer: WPS Commercial |
$0.17
|
|
|
Naropin (Ropivicaine) 1% 20mL vial [Med]
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
2974966
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.63 |
| Max. Negotiated Rate |
$80.04 |
| Rate for Payer: Aetna Commercial |
$78.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.11
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$80.04
|
| Rate for Payer: Health EOS Commercial |
$77.43
|
| Rate for Payer: HFN Commercial |
$80.04
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: NAPHCARE Commercial |
$52.20
|
| Rate for Payer: Preferred Network Access Commercial |
$80.04
|
| Rate for Payer: Quartz Beloit One Network |
$42.63
|
| Rate for Payer: Quartz Commercial |
$52.20
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$64.44
|
|
|
Naropin (Ropivicaine) 1% 20mL vial [Med]
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
2974966
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$348.00 |
| Rate for Payer: Aetna Commercial |
$78.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.82
|
| Rate for Payer: Aetna Managed Medicare |
$24.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.11
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$80.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.09
|
| Rate for Payer: Health EOS Commercial |
$77.43
|
| Rate for Payer: HFN Commercial |
$80.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.25
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: NAPHCARE Commercial |
$52.20
|
| Rate for Payer: Preferred Network Access Commercial |
$80.04
|
| Rate for Payer: Quartz Beloit One Network |
$42.63
|
| Rate for Payer: Quartz Commercial |
$56.55
|
| Rate for Payer: Quartz Medicare Advantage |
$52.20
|
| Rate for Payer: The Alliance Commercial |
$348.00
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$0.17
|
|
|
Nasal Cannula
|
Facility
|
IP
|
$48.00
|
|
| Hospital Charge Code |
3101746
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$44.16 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$28.80
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
Nasal Cannula
|
Facility
|
OP
|
$48.00
|
|
| Hospital Charge Code |
3101746
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Aetna Managed Medicare |
$13.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.86
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$31.20
|
| Rate for Payer: Quartz Medicare Advantage |
$28.80
|
| Rate for Payer: The Alliance Commercial |
$192.00
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
Nasal Cannula - Adult
|
Facility
|
IP
|
$1.00
|
|
| Hospital Charge Code |
3040335
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna Commercial |
$0.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.53
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.92
|
| Rate for Payer: Health EOS Commercial |
$0.89
|
| Rate for Payer: HFN Commercial |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: NAPHCARE Commercial |
$0.60
|
| Rate for Payer: Preferred Network Access Commercial |
$0.92
|
| Rate for Payer: Quartz Beloit One Network |
$0.49
|
| Rate for Payer: Quartz Commercial |
$0.60
|
| Rate for Payer: WEA Trust Commercial |
$0.55
|
| Rate for Payer: WPS Commercial |
$0.74
|
|
|
Nasal Cannula - Adult
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
3040335
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial |
$0.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.86
|
| Rate for Payer: Aetna Managed Medicare |
$0.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$0.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$0.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.53
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.56
|
| Rate for Payer: Health EOS Commercial |
$0.89
|
| Rate for Payer: HFN Commercial |
$0.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: NAPHCARE Commercial |
$0.60
|
| Rate for Payer: Preferred Network Access Commercial |
$0.92
|
| Rate for Payer: Quartz Beloit One Network |
$0.49
|
| Rate for Payer: Quartz Commercial |
$0.65
|
| Rate for Payer: Quartz Medicare Advantage |
$0.60
|
| Rate for Payer: The Alliance Commercial |
$4.00
|
| Rate for Payer: WEA Trust Commercial |
$0.55
|
| Rate for Payer: WPS Commercial |
$0.74
|
|
|
Nasal Cannula Holder
|
Facility
|
OP
|
$29.00
|
|
| Hospital Charge Code |
4628703
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$8.12 |
| Max. Negotiated Rate |
$116.00 |
| Rate for Payer: Aetna Commercial |
$26.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.94
|
| Rate for Payer: Aetna Managed Medicare |
$8.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.37
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$26.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.23
|
| Rate for Payer: Health EOS Commercial |
$25.81
|
| Rate for Payer: HFN Commercial |
$26.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.75
|
| Rate for Payer: Multiplan Commercial |
$23.20
|
| Rate for Payer: NAPHCARE Commercial |
$17.40
|
| Rate for Payer: Preferred Network Access Commercial |
$26.68
|
| Rate for Payer: Quartz Beloit One Network |
$14.21
|
| Rate for Payer: Quartz Commercial |
$18.85
|
| Rate for Payer: Quartz Medicare Advantage |
$17.40
|
| Rate for Payer: The Alliance Commercial |
$116.00
|
| Rate for Payer: WEA Trust Commercial |
$15.95
|
| Rate for Payer: WPS Commercial |
$21.48
|
|
|
Nasal Cannula Holder
|
Facility
|
IP
|
$29.00
|
|
| Hospital Charge Code |
4628703
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.21 |
| Max. Negotiated Rate |
$26.68 |
| Rate for Payer: Aetna Commercial |
$26.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.37
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$26.68
|
| Rate for Payer: Health EOS Commercial |
$25.81
|
| Rate for Payer: HFN Commercial |
$26.68
|
| Rate for Payer: Multiplan Commercial |
$23.20
|
| Rate for Payer: NAPHCARE Commercial |
$17.40
|
| Rate for Payer: Preferred Network Access Commercial |
$26.68
|
| Rate for Payer: Quartz Beloit One Network |
$14.21
|
| Rate for Payer: Quartz Commercial |
$17.40
|
| Rate for Payer: WEA Trust Commercial |
$15.95
|
| Rate for Payer: WPS Commercial |
$21.48
|
|
|
NASAL DRESSING 7.5CM INFLATABLE UNILATERAL RR750
|
Facility
|
OP
|
$674.00
|
|
| Hospital Charge Code |
2969616
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$188.72 |
| Max. Negotiated Rate |
$2,696.00 |
| Rate for Payer: Aetna Commercial |
$606.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$579.64
|
| Rate for Payer: Aetna Managed Medicare |
$188.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$438.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$337.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$323.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$357.22
|
| Rate for Payer: Cash Price |
$202.20
|
| Rate for Payer: Cigna Commercial |
$620.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$377.17
|
| Rate for Payer: Health EOS Commercial |
$599.86
|
| Rate for Payer: HFN Commercial |
$620.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$505.50
|
| Rate for Payer: Multiplan Commercial |
$539.20
|
| Rate for Payer: NAPHCARE Commercial |
$404.40
|
| Rate for Payer: Preferred Network Access Commercial |
$620.08
|
| Rate for Payer: Quartz Beloit One Network |
$330.26
|
| Rate for Payer: Quartz Commercial |
$438.10
|
| Rate for Payer: Quartz Medicare Advantage |
$404.40
|
| Rate for Payer: The Alliance Commercial |
$2,696.00
|
| Rate for Payer: WEA Trust Commercial |
$370.70
|
| Rate for Payer: WPS Commercial |
$499.23
|
|
|
NASAL DRESSING 7.5CM INFLATABLE UNILATERAL RR750
|
Facility
|
IP
|
$674.00
|
|
| Hospital Charge Code |
2969616
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.26 |
| Max. Negotiated Rate |
$620.08 |
| Rate for Payer: Aetna Commercial |
$606.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$579.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$357.22
|
| Rate for Payer: Cash Price |
$202.20
|
| Rate for Payer: Cigna Commercial |
$620.08
|
| Rate for Payer: Health EOS Commercial |
$599.86
|
| Rate for Payer: HFN Commercial |
$620.08
|
| Rate for Payer: Multiplan Commercial |
$539.20
|
| Rate for Payer: NAPHCARE Commercial |
$404.40
|
| Rate for Payer: Preferred Network Access Commercial |
$620.08
|
| Rate for Payer: Quartz Beloit One Network |
$330.26
|
| Rate for Payer: Quartz Commercial |
$404.40
|
| Rate for Payer: WEA Trust Commercial |
$370.70
|
| Rate for Payer: WPS Commercial |
$499.23
|
|
|
NASAL DRESSING HEMOPORE 5400-020-208
|
Facility
|
OP
|
$2,412.00
|
|
| Hospital Charge Code |
5106736
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$675.36 |
| Max. Negotiated Rate |
$9,648.00 |
| Rate for Payer: Aetna Commercial |
$2,170.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,074.32
|
| Rate for Payer: Aetna Managed Medicare |
$675.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,567.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,206.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,157.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,278.36
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cigna Commercial |
$2,219.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,349.76
|
| Rate for Payer: Health EOS Commercial |
$2,146.68
|
| Rate for Payer: HFN Commercial |
$2,219.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,809.00
|
| Rate for Payer: Multiplan Commercial |
$1,929.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,447.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,219.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,181.88
|
| Rate for Payer: Quartz Commercial |
$1,567.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,447.20
|
| Rate for Payer: The Alliance Commercial |
$9,648.00
|
| Rate for Payer: WEA Trust Commercial |
$1,326.60
|
| Rate for Payer: WPS Commercial |
$1,786.57
|
|
|
NASAL DRESSING HEMOPORE 5400-020-208
|
Facility
|
IP
|
$2,412.00
|
|
| Hospital Charge Code |
5106736
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,181.88 |
| Max. Negotiated Rate |
$2,219.04 |
| Rate for Payer: Aetna Commercial |
$2,170.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,074.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,278.36
|
| Rate for Payer: Cash Price |
$723.60
|
| Rate for Payer: Cigna Commercial |
$2,219.04
|
| Rate for Payer: Health EOS Commercial |
$2,146.68
|
| Rate for Payer: HFN Commercial |
$2,219.04
|
| Rate for Payer: Multiplan Commercial |
$1,929.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,447.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,219.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,181.88
|
| Rate for Payer: Quartz Commercial |
$1,447.20
|
| Rate for Payer: WEA Trust Commercial |
$1,326.60
|
| Rate for Payer: WPS Commercial |
$1,786.57
|
|
|
NASAL DRESSING MEROCEL 8CM STD 440402
|
Facility
|
OP
|
$369.00
|
|
| Hospital Charge Code |
2965337
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$103.32 |
| Max. Negotiated Rate |
$1,476.00 |
| Rate for Payer: Aetna Commercial |
$332.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$317.34
|
| Rate for Payer: Aetna Managed Medicare |
$103.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$177.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.57
|
| Rate for Payer: Cash Price |
$110.70
|
| Rate for Payer: Cigna Commercial |
$339.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$206.49
|
| Rate for Payer: Health EOS Commercial |
$328.41
|
| Rate for Payer: HFN Commercial |
$339.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$276.75
|
| Rate for Payer: Multiplan Commercial |
$295.20
|
| Rate for Payer: NAPHCARE Commercial |
$221.40
|
| Rate for Payer: Preferred Network Access Commercial |
$339.48
|
| Rate for Payer: Quartz Beloit One Network |
$180.81
|
| Rate for Payer: Quartz Commercial |
$239.85
|
| Rate for Payer: Quartz Medicare Advantage |
$221.40
|
| Rate for Payer: The Alliance Commercial |
$1,476.00
|
| Rate for Payer: WEA Trust Commercial |
$202.95
|
| Rate for Payer: WPS Commercial |
$273.32
|
|
|
NASAL DRESSING MEROCEL 8CM STD 440402
|
Facility
|
IP
|
$369.00
|
|
| Hospital Charge Code |
2965337
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$180.81 |
| Max. Negotiated Rate |
$339.48 |
| Rate for Payer: Aetna Commercial |
$332.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$317.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.57
|
| Rate for Payer: Cash Price |
$110.70
|
| Rate for Payer: Cigna Commercial |
$339.48
|
| Rate for Payer: Health EOS Commercial |
$328.41
|
| Rate for Payer: HFN Commercial |
$339.48
|
| Rate for Payer: Multiplan Commercial |
$295.20
|
| Rate for Payer: NAPHCARE Commercial |
$221.40
|
| Rate for Payer: Preferred Network Access Commercial |
$339.48
|
| Rate for Payer: Quartz Beloit One Network |
$180.81
|
| Rate for Payer: Quartz Commercial |
$221.40
|
| Rate for Payer: WEA Trust Commercial |
$202.95
|
| Rate for Payer: WPS Commercial |
$273.32
|
|
