|
Nano 3.5mm x 40mm 150cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547004
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Nano 3.5mm x 80mm 150cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Nano 3.5mm x 80mm 150cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Nano 3.5mm x 80mm 150cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Nano 4.0mm x 120mm 150cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547020
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Nano 4.0mm x 120mm 150cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547020
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Nano 4.0mm x 120mm 150cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547020
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Nano 4.0mm x 150mm 150cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547022
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Nano 4.0mm x 150mm 150cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547022
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Nano 4.0mm x 150mm 150cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547022
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Nano 4.0mm x 20mm 150cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547014
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Nano 4.0mm x 20mm 150cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547014
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Nano 4.0mm x 20mm 150cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547014
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Nano 4.0mm x 210mm 150cm
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547024
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Nano 4.0mm x 210mm 150cm
|
Facility
|
IP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547024
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
Nano 4.0mm x 210mm 150cm
|
Facility
|
OP
|
$1,708.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2547024
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
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 |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
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 |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
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 |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
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 |
$870.40 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,065.79
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
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 |
$497.37 |
| Max. Negotiated Rate |
$1,634.21 |
| Rate for Payer: Aetna Commercial |
$1,598.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$497.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,154.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$888.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$941.45
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,634.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$994.06
|
| Rate for Payer: Health EOS Commercial |
$1,580.92
|
| Rate for Payer: HFN Commercial |
$1,634.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,332.24
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,634.21
|
| Rate for Payer: Quartz Beloit One Network |
$870.40
|
| Rate for Payer: Quartz Commercial |
$1,154.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.79
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
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 |
$781.58 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$888.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.79
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: The Alliance Commercial |
$888.16
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$1,315.67
|
|
|
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 |
$76.44 |
| Max. Negotiated Rate |
$143.52 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$93.60
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
|
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 |
$68.64 |
| Max. Negotiated Rate |
$148.20 |
| Rate for Payer: Aetna Commercial |
$148.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$148.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$78.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$93.60
|
| Rate for Payer: Health EOS Commercial |
$141.96
|
| Rate for Payer: HFN Commercial |
$148.20
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: Preferred Network Access Commercial |
$148.20
|
| Rate for Payer: Quartz Beloit One Network |
$68.64
|
| Rate for Payer: Quartz Commercial |
$88.92
|
| Rate for Payer: The Alliance Commercial |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
|
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 |
$43.68 |
| Max. Negotiated Rate |
$143.52 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Aetna Managed Medicare |
$43.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$101.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$74.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.30
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.00
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: NAPHCARE Commercial |
$93.60
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$101.40
|
| Rate for Payer: Quartz Medicare Advantage |
$93.60
|
| Rate for Payer: The Alliance Commercial |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
