|
Parvovirus B19 Antibody IgM
|
Facility
|
IP
|
$263.00
|
|
|
Service Code
|
CPT 86747
|
| Hospital Charge Code |
978036
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$128.87 |
| Max. Negotiated Rate |
$241.96 |
| Rate for Payer: Aetna Commercial |
$236.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$226.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$139.39
|
| Rate for Payer: Cash Price |
$78.90
|
| Rate for Payer: Cigna Commercial |
$241.96
|
| Rate for Payer: Health EOS Commercial |
$234.07
|
| Rate for Payer: HFN Commercial |
$241.96
|
| Rate for Payer: Multiplan Commercial |
$210.40
|
| Rate for Payer: NAPHCARE Commercial |
$157.80
|
| Rate for Payer: Preferred Network Access Commercial |
$241.96
|
| Rate for Payer: Quartz Beloit One Network |
$128.87
|
| Rate for Payer: Quartz Commercial |
$157.80
|
| Rate for Payer: WEA Trust Commercial |
$144.65
|
| Rate for Payer: WPS Commercial |
$194.80
|
|
|
Parvovirus B19 Antibody IgM
|
Professional
|
Both
|
$263.00
|
|
|
Service Code
|
CPT 86747
|
| Hospital Charge Code |
978036
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.06 |
| Max. Negotiated Rate |
$249.85 |
| Rate for Payer: Aetna Commercial |
$249.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$226.18
|
| Rate for Payer: Cash Price |
$78.90
|
| Rate for Payer: Cash Price |
$78.90
|
| Rate for Payer: Cigna Commercial |
$249.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$131.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$157.80
|
| Rate for Payer: Health EOS Commercial |
$239.33
|
| Rate for Payer: HFN Commercial |
$249.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.06
|
| Rate for Payer: Multiplan Commercial |
$210.40
|
| Rate for Payer: Preferred Network Access Commercial |
$249.85
|
| Rate for Payer: Quartz Beloit One Network |
$115.72
|
| Rate for Payer: Quartz Commercial |
$149.91
|
| Rate for Payer: The Alliance Commercial |
$131.50
|
| Rate for Payer: WEA Trust Commercial |
$144.65
|
| Rate for Payer: WPS Commercial |
$194.80
|
|
|
Parvovirus B19, DNA, Qual, PCR
|
Professional
|
Both
|
$405.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
983357
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$123.87 |
| Max. Negotiated Rate |
$384.75 |
| Rate for Payer: Aetna Commercial |
$384.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$384.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$202.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$243.00
|
| Rate for Payer: Health EOS Commercial |
$368.55
|
| Rate for Payer: HFN Commercial |
$384.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$123.87
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: Preferred Network Access Commercial |
$384.75
|
| Rate for Payer: Quartz Beloit One Network |
$178.20
|
| Rate for Payer: Quartz Commercial |
$230.85
|
| Rate for Payer: The Alliance Commercial |
$202.50
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
Parvovirus B19, DNA, Qual, PCR
|
Facility
|
IP
|
$405.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
983357
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$198.45 |
| Max. Negotiated Rate |
$372.60 |
| Rate for Payer: Aetna Commercial |
$364.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.65
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$372.60
|
| Rate for Payer: Health EOS Commercial |
$360.45
|
| Rate for Payer: HFN Commercial |
$372.60
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: NAPHCARE Commercial |
$243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$372.60
|
| Rate for Payer: Quartz Beloit One Network |
$198.45
|
| Rate for Payer: Quartz Commercial |
$243.00
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
Parvovirus B19, DNA, Qual, PCR
|
Facility
|
OP
|
$405.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
983357
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$372.60 |
| Rate for Payer: Aetna Commercial |
$364.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Aetna Managed Medicare |
$35.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.25
|
| Rate for Payer: Anthem Medicaid |
$36.26
|
| Rate for Payer: Anthem Medicare Advantage |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.09
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$372.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$35.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.64
|
| Rate for Payer: Dean Health Medicaid |
$36.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$35.09
|
| Rate for Payer: Health EOS Commercial |
$360.45
|
| Rate for Payer: HFN Commercial |
$372.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$35.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$36.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.09
|
| Rate for Payer: Managed Health Services Medicaid |
$37.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$35.09
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: NAPHCARE Commercial |
$52.64
|
| Rate for Payer: Preferred Network Access Commercial |
$372.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$36.26
|
| Rate for Payer: Quartz Beloit One Network |
$198.45
|
| Rate for Payer: Quartz Commercial |
$263.25
|
| Rate for Payer: Quartz Medicare Advantage |
$35.09
|
| Rate for Payer: The Alliance Commercial |
$140.36
|
| Rate for Payer: United Healthcare Medicaid |
$36.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare PPO |
$303.75
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: Wellcare Medicare |
$35.09
|
| Rate for Payer: WMAP Medicaid |
$36.26
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
Parvovirus B19 IgM Antibody
|
Facility
|
IP
|
$185.00
|
|
|
Service Code
|
CPT 86747
|
| Hospital Charge Code |
2942967
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$90.65 |
| Max. Negotiated Rate |
$170.20 |
| Rate for Payer: Aetna Commercial |
$166.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.05
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cigna Commercial |
$170.20
|
| Rate for Payer: Health EOS Commercial |
$164.65
|
| Rate for Payer: HFN Commercial |
$170.20
|
| Rate for Payer: Multiplan Commercial |
$148.00
|
| Rate for Payer: NAPHCARE Commercial |
$111.00
|
| Rate for Payer: Preferred Network Access Commercial |
$170.20
|
| Rate for Payer: Quartz Beloit One Network |
$90.65
|
| Rate for Payer: Quartz Commercial |
$111.00
|
| Rate for Payer: WEA Trust Commercial |
$101.75
|
| Rate for Payer: WPS Commercial |
$137.03
|
|
|
Parvovirus B19 IgM Antibody
|
Professional
|
Both
|
$185.00
|
|
|
Service Code
|
CPT 86747
|
| Hospital Charge Code |
2942967
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.06 |
| Max. Negotiated Rate |
$175.75 |
| Rate for Payer: Aetna Commercial |
$175.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.10
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cigna Commercial |
$175.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$92.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.00
|
| Rate for Payer: Health EOS Commercial |
$168.35
|
| Rate for Payer: HFN Commercial |
$175.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.06
|
| Rate for Payer: Multiplan Commercial |
$148.00
|
| Rate for Payer: Preferred Network Access Commercial |
$175.75
|
| Rate for Payer: Quartz Beloit One Network |
$81.40
|
| Rate for Payer: Quartz Commercial |
$105.45
|
| Rate for Payer: The Alliance Commercial |
$92.50
|
| Rate for Payer: WEA Trust Commercial |
$101.75
|
| Rate for Payer: WPS Commercial |
$137.03
|
|
|
Parvovirus B19 IgM Antibody
|
Facility
|
OP
|
$185.00
|
|
|
Service Code
|
CPT 86747
|
| Hospital Charge Code |
2942967
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.03 |
| Max. Negotiated Rate |
$170.20 |
| Rate for Payer: Aetna Commercial |
$166.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.10
|
| Rate for Payer: Aetna Managed Medicare |
$15.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.30
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.95
|
| Rate for Payer: Anthem Medicaid |
$15.53
|
| Rate for Payer: Anthem Medicare Advantage |
$15.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.03
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cigna Commercial |
$170.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$103.53
|
| Rate for Payer: Dean Health Medicaid |
$15.53
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.03
|
| Rate for Payer: Health EOS Commercial |
$164.65
|
| Rate for Payer: HFN Commercial |
$170.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.03
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.03
|
| Rate for Payer: Managed Health Services Medicaid |
$16.15
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.03
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.03
|
| Rate for Payer: Multiplan Commercial |
$148.00
|
| Rate for Payer: NAPHCARE Commercial |
$22.54
|
| Rate for Payer: Preferred Network Access Commercial |
$170.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.53
|
| Rate for Payer: Quartz Beloit One Network |
$90.65
|
| Rate for Payer: Quartz Commercial |
$120.25
|
| Rate for Payer: Quartz Medicare Advantage |
$15.03
|
| Rate for Payer: The Alliance Commercial |
$60.12
|
| Rate for Payer: United Healthcare Medicaid |
$15.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.03
|
| Rate for Payer: United Healthcare PPO |
$138.75
|
| Rate for Payer: WEA Trust Commercial |
$101.75
|
| Rate for Payer: Wellcare Medicare |
$15.03
|
| Rate for Payer: WMAP Medicaid |
$15.53
|
| Rate for Payer: WPS Commercial |
$137.03
|
|
|
PASSING NEEDLE CERCLAGE MD SINGLE USE AR-7816
|
Facility
|
OP
|
$1,459.00
|
|
| Hospital Charge Code |
5803671
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$408.52 |
| Max. Negotiated Rate |
$5,836.00 |
| Rate for Payer: Aetna Commercial |
$1,313.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,254.74
|
| Rate for Payer: Aetna Managed Medicare |
$408.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$948.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$729.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$700.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$773.27
|
| Rate for Payer: Cash Price |
$437.70
|
| Rate for Payer: Cigna Commercial |
$1,342.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$816.46
|
| Rate for Payer: Health EOS Commercial |
$1,298.51
|
| Rate for Payer: HFN Commercial |
$1,342.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,094.25
|
| Rate for Payer: Multiplan Commercial |
$1,167.20
|
| Rate for Payer: NAPHCARE Commercial |
$875.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,342.28
|
| Rate for Payer: Quartz Beloit One Network |
$714.91
|
| Rate for Payer: Quartz Commercial |
$948.35
|
| Rate for Payer: Quartz Medicare Advantage |
$875.40
|
| Rate for Payer: The Alliance Commercial |
$5,836.00
|
| Rate for Payer: WEA Trust Commercial |
$802.45
|
| Rate for Payer: WPS Commercial |
$1,080.68
|
|
|
PASSING NEEDLE CERCLAGE MD SINGLE USE AR-7816
|
Facility
|
IP
|
$1,459.00
|
|
| Hospital Charge Code |
5803671
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$714.91 |
| Max. Negotiated Rate |
$1,342.28 |
| Rate for Payer: Aetna Commercial |
$1,313.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,254.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$773.27
|
| Rate for Payer: Cash Price |
$437.70
|
| Rate for Payer: Cigna Commercial |
$1,342.28
|
| Rate for Payer: Health EOS Commercial |
$1,298.51
|
| Rate for Payer: HFN Commercial |
$1,342.28
|
| Rate for Payer: Multiplan Commercial |
$1,167.20
|
| Rate for Payer: NAPHCARE Commercial |
$875.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,342.28
|
| Rate for Payer: Quartz Beloit One Network |
$714.91
|
| Rate for Payer: Quartz Commercial |
$875.40
|
| Rate for Payer: WEA Trust Commercial |
$802.45
|
| Rate for Payer: WPS Commercial |
$1,080.68
|
|
|
PASSING NEEDLE CERCLAGE MD STRAIGHT SINGLE USE AR-7821
|
Facility
|
IP
|
$2,213.00
|
|
| Hospital Charge Code |
6166116
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,084.37 |
| Max. Negotiated Rate |
$2,035.96 |
| Rate for Payer: Aetna Commercial |
$1,991.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,903.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,172.89
|
| Rate for Payer: Cash Price |
$663.90
|
| Rate for Payer: Cigna Commercial |
$2,035.96
|
| Rate for Payer: Health EOS Commercial |
$1,969.57
|
| Rate for Payer: HFN Commercial |
$2,035.96
|
| Rate for Payer: Multiplan Commercial |
$1,770.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,327.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,035.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,084.37
|
| Rate for Payer: Quartz Commercial |
$1,327.80
|
| Rate for Payer: WEA Trust Commercial |
$1,217.15
|
| Rate for Payer: WPS Commercial |
$1,639.17
|
|
|
PASSING NEEDLE CERCLAGE MD STRAIGHT SINGLE USE AR-7821
|
Facility
|
OP
|
$2,213.00
|
|
| Hospital Charge Code |
6166116
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$619.64 |
| Max. Negotiated Rate |
$8,852.00 |
| Rate for Payer: Aetna Commercial |
$1,991.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,903.18
|
| Rate for Payer: Aetna Managed Medicare |
$619.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,438.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,106.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,062.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,172.89
|
| Rate for Payer: Cash Price |
$663.90
|
| Rate for Payer: Cigna Commercial |
$2,035.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,238.39
|
| Rate for Payer: Health EOS Commercial |
$1,969.57
|
| Rate for Payer: HFN Commercial |
$2,035.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,659.75
|
| Rate for Payer: Multiplan Commercial |
$1,770.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,327.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,035.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,084.37
|
| Rate for Payer: Quartz Commercial |
$1,438.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,327.80
|
| Rate for Payer: The Alliance Commercial |
$8,852.00
|
| Rate for Payer: WEA Trust Commercial |
$1,217.15
|
| Rate for Payer: WPS Commercial |
$1,639.17
|
|
|
PASSING WIRE SUTURE AR-1255-18
|
Facility
|
IP
|
$1,581.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2964709
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$774.69 |
| Max. Negotiated Rate |
$1,454.52 |
| Rate for Payer: Aetna Commercial |
$1,422.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,359.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$837.93
|
| Rate for Payer: Cash Price |
$474.30
|
| Rate for Payer: Cigna Commercial |
$1,454.52
|
| Rate for Payer: Health EOS Commercial |
$1,407.09
|
| Rate for Payer: HFN Commercial |
$1,454.52
|
| Rate for Payer: Multiplan Commercial |
$1,264.80
|
| Rate for Payer: NAPHCARE Commercial |
$948.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,454.52
|
| Rate for Payer: Quartz Beloit One Network |
$774.69
|
| Rate for Payer: Quartz Commercial |
$948.60
|
| Rate for Payer: WEA Trust Commercial |
$869.55
|
| Rate for Payer: WPS Commercial |
$1,171.05
|
|
|
PASSING WIRE SUTURE AR-1255-18
|
Facility
|
OP
|
$1,581.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2964709
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$442.68 |
| Max. Negotiated Rate |
$6,324.00 |
| Rate for Payer: Aetna Commercial |
$1,422.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,359.66
|
| Rate for Payer: Aetna Managed Medicare |
$442.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,027.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$790.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$758.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$837.93
|
| Rate for Payer: Cash Price |
$474.30
|
| Rate for Payer: Cigna Commercial |
$1,454.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$884.73
|
| Rate for Payer: Health EOS Commercial |
$1,407.09
|
| Rate for Payer: HFN Commercial |
$1,454.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,185.75
|
| Rate for Payer: Multiplan Commercial |
$1,264.80
|
| Rate for Payer: NAPHCARE Commercial |
$948.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,454.52
|
| Rate for Payer: Quartz Beloit One Network |
$774.69
|
| Rate for Payer: Quartz Commercial |
$1,027.65
|
| Rate for Payer: Quartz Medicare Advantage |
$948.60
|
| Rate for Payer: The Alliance Commercial |
$6,324.00
|
| Rate for Payer: WEA Trust Commercial |
$869.55
|
| Rate for Payer: WPS Commercial |
$1,171.05
|
|
|
PASSPORT BUTTON CANNULA AR--6592-12-40
|
Facility
|
IP
|
$1,321.00
|
|
| Hospital Charge Code |
5611602
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$647.29 |
| Max. Negotiated Rate |
$1,215.32 |
| Rate for Payer: Aetna Commercial |
$1,188.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.13
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,215.32
|
| Rate for Payer: Health EOS Commercial |
$1,175.69
|
| Rate for Payer: HFN Commercial |
$1,215.32
|
| Rate for Payer: Multiplan Commercial |
$1,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$792.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,215.32
|
| Rate for Payer: Quartz Beloit One Network |
$647.29
|
| Rate for Payer: Quartz Commercial |
$792.60
|
| Rate for Payer: WEA Trust Commercial |
$726.55
|
| Rate for Payer: WPS Commercial |
$978.46
|
|
|
PASSPORT BUTTON CANNULA AR--6592-12-40
|
Facility
|
OP
|
$1,321.00
|
|
| Hospital Charge Code |
5611602
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$369.88 |
| Max. Negotiated Rate |
$5,284.00 |
| Rate for Payer: Aetna Commercial |
$1,188.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.06
|
| Rate for Payer: Aetna Managed Medicare |
$369.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$858.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$660.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$634.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.13
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,215.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$739.23
|
| Rate for Payer: Health EOS Commercial |
$1,175.69
|
| Rate for Payer: HFN Commercial |
$1,215.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$990.75
|
| Rate for Payer: Multiplan Commercial |
$1,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$792.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,215.32
|
| Rate for Payer: Quartz Beloit One Network |
$647.29
|
| Rate for Payer: Quartz Commercial |
$858.65
|
| Rate for Payer: Quartz Medicare Advantage |
$792.60
|
| Rate for Payer: The Alliance Commercial |
$5,284.00
|
| Rate for Payer: WEA Trust Commercial |
$726.55
|
| Rate for Payer: WPS Commercial |
$978.46
|
|
|
PASSPORT DIVIDER AR-6592-12D
|
Facility
|
IP
|
$1,321.00
|
|
| Hospital Charge Code |
5611603
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$647.29 |
| Max. Negotiated Rate |
$1,215.32 |
| Rate for Payer: Aetna Commercial |
$1,188.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.13
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,215.32
|
| Rate for Payer: Health EOS Commercial |
$1,175.69
|
| Rate for Payer: HFN Commercial |
$1,215.32
|
| Rate for Payer: Multiplan Commercial |
$1,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$792.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,215.32
|
| Rate for Payer: Quartz Beloit One Network |
$647.29
|
| Rate for Payer: Quartz Commercial |
$792.60
|
| Rate for Payer: WEA Trust Commercial |
$726.55
|
| Rate for Payer: WPS Commercial |
$978.46
|
|
|
PASSPORT DIVIDER AR-6592-12D
|
Facility
|
OP
|
$1,321.00
|
|
| Hospital Charge Code |
5611603
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$369.88 |
| Max. Negotiated Rate |
$5,284.00 |
| Rate for Payer: Aetna Commercial |
$1,188.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.06
|
| Rate for Payer: Aetna Managed Medicare |
$369.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$858.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$660.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$634.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.13
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,215.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$739.23
|
| Rate for Payer: Health EOS Commercial |
$1,175.69
|
| Rate for Payer: HFN Commercial |
$1,215.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$990.75
|
| Rate for Payer: Multiplan Commercial |
$1,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$792.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,215.32
|
| Rate for Payer: Quartz Beloit One Network |
$647.29
|
| Rate for Payer: Quartz Commercial |
$858.65
|
| Rate for Payer: Quartz Medicare Advantage |
$792.60
|
| Rate for Payer: The Alliance Commercial |
$5,284.00
|
| Rate for Payer: WEA Trust Commercial |
$726.55
|
| Rate for Payer: WPS Commercial |
$978.46
|
|
|
PASTE STOMA ADAPT 2oz 79300
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
HCPCS A4406
|
| Hospital Charge Code |
2964041
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$728.00 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Aetna Managed Medicare |
$50.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$118.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$91.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$87.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$96.46
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$101.85
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$167.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.50
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: NAPHCARE Commercial |
$109.20
|
| Rate for Payer: Preferred Network Access Commercial |
$167.44
|
| Rate for Payer: Quartz Beloit One Network |
$89.18
|
| Rate for Payer: Quartz Commercial |
$118.30
|
| Rate for Payer: Quartz Medicare Advantage |
$109.20
|
| Rate for Payer: The Alliance Commercial |
$728.00
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.81
|
|
|
PASTE STOMA ADAPT 2oz 79300
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
HCPCS A4406
|
| Hospital Charge Code |
2964041
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$89.18 |
| Max. Negotiated Rate |
$167.44 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$96.46
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$167.44
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: NAPHCARE Commercial |
$109.20
|
| Rate for Payer: Preferred Network Access Commercial |
$167.44
|
| Rate for Payer: Quartz Beloit One Network |
$89.18
|
| Rate for Payer: Quartz Commercial |
$109.20
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.81
|
|
|
PATCH CARDIOVASCULAR 0.3IN X 3IN (0.8CM X 75CM) M002000195090
|
Facility
|
OP
|
$1,721.00
|
|
| Hospital Charge Code |
2964758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$481.88 |
| Max. Negotiated Rate |
$6,884.00 |
| Rate for Payer: Aetna Commercial |
$1,548.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,480.06
|
| Rate for Payer: Aetna Managed Medicare |
$481.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,118.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$860.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$826.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$912.13
|
| Rate for Payer: Cash Price |
$516.30
|
| Rate for Payer: Cigna Commercial |
$1,583.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$963.07
|
| Rate for Payer: Health EOS Commercial |
$1,531.69
|
| Rate for Payer: HFN Commercial |
$1,583.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,290.75
|
| Rate for Payer: Multiplan Commercial |
$1,376.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,032.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,583.32
|
| Rate for Payer: Quartz Beloit One Network |
$843.29
|
| Rate for Payer: Quartz Commercial |
$1,118.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,032.60
|
| Rate for Payer: The Alliance Commercial |
$6,884.00
|
| Rate for Payer: WEA Trust Commercial |
$946.55
|
| Rate for Payer: WPS Commercial |
$1,274.74
|
|
|
PATCH CARDIOVASCULAR 0.3IN X 3IN (0.8CM X 75CM) M002000195090
|
Facility
|
IP
|
$1,721.00
|
|
| Hospital Charge Code |
2964758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$843.29 |
| Max. Negotiated Rate |
$1,583.32 |
| Rate for Payer: Aetna Commercial |
$1,548.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,480.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$912.13
|
| Rate for Payer: Cash Price |
$516.30
|
| Rate for Payer: Cigna Commercial |
$1,583.32
|
| Rate for Payer: Health EOS Commercial |
$1,531.69
|
| Rate for Payer: HFN Commercial |
$1,583.32
|
| Rate for Payer: Multiplan Commercial |
$1,376.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,032.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,583.32
|
| Rate for Payer: Quartz Beloit One Network |
$843.29
|
| Rate for Payer: Quartz Commercial |
$1,032.60
|
| Rate for Payer: WEA Trust Commercial |
$946.55
|
| Rate for Payer: WPS Commercial |
$1,274.74
|
|
|
PATCH FELT TEFLON 2X2 007977
|
Facility
|
OP
|
$514.00
|
|
| Hospital Charge Code |
2973437
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$143.92 |
| Max. Negotiated Rate |
$2,056.00 |
| Rate for Payer: Aetna Commercial |
$462.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.04
|
| Rate for Payer: Aetna Managed Medicare |
$143.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$334.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$257.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.42
|
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Cigna Commercial |
$472.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$287.63
|
| Rate for Payer: Health EOS Commercial |
$457.46
|
| Rate for Payer: HFN Commercial |
$472.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$385.50
|
| Rate for Payer: Multiplan Commercial |
$411.20
|
| Rate for Payer: NAPHCARE Commercial |
$308.40
|
| Rate for Payer: Preferred Network Access Commercial |
$472.88
|
| Rate for Payer: Quartz Beloit One Network |
$251.86
|
| Rate for Payer: Quartz Commercial |
$334.10
|
| Rate for Payer: Quartz Medicare Advantage |
$308.40
|
| Rate for Payer: The Alliance Commercial |
$2,056.00
|
| Rate for Payer: WEA Trust Commercial |
$282.70
|
| Rate for Payer: WPS Commercial |
$380.72
|
|
|
PATCH FELT TEFLON 2X2 007977
|
Facility
|
IP
|
$514.00
|
|
| Hospital Charge Code |
2973437
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$251.86 |
| Max. Negotiated Rate |
$472.88 |
| Rate for Payer: Aetna Commercial |
$462.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.42
|
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Cigna Commercial |
$472.88
|
| Rate for Payer: Health EOS Commercial |
$457.46
|
| Rate for Payer: HFN Commercial |
$472.88
|
| Rate for Payer: Multiplan Commercial |
$411.20
|
| Rate for Payer: NAPHCARE Commercial |
$308.40
|
| Rate for Payer: Preferred Network Access Commercial |
$472.88
|
| Rate for Payer: Quartz Beloit One Network |
$251.86
|
| Rate for Payer: Quartz Commercial |
$308.40
|
| Rate for Payer: WEA Trust Commercial |
$282.70
|
| Rate for Payer: WPS Commercial |
$380.72
|
|
|
PATCH IONTO #199589-001***OBSOLETE FROM DJO
|
Facility
|
IP
|
$197.00
|
|
| Hospital Charge Code |
2969754
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$96.53 |
| Max. Negotiated Rate |
$181.24 |
| Rate for Payer: Aetna Commercial |
$177.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.41
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$181.24
|
| Rate for Payer: Health EOS Commercial |
$175.33
|
| Rate for Payer: HFN Commercial |
$181.24
|
| Rate for Payer: Multiplan Commercial |
$157.60
|
| Rate for Payer: NAPHCARE Commercial |
$118.20
|
| Rate for Payer: Preferred Network Access Commercial |
$181.24
|
| Rate for Payer: Quartz Beloit One Network |
$96.53
|
| Rate for Payer: Quartz Commercial |
$118.20
|
| Rate for Payer: WEA Trust Commercial |
$108.35
|
| Rate for Payer: WPS Commercial |
$145.92
|
|
