|
PATELLA TRIATHLON S39MM 5550-G-391
|
Facility
|
OP
|
$5,699.00
|
|
| Hospital Charge Code |
4100376
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,595.72 |
| Max. Negotiated Rate |
$22,796.00 |
| Rate for Payer: Aetna Commercial |
$5,129.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,901.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,595.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,704.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,849.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,735.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,020.47
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,243.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,189.16
|
| Rate for Payer: Health EOS Commercial |
$5,072.11
|
| Rate for Payer: HFN Commercial |
$5,243.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,274.25
|
| Rate for Payer: Multiplan Commercial |
$4,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,419.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,243.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,792.51
|
| Rate for Payer: Quartz Commercial |
$3,704.35
|
| Rate for Payer: Quartz Medicare Advantage |
$3,419.40
|
| Rate for Payer: The Alliance Commercial |
$22,796.00
|
| Rate for Payer: WEA Trust Commercial |
$3,134.45
|
| Rate for Payer: WPS Commercial |
$4,221.25
|
|
|
PATELLA TRIATHLON S39MM 5550-G-391
|
Facility
|
IP
|
$5,699.00
|
|
| Hospital Charge Code |
4100376
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,792.51 |
| Max. Negotiated Rate |
$5,243.08 |
| Rate for Payer: Aetna Commercial |
$5,129.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,901.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,020.47
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,243.08
|
| Rate for Payer: Health EOS Commercial |
$5,072.11
|
| Rate for Payer: HFN Commercial |
$5,243.08
|
| Rate for Payer: Multiplan Commercial |
$4,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,419.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,243.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,792.51
|
| Rate for Payer: Quartz Commercial |
$3,419.40
|
| Rate for Payer: WEA Trust Commercial |
$3,134.45
|
| Rate for Payer: WPS Commercial |
$4,221.25
|
|
|
PATELLA TRIATHLON SZ 36MM 5550-G-360
|
Facility
|
OP
|
$5,699.00
|
|
| Hospital Charge Code |
3935332
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,595.72 |
| Max. Negotiated Rate |
$22,796.00 |
| Rate for Payer: Aetna Commercial |
$5,129.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,901.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,595.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,704.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,849.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,735.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,020.47
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,243.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,189.16
|
| Rate for Payer: Health EOS Commercial |
$5,072.11
|
| Rate for Payer: HFN Commercial |
$5,243.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,274.25
|
| Rate for Payer: Multiplan Commercial |
$4,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,419.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,243.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,792.51
|
| Rate for Payer: Quartz Commercial |
$3,704.35
|
| Rate for Payer: Quartz Medicare Advantage |
$3,419.40
|
| Rate for Payer: The Alliance Commercial |
$22,796.00
|
| Rate for Payer: WEA Trust Commercial |
$3,134.45
|
| Rate for Payer: WPS Commercial |
$4,221.25
|
|
|
PATELLA TRIATHLON SZ 36MM 5550-G-360
|
Facility
|
IP
|
$5,699.00
|
|
| Hospital Charge Code |
3935332
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,792.51 |
| Max. Negotiated Rate |
$5,243.08 |
| Rate for Payer: Aetna Commercial |
$5,129.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,901.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,020.47
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,243.08
|
| Rate for Payer: Health EOS Commercial |
$5,072.11
|
| Rate for Payer: HFN Commercial |
$5,243.08
|
| Rate for Payer: Multiplan Commercial |
$4,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,419.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,243.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,792.51
|
| Rate for Payer: Quartz Commercial |
$3,419.40
|
| Rate for Payer: WEA Trust Commercial |
$3,134.45
|
| Rate for Payer: WPS Commercial |
$4,221.25
|
|
|
PATELLA TRIATHLON SZ S31MM 5550-G-319
|
Facility
|
OP
|
$5,488.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3779535
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,536.64 |
| Max. Negotiated Rate |
$21,952.00 |
| Rate for Payer: Aetna Commercial |
$4,939.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,719.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,536.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,567.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,744.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,634.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,908.64
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,048.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,071.08
|
| Rate for Payer: Health EOS Commercial |
$4,884.32
|
| Rate for Payer: HFN Commercial |
$5,048.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,116.00
|
| Rate for Payer: Multiplan Commercial |
$4,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,292.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,048.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,689.12
|
| Rate for Payer: Quartz Commercial |
$3,567.20
|
| Rate for Payer: Quartz Medicare Advantage |
$3,292.80
|
| Rate for Payer: The Alliance Commercial |
$21,952.00
|
| Rate for Payer: WEA Trust Commercial |
$3,018.40
|
| Rate for Payer: WPS Commercial |
$4,064.96
|
|
|
PATELLA TRIATHLON SZ S31MM 5550-G-319
|
Facility
|
IP
|
$5,488.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3779535
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,689.12 |
| Max. Negotiated Rate |
$5,048.96 |
| Rate for Payer: Aetna Commercial |
$4,939.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,719.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,908.64
|
| Rate for Payer: Cash Price |
$1,646.40
|
| Rate for Payer: Cigna Commercial |
$5,048.96
|
| Rate for Payer: Health EOS Commercial |
$4,884.32
|
| Rate for Payer: HFN Commercial |
$5,048.96
|
| Rate for Payer: Multiplan Commercial |
$4,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,292.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,048.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,689.12
|
| Rate for Payer: Quartz Commercial |
$3,292.80
|
| Rate for Payer: WEA Trust Commercial |
$3,018.40
|
| Rate for Payer: WPS Commercial |
$4,064.96
|
|
|
PATELLA TRIATHLON SZ S33MM 5550-G-339
|
Facility
|
IP
|
$5,699.00
|
|
| Hospital Charge Code |
3779518
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,792.51 |
| Max. Negotiated Rate |
$5,243.08 |
| Rate for Payer: Aetna Commercial |
$5,129.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,901.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,020.47
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,243.08
|
| Rate for Payer: Health EOS Commercial |
$5,072.11
|
| Rate for Payer: HFN Commercial |
$5,243.08
|
| Rate for Payer: Multiplan Commercial |
$4,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,419.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,243.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,792.51
|
| Rate for Payer: Quartz Commercial |
$3,419.40
|
| Rate for Payer: WEA Trust Commercial |
$3,134.45
|
| Rate for Payer: WPS Commercial |
$4,221.25
|
|
|
PATELLA TRIATHLON SZ S33MM 5550-G-339
|
Facility
|
OP
|
$5,699.00
|
|
| Hospital Charge Code |
3779518
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,595.72 |
| Max. Negotiated Rate |
$22,796.00 |
| Rate for Payer: Aetna Commercial |
$5,129.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,901.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,595.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,704.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,849.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,735.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,020.47
|
| Rate for Payer: Cash Price |
$1,709.70
|
| Rate for Payer: Cigna Commercial |
$5,243.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,189.16
|
| Rate for Payer: Health EOS Commercial |
$5,072.11
|
| Rate for Payer: HFN Commercial |
$5,243.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,274.25
|
| Rate for Payer: Multiplan Commercial |
$4,559.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,419.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,243.08
|
| Rate for Payer: Quartz Beloit One Network |
$2,792.51
|
| Rate for Payer: Quartz Commercial |
$3,704.35
|
| Rate for Payer: Quartz Medicare Advantage |
$3,419.40
|
| Rate for Payer: The Alliance Commercial |
$22,796.00
|
| Rate for Payer: WEA Trust Commercial |
$3,134.45
|
| Rate for Payer: WPS Commercial |
$4,221.25
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC
|
Facility
|
IP
|
$29,318.00
|
|
|
Service Code
|
MSDRG 543
|
| Min. Negotiated Rate |
$10,545.95 |
| Max. Negotiated Rate |
$29,318.00 |
| Rate for Payer: Aetna Managed Medicare |
$10,545.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22,868.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,528.29
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,653.02
|
| Rate for Payer: Anthem Medicare Advantage |
$10,545.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,545.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,545.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,545.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,486.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,545.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,268.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,545.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,545.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,545.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,545.95
|
| Rate for Payer: NAPHCARE Commercial |
$15,818.92
|
| Rate for Payer: Quartz Medicare Advantage |
$10,545.95
|
| Rate for Payer: The Alliance Commercial |
$29,318.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,545.95
|
| Rate for Payer: United Healthcare PPO |
$16,557.92
|
| Rate for Payer: Wellcare Medicare |
$10,545.95
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC
|
Facility
|
IP
|
$48,805.00
|
|
|
Service Code
|
MSDRG 542
|
| Min. Negotiated Rate |
$17,555.85 |
| Max. Negotiated Rate |
$48,805.00 |
| Rate for Payer: Aetna Managed Medicare |
$17,555.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38,183.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29,267.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27,805.96
|
| Rate for Payer: Anthem Medicare Advantage |
$17,555.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,555.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,555.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,555.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30,867.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,555.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$35,562.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,555.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,555.85
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,555.85
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,555.85
|
| Rate for Payer: NAPHCARE Commercial |
$26,333.78
|
| Rate for Payer: Quartz Medicare Advantage |
$17,555.85
|
| Rate for Payer: The Alliance Commercial |
$48,805.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,555.85
|
| Rate for Payer: United Healthcare PPO |
$27,685.59
|
| Rate for Payer: Wellcare Medicare |
$17,555.85
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$20,725.00
|
|
|
Service Code
|
MSDRG 544
|
| Min. Negotiated Rate |
$7,455.10 |
| Max. Negotiated Rate |
$20,725.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,455.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,154.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,382.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,764.06
|
| Rate for Payer: Anthem Medicare Advantage |
$7,455.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,455.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,455.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,455.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,059.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,455.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,966.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,455.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,455.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,455.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,455.10
|
| Rate for Payer: NAPHCARE Commercial |
$11,182.65
|
| Rate for Payer: Quartz Medicare Advantage |
$7,455.10
|
| Rate for Payer: The Alliance Commercial |
$20,725.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,455.10
|
| Rate for Payer: United Healthcare PPO |
$11,651.42
|
| Rate for Payer: Wellcare Medicare |
$7,455.10
|
|
|
PATHWAY TRAINER TR-20 #2933-01
|
Facility
|
OP
|
$6,018.00
|
|
| Hospital Charge Code |
2973682
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,685.04 |
| Max. Negotiated Rate |
$24,072.00 |
| Rate for Payer: Aetna Commercial |
$5,416.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,175.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,685.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,911.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,009.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,888.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,189.54
|
| Rate for Payer: Cash Price |
$1,805.40
|
| Rate for Payer: Cigna Commercial |
$5,536.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,367.67
|
| Rate for Payer: Health EOS Commercial |
$5,356.02
|
| Rate for Payer: HFN Commercial |
$5,536.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,513.50
|
| Rate for Payer: Multiplan Commercial |
$4,814.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,610.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,536.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,948.82
|
| Rate for Payer: Quartz Commercial |
$3,911.70
|
| Rate for Payer: Quartz Medicare Advantage |
$3,610.80
|
| Rate for Payer: The Alliance Commercial |
$24,072.00
|
| Rate for Payer: WEA Trust Commercial |
$3,309.90
|
| Rate for Payer: WPS Commercial |
$4,457.53
|
|
|
PATHWAY TRAINER TR-20 #2933-01
|
Facility
|
IP
|
$6,018.00
|
|
| Hospital Charge Code |
2973682
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2,948.82 |
| Max. Negotiated Rate |
$5,536.56 |
| Rate for Payer: Aetna Commercial |
$5,416.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,175.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,189.54
|
| Rate for Payer: Cash Price |
$1,805.40
|
| Rate for Payer: Cigna Commercial |
$5,536.56
|
| Rate for Payer: Health EOS Commercial |
$5,356.02
|
| Rate for Payer: HFN Commercial |
$5,536.56
|
| Rate for Payer: Multiplan Commercial |
$4,814.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,610.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,536.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,948.82
|
| Rate for Payer: Quartz Commercial |
$3,610.80
|
| Rate for Payer: WEA Trust Commercial |
$3,309.90
|
| Rate for Payer: WPS Commercial |
$4,457.53
|
|
|
PATIENT KIT GENTLE TOUCH II SPINAL TOP DISP MIZUHO 5808
|
Facility
|
IP
|
$427.76
|
|
| Hospital Charge Code |
6244185
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$209.60 |
| Max. Negotiated Rate |
$393.54 |
| Rate for Payer: Aetna Commercial |
$384.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$367.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$226.71
|
| Rate for Payer: Cash Price |
$128.33
|
| Rate for Payer: Cigna Commercial |
$393.54
|
| Rate for Payer: Health EOS Commercial |
$380.71
|
| Rate for Payer: HFN Commercial |
$393.54
|
| Rate for Payer: Multiplan Commercial |
$342.21
|
| Rate for Payer: NAPHCARE Commercial |
$256.66
|
| Rate for Payer: Preferred Network Access Commercial |
$393.54
|
| Rate for Payer: Quartz Beloit One Network |
$209.60
|
| Rate for Payer: Quartz Commercial |
$256.66
|
| Rate for Payer: WEA Trust Commercial |
$235.27
|
| Rate for Payer: WPS Commercial |
$316.84
|
|
|
PATIENT KIT GENTLE TOUCH II SPINAL TOP DISP MIZUHO 5808
|
Facility
|
OP
|
$427.76
|
|
| Hospital Charge Code |
6244185
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$119.77 |
| Max. Negotiated Rate |
$1,711.04 |
| Rate for Payer: Aetna Commercial |
$384.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$367.87
|
| Rate for Payer: Aetna Managed Medicare |
$119.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$278.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$213.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$205.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$226.71
|
| Rate for Payer: Cash Price |
$128.33
|
| Rate for Payer: Cigna Commercial |
$393.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$239.37
|
| Rate for Payer: Health EOS Commercial |
$380.71
|
| Rate for Payer: HFN Commercial |
$393.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$320.82
|
| Rate for Payer: Multiplan Commercial |
$342.21
|
| Rate for Payer: NAPHCARE Commercial |
$256.66
|
| Rate for Payer: Preferred Network Access Commercial |
$393.54
|
| Rate for Payer: Quartz Beloit One Network |
$209.60
|
| Rate for Payer: Quartz Commercial |
$278.04
|
| Rate for Payer: Quartz Medicare Advantage |
$256.66
|
| Rate for Payer: The Alliance Commercial |
$1,711.04
|
| Rate for Payer: WEA Trust Commercial |
$235.27
|
| Rate for Payer: WPS Commercial |
$316.84
|
|
|
PBP2' Test
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
1562808
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.54 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Aetna Managed Medicare |
$11.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.16
|
| Rate for Payer: Anthem Medicaid |
$11.92
|
| Rate for Payer: Anthem Medicare Advantage |
$11.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.54
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.34
|
| Rate for Payer: Dean Health Medicaid |
$11.92
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.54
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.54
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11.92
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.54
|
| Rate for Payer: Managed Health Services Medicaid |
$12.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.54
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.54
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$17.31
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11.92
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$36.40
|
| Rate for Payer: Quartz Medicare Advantage |
$11.54
|
| Rate for Payer: The Alliance Commercial |
$46.16
|
| Rate for Payer: United Healthcare Medicaid |
$11.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.54
|
| Rate for Payer: United Healthcare PPO |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: Wellcare Medicare |
$11.54
|
| Rate for Payer: WMAP Medicaid |
$11.92
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
PBP2' Test
|
Professional
|
Both
|
$56.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
1562808
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.64 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.60
|
| Rate for Payer: Health EOS Commercial |
$50.96
|
| Rate for Payer: HFN Commercial |
$53.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.74
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: Preferred Network Access Commercial |
$53.20
|
| Rate for Payer: Quartz Beloit One Network |
$24.64
|
| Rate for Payer: Quartz Commercial |
$31.92
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
PBP2' Test
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
1562808
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$33.60
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
PCA PUMP
|
Facility
|
OP
|
$565.00
|
|
| Hospital Charge Code |
3075869
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$158.20 |
| Max. Negotiated Rate |
$2,260.00 |
| Rate for Payer: Aetna Commercial |
$508.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$485.90
|
| Rate for Payer: Aetna Managed Medicare |
$158.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$367.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$282.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$271.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$299.45
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$519.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$316.17
|
| Rate for Payer: Health EOS Commercial |
$502.85
|
| Rate for Payer: HFN Commercial |
$519.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$423.75
|
| Rate for Payer: Multiplan Commercial |
$452.00
|
| Rate for Payer: NAPHCARE Commercial |
$339.00
|
| Rate for Payer: Preferred Network Access Commercial |
$519.80
|
| Rate for Payer: Quartz Beloit One Network |
$276.85
|
| Rate for Payer: Quartz Commercial |
$367.25
|
| Rate for Payer: Quartz Medicare Advantage |
$339.00
|
| Rate for Payer: The Alliance Commercial |
$2,260.00
|
| Rate for Payer: WEA Trust Commercial |
$310.75
|
| Rate for Payer: WPS Commercial |
$418.50
|
|
|
PCA PUMP
|
Facility
|
IP
|
$565.00
|
|
| Hospital Charge Code |
3075869
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$276.85 |
| Max. Negotiated Rate |
$519.80 |
| Rate for Payer: Aetna Commercial |
$508.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$485.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$299.45
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$519.80
|
| Rate for Payer: Health EOS Commercial |
$502.85
|
| Rate for Payer: HFN Commercial |
$519.80
|
| Rate for Payer: Multiplan Commercial |
$452.00
|
| Rate for Payer: NAPHCARE Commercial |
$339.00
|
| Rate for Payer: Preferred Network Access Commercial |
$519.80
|
| Rate for Payer: Quartz Beloit One Network |
$276.85
|
| Rate for Payer: Quartz Commercial |
$339.00
|
| Rate for Payer: WEA Trust Commercial |
$310.75
|
| Rate for Payer: WPS Commercial |
$418.50
|
|
|
PCA Pump - Devices and Equipment
|
Facility
|
OP
|
$543.00
|
|
| Hospital Charge Code |
3002377
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$152.04 |
| Max. Negotiated Rate |
$2,172.00 |
| Rate for Payer: Aetna Commercial |
$488.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$466.98
|
| Rate for Payer: Aetna Managed Medicare |
$152.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$352.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$271.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$260.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$287.79
|
| Rate for Payer: Cash Price |
$162.90
|
| Rate for Payer: Cigna Commercial |
$499.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$303.86
|
| Rate for Payer: Health EOS Commercial |
$483.27
|
| Rate for Payer: HFN Commercial |
$499.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$407.25
|
| Rate for Payer: Multiplan Commercial |
$434.40
|
| Rate for Payer: NAPHCARE Commercial |
$325.80
|
| Rate for Payer: Preferred Network Access Commercial |
$499.56
|
| Rate for Payer: Quartz Beloit One Network |
$266.07
|
| Rate for Payer: Quartz Commercial |
$352.95
|
| Rate for Payer: Quartz Medicare Advantage |
$325.80
|
| Rate for Payer: The Alliance Commercial |
$2,172.00
|
| Rate for Payer: WEA Trust Commercial |
$298.65
|
| Rate for Payer: WPS Commercial |
$402.20
|
|
|
PCA Pump - Devices and Equipment
|
Facility
|
IP
|
$543.00
|
|
| Hospital Charge Code |
3002377
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$266.07 |
| Max. Negotiated Rate |
$499.56 |
| Rate for Payer: Aetna Commercial |
$488.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$466.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$287.79
|
| Rate for Payer: Cash Price |
$162.90
|
| Rate for Payer: Cigna Commercial |
$499.56
|
| Rate for Payer: Health EOS Commercial |
$483.27
|
| Rate for Payer: HFN Commercial |
$499.56
|
| Rate for Payer: Multiplan Commercial |
$434.40
|
| Rate for Payer: NAPHCARE Commercial |
$325.80
|
| Rate for Payer: Preferred Network Access Commercial |
$499.56
|
| Rate for Payer: Quartz Beloit One Network |
$266.07
|
| Rate for Payer: Quartz Commercial |
$325.80
|
| Rate for Payer: WEA Trust Commercial |
$298.65
|
| Rate for Payer: WPS Commercial |
$402.20
|
|
|
PCA SET TUBING Y-CONNECTOR DEHP-FREE 3ML 10800175
|
Facility
|
OP
|
$146.00
|
|
| Hospital Charge Code |
4089811
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.88 |
| Max. Negotiated Rate |
$584.00 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Aetna Managed Medicare |
$40.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$94.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$70.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.38
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$134.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.70
|
| Rate for Payer: Health EOS Commercial |
$129.94
|
| Rate for Payer: HFN Commercial |
$134.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.50
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: NAPHCARE Commercial |
$87.60
|
| Rate for Payer: Preferred Network Access Commercial |
$134.32
|
| Rate for Payer: Quartz Beloit One Network |
$71.54
|
| Rate for Payer: Quartz Commercial |
$94.90
|
| Rate for Payer: Quartz Medicare Advantage |
$87.60
|
| Rate for Payer: The Alliance Commercial |
$584.00
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
PCA SET TUBING Y-CONNECTOR DEHP-FREE 3ML 10800175
|
Facility
|
IP
|
$146.00
|
|
| Hospital Charge Code |
4089811
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.54 |
| Max. Negotiated Rate |
$134.32 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.38
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$134.32
|
| Rate for Payer: Health EOS Commercial |
$129.94
|
| Rate for Payer: HFN Commercial |
$134.32
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: NAPHCARE Commercial |
$87.60
|
| Rate for Payer: Preferred Network Access Commercial |
$134.32
|
| Rate for Payer: Quartz Beloit One Network |
$71.54
|
| Rate for Payer: Quartz Commercial |
$87.60
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
PCP Screen
|
Professional
|
Both
|
$48.00
|
|
| Hospital Charge Code |
2942894
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.12 |
| Max. Negotiated Rate |
$45.60 |
| Rate for Payer: Aetna Commercial |
$45.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.80
|
| Rate for Payer: Health EOS Commercial |
$43.68
|
| Rate for Payer: HFN Commercial |
$45.60
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.60
|
| Rate for Payer: Quartz Beloit One Network |
$21.12
|
| Rate for Payer: Quartz Commercial |
$27.36
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
