|
ARGON PLASMA COAGULATORY
|
Facility
|
OP
|
$1,643.00
|
|
| Hospital Charge Code |
2969255
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$460.04 |
| Max. Negotiated Rate |
$6,572.00 |
| Rate for Payer: Aetna Commercial |
$1,478.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,412.98
|
| Rate for Payer: Aetna Managed Medicare |
$460.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,067.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$821.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$788.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$870.79
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cigna Commercial |
$1,511.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$919.42
|
| Rate for Payer: Health EOS Commercial |
$1,462.27
|
| Rate for Payer: HFN Commercial |
$1,511.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,232.25
|
| Rate for Payer: Multiplan Commercial |
$1,314.40
|
| Rate for Payer: NAPHCARE Commercial |
$985.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,511.56
|
| Rate for Payer: Quartz Beloit One Network |
$805.07
|
| Rate for Payer: Quartz Commercial |
$1,067.95
|
| Rate for Payer: Quartz Medicare Advantage |
$985.80
|
| Rate for Payer: The Alliance Commercial |
$6,572.00
|
| Rate for Payer: WEA Trust Commercial |
$903.65
|
| Rate for Payer: WPS Commercial |
$1,216.97
|
|
|
ARGON PLASMA COAGULATORY
|
Facility
|
IP
|
$1,643.00
|
|
| Hospital Charge Code |
2969255
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$805.07 |
| Max. Negotiated Rate |
$1,511.56 |
| Rate for Payer: Aetna Commercial |
$1,478.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,412.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$870.79
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cigna Commercial |
$1,511.56
|
| Rate for Payer: Health EOS Commercial |
$1,462.27
|
| Rate for Payer: HFN Commercial |
$1,511.56
|
| Rate for Payer: Multiplan Commercial |
$1,314.40
|
| Rate for Payer: NAPHCARE Commercial |
$985.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,511.56
|
| Rate for Payer: Quartz Beloit One Network |
$805.07
|
| Rate for Payer: Quartz Commercial |
$985.80
|
| Rate for Payer: WEA Trust Commercial |
$903.65
|
| Rate for Payer: WPS Commercial |
$1,216.97
|
|
|
Aripiprazole (Abilify)
|
Facility
|
IP
|
$234.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3256219
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$140.40
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Aripiprazole (Abilify)
|
Professional
|
Both
|
$234.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3256219
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.80 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Aetna Commercial |
$222.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$222.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.40
|
| Rate for Payer: Health EOS Commercial |
$212.94
|
| Rate for Payer: HFN Commercial |
$222.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.80
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: Preferred Network Access Commercial |
$222.30
|
| Rate for Payer: Quartz Beloit One Network |
$102.96
|
| Rate for Payer: Quartz Commercial |
$133.38
|
| Rate for Payer: The Alliance Commercial |
$117.00
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Aripiprazole (Abilify)
|
Facility
|
OP
|
$234.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3256219
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$18.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.94
|
| Rate for Payer: Anthem Medicaid |
$19.26
|
| Rate for Payer: Anthem Medicare Advantage |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.64
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.95
|
| Rate for Payer: Dean Health Medicaid |
$19.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.64
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.64
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.64
|
| Rate for Payer: Managed Health Services Medicaid |
$20.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$27.96
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.26
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$18.64
|
| Rate for Payer: The Alliance Commercial |
$74.56
|
| Rate for Payer: United Healthcare Medicaid |
$19.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare PPO |
$175.50
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: Wellcare Medicare |
$18.64
|
| Rate for Payer: WMAP Medicaid |
$19.26
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
ARISTA AH ABSORBABLE HEMASTATIC PARTICLES 3G SM0002-USA
|
Facility
|
IP
|
$2,551.00
|
|
| Hospital Charge Code |
4594721
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,249.99 |
| Max. Negotiated Rate |
$2,346.92 |
| Rate for Payer: Aetna Commercial |
$2,295.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,193.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,352.03
|
| Rate for Payer: Cash Price |
$765.30
|
| Rate for Payer: Cigna Commercial |
$2,346.92
|
| Rate for Payer: Health EOS Commercial |
$2,270.39
|
| Rate for Payer: HFN Commercial |
$2,346.92
|
| Rate for Payer: Multiplan Commercial |
$2,040.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,530.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,346.92
|
| Rate for Payer: Quartz Beloit One Network |
$1,249.99
|
| Rate for Payer: Quartz Commercial |
$1,530.60
|
| Rate for Payer: WEA Trust Commercial |
$1,403.05
|
| Rate for Payer: WPS Commercial |
$1,889.53
|
|
|
ARISTA AH ABSORBABLE HEMASTATIC PARTICLES 3G SM0002-USA
|
Facility
|
OP
|
$2,551.00
|
|
| Hospital Charge Code |
4594721
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$714.28 |
| Max. Negotiated Rate |
$10,204.00 |
| Rate for Payer: Aetna Commercial |
$2,295.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,193.86
|
| Rate for Payer: Aetna Managed Medicare |
$714.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,658.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,275.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,224.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,352.03
|
| Rate for Payer: Cash Price |
$765.30
|
| Rate for Payer: Cigna Commercial |
$2,346.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,427.54
|
| Rate for Payer: Health EOS Commercial |
$2,270.39
|
| Rate for Payer: HFN Commercial |
$2,346.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,913.25
|
| Rate for Payer: Multiplan Commercial |
$2,040.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,530.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,346.92
|
| Rate for Payer: Quartz Beloit One Network |
$1,249.99
|
| Rate for Payer: Quartz Commercial |
$1,658.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,530.60
|
| Rate for Payer: The Alliance Commercial |
$10,204.00
|
| Rate for Payer: WEA Trust Commercial |
$1,403.05
|
| Rate for Payer: WPS Commercial |
$1,889.53
|
|
|
ARM CRADLE POSITIONER NON081344
|
Facility
|
IP
|
$303.00
|
|
| Hospital Charge Code |
2965825
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$148.47 |
| Max. Negotiated Rate |
$278.76 |
| Rate for Payer: Aetna Commercial |
$272.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$260.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.59
|
| Rate for Payer: Cash Price |
$90.90
|
| Rate for Payer: Cigna Commercial |
$278.76
|
| Rate for Payer: Health EOS Commercial |
$269.67
|
| Rate for Payer: HFN Commercial |
$278.76
|
| Rate for Payer: Multiplan Commercial |
$242.40
|
| Rate for Payer: NAPHCARE Commercial |
$181.80
|
| Rate for Payer: Preferred Network Access Commercial |
$278.76
|
| Rate for Payer: Quartz Beloit One Network |
$148.47
|
| Rate for Payer: Quartz Commercial |
$181.80
|
| Rate for Payer: WEA Trust Commercial |
$166.65
|
| Rate for Payer: WPS Commercial |
$224.43
|
|
|
ARM CRADLE POSITIONER NON081344
|
Facility
|
OP
|
$303.00
|
|
| Hospital Charge Code |
2965825
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$84.84 |
| Max. Negotiated Rate |
$1,212.00 |
| Rate for Payer: Aetna Commercial |
$272.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$260.58
|
| Rate for Payer: Aetna Managed Medicare |
$84.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$196.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$151.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$145.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.59
|
| Rate for Payer: Cash Price |
$90.90
|
| Rate for Payer: Cigna Commercial |
$278.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$169.56
|
| Rate for Payer: Health EOS Commercial |
$269.67
|
| Rate for Payer: HFN Commercial |
$278.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$227.25
|
| Rate for Payer: Multiplan Commercial |
$242.40
|
| Rate for Payer: NAPHCARE Commercial |
$181.80
|
| Rate for Payer: Preferred Network Access Commercial |
$278.76
|
| Rate for Payer: Quartz Beloit One Network |
$148.47
|
| Rate for Payer: Quartz Commercial |
$196.95
|
| Rate for Payer: Quartz Medicare Advantage |
$181.80
|
| Rate for Payer: The Alliance Commercial |
$1,212.00
|
| Rate for Payer: WEA Trust Commercial |
$166.65
|
| Rate for Payer: WPS Commercial |
$224.43
|
|
|
ARM SLEEVE LATERAL TRACTION AR-1635
|
Facility
|
OP
|
$861.00
|
|
| Hospital Charge Code |
5685637
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$241.08 |
| Max. Negotiated Rate |
$3,444.00 |
| Rate for Payer: Aetna Commercial |
$774.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$740.46
|
| Rate for Payer: Aetna Managed Medicare |
$241.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$559.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$430.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$413.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$456.33
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$792.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$481.82
|
| Rate for Payer: Health EOS Commercial |
$766.29
|
| Rate for Payer: HFN Commercial |
$792.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$645.75
|
| Rate for Payer: Multiplan Commercial |
$688.80
|
| Rate for Payer: NAPHCARE Commercial |
$516.60
|
| Rate for Payer: Preferred Network Access Commercial |
$792.12
|
| Rate for Payer: Quartz Beloit One Network |
$421.89
|
| Rate for Payer: Quartz Commercial |
$559.65
|
| Rate for Payer: Quartz Medicare Advantage |
$516.60
|
| Rate for Payer: The Alliance Commercial |
$3,444.00
|
| Rate for Payer: WEA Trust Commercial |
$473.55
|
| Rate for Payer: WPS Commercial |
$637.74
|
|
|
ARM SLEEVE LATERAL TRACTION AR-1635
|
Facility
|
IP
|
$861.00
|
|
| Hospital Charge Code |
5685637
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$421.89 |
| Max. Negotiated Rate |
$792.12 |
| Rate for Payer: Aetna Commercial |
$774.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$740.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$456.33
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$792.12
|
| Rate for Payer: Health EOS Commercial |
$766.29
|
| Rate for Payer: HFN Commercial |
$792.12
|
| Rate for Payer: Multiplan Commercial |
$688.80
|
| Rate for Payer: NAPHCARE Commercial |
$516.60
|
| Rate for Payer: Preferred Network Access Commercial |
$792.12
|
| Rate for Payer: Quartz Beloit One Network |
$421.89
|
| Rate for Payer: Quartz Commercial |
$516.60
|
| Rate for Payer: WEA Trust Commercial |
$473.55
|
| Rate for Payer: WPS Commercial |
$637.74
|
|
|
ARM SLING LARGE TX990205
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
HCPCS A4565
|
| Hospital Charge Code |
2974223
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$30.52 |
| Max. Negotiated Rate |
$436.00 |
| Rate for Payer: Aetna Commercial |
$98.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Aetna Managed Medicare |
$30.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.77
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$100.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.00
|
| Rate for Payer: Health EOS Commercial |
$97.01
|
| Rate for Payer: HFN Commercial |
$100.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.75
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: NAPHCARE Commercial |
$65.40
|
| Rate for Payer: Preferred Network Access Commercial |
$100.28
|
| Rate for Payer: Quartz Beloit One Network |
$53.41
|
| Rate for Payer: Quartz Commercial |
$70.85
|
| Rate for Payer: Quartz Medicare Advantage |
$65.40
|
| Rate for Payer: The Alliance Commercial |
$436.00
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
|
ARM SLING LARGE TX990205
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
HCPCS A4565
|
| Hospital Charge Code |
2974223
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$53.41 |
| Max. Negotiated Rate |
$100.28 |
| Rate for Payer: Aetna Commercial |
$98.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.77
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$100.28
|
| Rate for Payer: Health EOS Commercial |
$97.01
|
| Rate for Payer: HFN Commercial |
$100.28
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: NAPHCARE Commercial |
$65.40
|
| Rate for Payer: Preferred Network Access Commercial |
$100.28
|
| Rate for Payer: Quartz Beloit One Network |
$53.41
|
| Rate for Payer: Quartz Commercial |
$65.40
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
|
ARM SLING MEDIUM TX990204
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
HCPCS A4565
|
| Hospital Charge Code |
2974222
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$30.52 |
| Max. Negotiated Rate |
$436.00 |
| Rate for Payer: Aetna Commercial |
$98.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Aetna Managed Medicare |
$30.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.77
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$100.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.00
|
| Rate for Payer: Health EOS Commercial |
$97.01
|
| Rate for Payer: HFN Commercial |
$100.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.75
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: NAPHCARE Commercial |
$65.40
|
| Rate for Payer: Preferred Network Access Commercial |
$100.28
|
| Rate for Payer: Quartz Beloit One Network |
$53.41
|
| Rate for Payer: Quartz Commercial |
$70.85
|
| Rate for Payer: Quartz Medicare Advantage |
$65.40
|
| Rate for Payer: The Alliance Commercial |
$436.00
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
|
ARM SLING MEDIUM TX990204
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
HCPCS A4565
|
| Hospital Charge Code |
2974222
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$53.41 |
| Max. Negotiated Rate |
$100.28 |
| Rate for Payer: Aetna Commercial |
$98.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.77
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$100.28
|
| Rate for Payer: Health EOS Commercial |
$97.01
|
| Rate for Payer: HFN Commercial |
$100.28
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: NAPHCARE Commercial |
$65.40
|
| Rate for Payer: Preferred Network Access Commercial |
$100.28
|
| Rate for Payer: Quartz Beloit One Network |
$53.41
|
| Rate for Payer: Quartz Commercial |
$65.40
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
|
ARM SLING SMALL TX990203
|
Facility
|
IP
|
$109.00
|
|
| Hospital Charge Code |
2974221
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$53.41 |
| Max. Negotiated Rate |
$100.28 |
| Rate for Payer: Aetna Commercial |
$98.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.77
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$100.28
|
| Rate for Payer: Health EOS Commercial |
$97.01
|
| Rate for Payer: HFN Commercial |
$100.28
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: NAPHCARE Commercial |
$65.40
|
| Rate for Payer: Preferred Network Access Commercial |
$100.28
|
| Rate for Payer: Quartz Beloit One Network |
$53.41
|
| Rate for Payer: Quartz Commercial |
$65.40
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
|
ARM SLING SMALL TX990203
|
Facility
|
OP
|
$109.00
|
|
| Hospital Charge Code |
2974221
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$30.52 |
| Max. Negotiated Rate |
$436.00 |
| Rate for Payer: Aetna Commercial |
$98.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Aetna Managed Medicare |
$30.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.77
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$100.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.00
|
| Rate for Payer: Health EOS Commercial |
$97.01
|
| Rate for Payer: HFN Commercial |
$100.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.75
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: NAPHCARE Commercial |
$65.40
|
| Rate for Payer: Preferred Network Access Commercial |
$100.28
|
| Rate for Payer: Quartz Beloit One Network |
$53.41
|
| Rate for Payer: Quartz Commercial |
$70.85
|
| Rate for Payer: Quartz Medicare Advantage |
$65.40
|
| Rate for Payer: The Alliance Commercial |
$436.00
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
|
ARM SLING (TX990206) XLARGE
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
HCPCS A4565
|
| Hospital Charge Code |
2974224
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$440.00 |
| Rate for Payer: Aetna Commercial |
$99.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.60
|
| Rate for Payer: Aetna Managed Medicare |
$30.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$55.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.30
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$101.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.56
|
| Rate for Payer: Health EOS Commercial |
$97.90
|
| Rate for Payer: HFN Commercial |
$101.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.50
|
| Rate for Payer: Multiplan Commercial |
$88.00
|
| Rate for Payer: NAPHCARE Commercial |
$66.00
|
| Rate for Payer: Preferred Network Access Commercial |
$101.20
|
| Rate for Payer: Quartz Beloit One Network |
$53.90
|
| Rate for Payer: Quartz Commercial |
$71.50
|
| Rate for Payer: Quartz Medicare Advantage |
$66.00
|
| Rate for Payer: The Alliance Commercial |
$440.00
|
| Rate for Payer: WEA Trust Commercial |
$60.50
|
| Rate for Payer: WPS Commercial |
$81.48
|
|
|
ARM SLING (TX990206) XLARGE
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
HCPCS A4565
|
| Hospital Charge Code |
2974224
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$53.90 |
| Max. Negotiated Rate |
$101.20 |
| Rate for Payer: Aetna Commercial |
$99.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.30
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$101.20
|
| Rate for Payer: Health EOS Commercial |
$97.90
|
| Rate for Payer: HFN Commercial |
$101.20
|
| Rate for Payer: Multiplan Commercial |
$88.00
|
| Rate for Payer: NAPHCARE Commercial |
$66.00
|
| Rate for Payer: Preferred Network Access Commercial |
$101.20
|
| Rate for Payer: Quartz Beloit One Network |
$53.90
|
| Rate for Payer: Quartz Commercial |
$66.00
|
| Rate for Payer: WEA Trust Commercial |
$60.50
|
| Rate for Payer: WPS Commercial |
$81.48
|
|
|
ARM UNIT TRIBUTE #UE-CG
|
Facility
|
OP
|
$5,035.00
|
|
| Hospital Charge Code |
2973640
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,409.80 |
| Max. Negotiated Rate |
$20,140.00 |
| Rate for Payer: Aetna Commercial |
$4,531.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,330.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,409.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,272.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,517.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,416.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,668.55
|
| Rate for Payer: Cash Price |
$1,510.50
|
| Rate for Payer: Cigna Commercial |
$4,632.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,817.59
|
| Rate for Payer: Health EOS Commercial |
$4,481.15
|
| Rate for Payer: HFN Commercial |
$4,632.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,776.25
|
| Rate for Payer: Multiplan Commercial |
$4,028.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,021.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,632.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,467.15
|
| Rate for Payer: Quartz Commercial |
$3,272.75
|
| Rate for Payer: Quartz Medicare Advantage |
$3,021.00
|
| Rate for Payer: The Alliance Commercial |
$20,140.00
|
| Rate for Payer: WEA Trust Commercial |
$2,769.25
|
| Rate for Payer: WPS Commercial |
$3,729.42
|
|
|
ARM UNIT TRIBUTE #UE-CG
|
Facility
|
IP
|
$5,035.00
|
|
| Hospital Charge Code |
2973640
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2,467.15 |
| Max. Negotiated Rate |
$4,632.20 |
| Rate for Payer: Aetna Commercial |
$4,531.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,330.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,668.55
|
| Rate for Payer: Cash Price |
$1,510.50
|
| Rate for Payer: Cigna Commercial |
$4,632.20
|
| Rate for Payer: Health EOS Commercial |
$4,481.15
|
| Rate for Payer: HFN Commercial |
$4,632.20
|
| Rate for Payer: Multiplan Commercial |
$4,028.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,021.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,632.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,467.15
|
| Rate for Payer: Quartz Commercial |
$3,021.00
|
| Rate for Payer: WEA Trust Commercial |
$2,769.25
|
| Rate for Payer: WPS Commercial |
$3,729.42
|
|
|
ARM WRAP MCCONNELL 12401
|
Facility
|
IP
|
$875.00
|
|
|
Service Code
|
HCPCS A6449
|
| Hospital Charge Code |
2965285
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$428.75 |
| Max. Negotiated Rate |
$805.00 |
| Rate for Payer: Aetna Commercial |
$787.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$752.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$463.75
|
| Rate for Payer: Cash Price |
$262.50
|
| Rate for Payer: Cigna Commercial |
$805.00
|
| Rate for Payer: Health EOS Commercial |
$778.75
|
| Rate for Payer: HFN Commercial |
$805.00
|
| Rate for Payer: Multiplan Commercial |
$700.00
|
| Rate for Payer: NAPHCARE Commercial |
$525.00
|
| Rate for Payer: Preferred Network Access Commercial |
$805.00
|
| Rate for Payer: Quartz Beloit One Network |
$428.75
|
| Rate for Payer: Quartz Commercial |
$525.00
|
| Rate for Payer: WEA Trust Commercial |
$481.25
|
| Rate for Payer: WPS Commercial |
$648.11
|
|
|
ARM WRAP MCCONNELL 12401
|
Facility
|
OP
|
$875.00
|
|
|
Service Code
|
HCPCS A6449
|
| Hospital Charge Code |
2965285
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$245.00 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$787.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$752.50
|
| Rate for Payer: Aetna Managed Medicare |
$245.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$568.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$437.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$420.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$463.75
|
| Rate for Payer: Cash Price |
$262.50
|
| Rate for Payer: Cigna Commercial |
$805.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$489.65
|
| Rate for Payer: Health EOS Commercial |
$778.75
|
| Rate for Payer: HFN Commercial |
$805.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$656.25
|
| Rate for Payer: Multiplan Commercial |
$700.00
|
| Rate for Payer: NAPHCARE Commercial |
$525.00
|
| Rate for Payer: Preferred Network Access Commercial |
$805.00
|
| Rate for Payer: Quartz Beloit One Network |
$428.75
|
| Rate for Payer: Quartz Commercial |
$568.75
|
| Rate for Payer: Quartz Medicare Advantage |
$525.00
|
| Rate for Payer: The Alliance Commercial |
$3,500.00
|
| Rate for Payer: WEA Trust Commercial |
$481.25
|
| Rate for Payer: WPS Commercial |
$648.11
|
|
|
Arrow Sure Shot Epidural Ndle
|
Facility
|
OP
|
$120.00
|
|
| Hospital Charge Code |
3101766
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$108.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Aetna Managed Medicare |
$33.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$60.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$57.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.15
|
| Rate for Payer: Health EOS Commercial |
$106.80
|
| Rate for Payer: HFN Commercial |
$110.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: NAPHCARE Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$110.40
|
| Rate for Payer: Quartz Beloit One Network |
$58.80
|
| Rate for Payer: Quartz Commercial |
$78.00
|
| Rate for Payer: Quartz Medicare Advantage |
$72.00
|
| Rate for Payer: The Alliance Commercial |
$480.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
Arrow Sure Shot Epidural Ndle
|
Facility
|
IP
|
$120.00
|
|
| Hospital Charge Code |
3101766
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$108.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Health EOS Commercial |
$106.80
|
| Rate for Payer: HFN Commercial |
$110.40
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: NAPHCARE Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$110.40
|
| Rate for Payer: Quartz Beloit One Network |
$58.80
|
| Rate for Payer: Quartz Commercial |
$72.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
