|
Pillcam Patency 91299-91110
|
Professional
|
Both
|
$1,948.00
|
|
|
Service Code
|
CPT 91299
|
| Hospital Charge Code |
4846612
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$857.12 |
| Max. Negotiated Rate |
$1,850.60 |
| Rate for Payer: Aetna Commercial |
$1,850.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,675.28
|
| Rate for Payer: Cash Price |
$584.40
|
| Rate for Payer: Cigna Commercial |
$1,850.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$974.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,168.80
|
| Rate for Payer: Health EOS Commercial |
$1,772.68
|
| Rate for Payer: HFN Commercial |
$1,850.60
|
| Rate for Payer: Multiplan Commercial |
$1,558.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,850.60
|
| Rate for Payer: Quartz Beloit One Network |
$857.12
|
| Rate for Payer: Quartz Commercial |
$1,110.36
|
| Rate for Payer: The Alliance Commercial |
$974.00
|
| Rate for Payer: WEA Trust Commercial |
$1,071.40
|
| Rate for Payer: WPS Commercial |
$1,442.88
|
|
|
PILLOW ABDUCTION M60-024-M Yellow
|
Facility
|
OP
|
$668.00
|
|
| Hospital Charge Code |
2963051
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$187.04 |
| Max. Negotiated Rate |
$2,672.00 |
| Rate for Payer: Aetna Commercial |
$601.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.48
|
| Rate for Payer: Aetna Managed Medicare |
$187.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$434.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$334.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$320.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.04
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$614.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$373.81
|
| Rate for Payer: Health EOS Commercial |
$594.52
|
| Rate for Payer: HFN Commercial |
$614.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$501.00
|
| Rate for Payer: Multiplan Commercial |
$534.40
|
| Rate for Payer: NAPHCARE Commercial |
$400.80
|
| Rate for Payer: Preferred Network Access Commercial |
$614.56
|
| Rate for Payer: Quartz Beloit One Network |
$327.32
|
| Rate for Payer: Quartz Commercial |
$434.20
|
| Rate for Payer: Quartz Medicare Advantage |
$400.80
|
| Rate for Payer: The Alliance Commercial |
$2,672.00
|
| Rate for Payer: WEA Trust Commercial |
$367.40
|
| Rate for Payer: WPS Commercial |
$494.79
|
|
|
PILLOW ABDUCTION M60-024-M Yellow
|
Facility
|
IP
|
$668.00
|
|
| Hospital Charge Code |
2963051
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$327.32 |
| Max. Negotiated Rate |
$614.56 |
| Rate for Payer: Aetna Commercial |
$601.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.04
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cigna Commercial |
$614.56
|
| Rate for Payer: Health EOS Commercial |
$594.52
|
| Rate for Payer: HFN Commercial |
$614.56
|
| Rate for Payer: Multiplan Commercial |
$534.40
|
| Rate for Payer: NAPHCARE Commercial |
$400.80
|
| Rate for Payer: Preferred Network Access Commercial |
$614.56
|
| Rate for Payer: Quartz Beloit One Network |
$327.32
|
| Rate for Payer: Quartz Commercial |
$400.80
|
| Rate for Payer: WEA Trust Commercial |
$367.40
|
| Rate for Payer: WPS Commercial |
$494.79
|
|
|
Pilocarpine 4% Ophth Solution 15ml [Med]
|
Facility
|
IP
|
$334.00
|
|
| Hospital Charge Code |
2974971
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$163.66 |
| Max. Negotiated Rate |
$307.28 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$200.40
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
Pilocarpine 4% Ophth Solution 15ml [Med]
|
Facility
|
OP
|
$334.00
|
|
| Hospital Charge Code |
2974971
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$93.52 |
| Max. Negotiated Rate |
$1,336.00 |
| Rate for Payer: Aetna Commercial |
$300.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.24
|
| Rate for Payer: Aetna Managed Medicare |
$93.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$167.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.02
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cigna Commercial |
$307.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.91
|
| Rate for Payer: Health EOS Commercial |
$297.26
|
| Rate for Payer: HFN Commercial |
$307.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.50
|
| Rate for Payer: Multiplan Commercial |
$267.20
|
| Rate for Payer: NAPHCARE Commercial |
$200.40
|
| Rate for Payer: Preferred Network Access Commercial |
$307.28
|
| Rate for Payer: Quartz Beloit One Network |
$163.66
|
| Rate for Payer: Quartz Commercial |
$217.10
|
| Rate for Payer: Quartz Medicare Advantage |
$200.40
|
| Rate for Payer: The Alliance Commercial |
$1,336.00
|
| Rate for Payer: WEA Trust Commercial |
$183.70
|
| Rate for Payer: WPS Commercial |
$247.39
|
|
|
PILONIDAL CYSTECTOMY
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960316
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
PILONIDAL CYSTECTOMY
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960316
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
PIN BALL JURGAN .035 W035-DB
|
Facility
|
OP
|
$74.00
|
|
| Hospital Charge Code |
2965215
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.72 |
| Max. Negotiated Rate |
$296.00 |
| Rate for Payer: Aetna Commercial |
$66.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$63.64
|
| Rate for Payer: Aetna Managed Medicare |
$20.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.22
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$68.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.41
|
| Rate for Payer: Health EOS Commercial |
$65.86
|
| Rate for Payer: HFN Commercial |
$68.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.50
|
| Rate for Payer: Multiplan Commercial |
$59.20
|
| Rate for Payer: NAPHCARE Commercial |
$44.40
|
| Rate for Payer: Preferred Network Access Commercial |
$68.08
|
| Rate for Payer: Quartz Beloit One Network |
$36.26
|
| Rate for Payer: Quartz Commercial |
$48.10
|
| Rate for Payer: Quartz Medicare Advantage |
$44.40
|
| Rate for Payer: The Alliance Commercial |
$296.00
|
| Rate for Payer: WEA Trust Commercial |
$40.70
|
| Rate for Payer: WPS Commercial |
$54.81
|
|
|
PIN BALL JURGAN .035 W035-DB
|
Facility
|
IP
|
$74.00
|
|
| Hospital Charge Code |
2965215
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$36.26 |
| Max. Negotiated Rate |
$68.08 |
| Rate for Payer: Aetna Commercial |
$66.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$63.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.22
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$68.08
|
| Rate for Payer: Health EOS Commercial |
$65.86
|
| Rate for Payer: HFN Commercial |
$68.08
|
| Rate for Payer: Multiplan Commercial |
$59.20
|
| Rate for Payer: NAPHCARE Commercial |
$44.40
|
| Rate for Payer: Preferred Network Access Commercial |
$68.08
|
| Rate for Payer: Quartz Beloit One Network |
$36.26
|
| Rate for Payer: Quartz Commercial |
$44.40
|
| Rate for Payer: WEA Trust Commercial |
$40.70
|
| Rate for Payer: WPS Commercial |
$54.81
|
|
|
PIN BALL JURGAN .045 W045-YL
|
Facility
|
IP
|
$74.00
|
|
| Hospital Charge Code |
2965216
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$36.26 |
| Max. Negotiated Rate |
$68.08 |
| Rate for Payer: Aetna Commercial |
$66.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$63.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.22
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$68.08
|
| Rate for Payer: Health EOS Commercial |
$65.86
|
| Rate for Payer: HFN Commercial |
$68.08
|
| Rate for Payer: Multiplan Commercial |
$59.20
|
| Rate for Payer: NAPHCARE Commercial |
$44.40
|
| Rate for Payer: Preferred Network Access Commercial |
$68.08
|
| Rate for Payer: Quartz Beloit One Network |
$36.26
|
| Rate for Payer: Quartz Commercial |
$44.40
|
| Rate for Payer: WEA Trust Commercial |
$40.70
|
| Rate for Payer: WPS Commercial |
$54.81
|
|
|
PIN BALL JURGAN .045 W045-YL
|
Facility
|
OP
|
$74.00
|
|
| Hospital Charge Code |
2965216
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.72 |
| Max. Negotiated Rate |
$296.00 |
| Rate for Payer: Aetna Commercial |
$66.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$63.64
|
| Rate for Payer: Aetna Managed Medicare |
$20.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.22
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$68.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.41
|
| Rate for Payer: Health EOS Commercial |
$65.86
|
| Rate for Payer: HFN Commercial |
$68.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.50
|
| Rate for Payer: Multiplan Commercial |
$59.20
|
| Rate for Payer: NAPHCARE Commercial |
$44.40
|
| Rate for Payer: Preferred Network Access Commercial |
$68.08
|
| Rate for Payer: Quartz Beloit One Network |
$36.26
|
| Rate for Payer: Quartz Commercial |
$48.10
|
| Rate for Payer: Quartz Medicare Advantage |
$44.40
|
| Rate for Payer: The Alliance Commercial |
$296.00
|
| Rate for Payer: WEA Trust Commercial |
$40.70
|
| Rate for Payer: WPS Commercial |
$54.81
|
|
|
PIN BALL JURGAN .062 W062-GN
|
Facility
|
OP
|
$74.00
|
|
| Hospital Charge Code |
2965217
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.72 |
| Max. Negotiated Rate |
$296.00 |
| Rate for Payer: Aetna Commercial |
$66.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$63.64
|
| Rate for Payer: Aetna Managed Medicare |
$20.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.22
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$68.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.41
|
| Rate for Payer: Health EOS Commercial |
$65.86
|
| Rate for Payer: HFN Commercial |
$68.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.50
|
| Rate for Payer: Multiplan Commercial |
$59.20
|
| Rate for Payer: NAPHCARE Commercial |
$44.40
|
| Rate for Payer: Preferred Network Access Commercial |
$68.08
|
| Rate for Payer: Quartz Beloit One Network |
$36.26
|
| Rate for Payer: Quartz Commercial |
$48.10
|
| Rate for Payer: Quartz Medicare Advantage |
$44.40
|
| Rate for Payer: The Alliance Commercial |
$296.00
|
| Rate for Payer: WEA Trust Commercial |
$40.70
|
| Rate for Payer: WPS Commercial |
$54.81
|
|
|
PIN BALL JURGAN .062 W062-GN
|
Facility
|
IP
|
$74.00
|
|
| Hospital Charge Code |
2965217
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$36.26 |
| Max. Negotiated Rate |
$68.08 |
| Rate for Payer: Aetna Commercial |
$66.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$63.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.22
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cigna Commercial |
$68.08
|
| Rate for Payer: Health EOS Commercial |
$65.86
|
| Rate for Payer: HFN Commercial |
$68.08
|
| Rate for Payer: Multiplan Commercial |
$59.20
|
| Rate for Payer: NAPHCARE Commercial |
$44.40
|
| Rate for Payer: Preferred Network Access Commercial |
$68.08
|
| Rate for Payer: Quartz Beloit One Network |
$36.26
|
| Rate for Payer: Quartz Commercial |
$44.40
|
| Rate for Payer: WEA Trust Commercial |
$40.70
|
| Rate for Payer: WPS Commercial |
$54.81
|
|
|
PIN BALL JURGAN 3/32 W332-CR
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2965218
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
PIN BALL JURGAN 3/32 W332-CR
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
2965218
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.17
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$42.00
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
PIN BALL X-SERIES 3MM X003
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2965219
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
PIN BALL X-SERIES 3MM X003
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
2965219
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.17
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$42.00
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
PIN BALL X-SERIES 4MM X004
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2965220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
PIN BALL X-SERIES 4MM X004
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
2965220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.17
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$42.00
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
PIN BALL X-SERIES 5MM X005
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2965222
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
PIN BALL X-SERIES 5MM X005
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
2965222
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.17
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$42.00
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
PIN BALL X-SERIES 6MM X006
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2965223
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
PIN BALL X-SERIES 6MM X006
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
2965223
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.17
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$42.00
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
PIN BAYONETTE 18 WITH EYELET 219382"
|
Facility
|
IP
|
$3,005.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2973126
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,472.45 |
| Max. Negotiated Rate |
$2,764.60 |
| Rate for Payer: Aetna Commercial |
$2,704.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,584.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,592.65
|
| Rate for Payer: Cash Price |
$901.50
|
| Rate for Payer: Cigna Commercial |
$2,764.60
|
| Rate for Payer: Health EOS Commercial |
$2,674.45
|
| Rate for Payer: HFN Commercial |
$2,764.60
|
| Rate for Payer: Multiplan Commercial |
$2,404.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,803.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,764.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,472.45
|
| Rate for Payer: Quartz Commercial |
$1,803.00
|
| Rate for Payer: WEA Trust Commercial |
$1,652.75
|
| Rate for Payer: WPS Commercial |
$2,225.80
|
|
|
PIN BAYONETTE 18 WITH EYELET 219382"
|
Facility
|
OP
|
$3,005.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2973126
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$841.40 |
| Max. Negotiated Rate |
$12,020.00 |
| Rate for Payer: Aetna Commercial |
$2,704.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,584.30
|
| Rate for Payer: Aetna Managed Medicare |
$841.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,953.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,502.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,442.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,592.65
|
| Rate for Payer: Cash Price |
$901.50
|
| Rate for Payer: Cigna Commercial |
$2,764.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,681.60
|
| Rate for Payer: Health EOS Commercial |
$2,674.45
|
| Rate for Payer: HFN Commercial |
$2,764.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,253.75
|
| Rate for Payer: Multiplan Commercial |
$2,404.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,803.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,764.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,472.45
|
| Rate for Payer: Quartz Commercial |
$1,953.25
|
| Rate for Payer: Quartz Medicare Advantage |
$1,803.00
|
| Rate for Payer: The Alliance Commercial |
$12,020.00
|
| Rate for Payer: WEA Trust Commercial |
$1,652.75
|
| Rate for Payer: WPS Commercial |
$2,225.80
|
|
