|
PACKING IODOFORM 1/4 X 5 YRD 7831
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
HCPCS A6266
|
| Hospital Charge Code |
2963725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.94 |
| Max. Negotiated Rate |
$93.77 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$61.15
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
PACKING IODOFORM 1/4 X 5 YRD 7831
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
HCPCS A6266
|
| Hospital Charge Code |
2963725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$93.77 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Aetna Managed Medicare |
$28.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.04
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.44
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: NAPHCARE Commercial |
$61.15
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$66.25
|
| Rate for Payer: Quartz Medicare Advantage |
$61.15
|
| Rate for Payer: The Alliance Commercial |
$11.32
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
PACKING NASAL 5.5cm ANTERIOR #551
|
Facility
|
IP
|
$719.00
|
|
| Hospital Charge Code |
2969617
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$366.40 |
| Max. Negotiated Rate |
$687.94 |
| Rate for Payer: Aetna Commercial |
$672.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.31
|
| Rate for Payer: Cash Price |
$215.70
|
| Rate for Payer: Cigna Commercial |
$687.94
|
| Rate for Payer: Health EOS Commercial |
$665.51
|
| Rate for Payer: HFN Commercial |
$687.94
|
| Rate for Payer: Multiplan Commercial |
$598.21
|
| Rate for Payer: Preferred Network Access Commercial |
$687.94
|
| Rate for Payer: Quartz Beloit One Network |
$366.40
|
| Rate for Payer: Quartz Commercial |
$448.66
|
| Rate for Payer: WEA Trust Commercial |
$411.27
|
| Rate for Payer: WPS Commercial |
$553.85
|
|
|
PACKING NASAL 5.5cm ANTERIOR #551
|
Facility
|
OP
|
$719.00
|
|
| Hospital Charge Code |
2969617
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$209.37 |
| Max. Negotiated Rate |
$687.94 |
| Rate for Payer: Aetna Commercial |
$672.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.07
|
| Rate for Payer: Aetna Managed Medicare |
$209.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$486.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$373.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$358.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.31
|
| Rate for Payer: Cash Price |
$215.70
|
| Rate for Payer: Cigna Commercial |
$687.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$418.46
|
| Rate for Payer: Health EOS Commercial |
$665.51
|
| Rate for Payer: HFN Commercial |
$687.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$560.82
|
| Rate for Payer: Multiplan Commercial |
$598.21
|
| Rate for Payer: NAPHCARE Commercial |
$448.66
|
| Rate for Payer: Preferred Network Access Commercial |
$687.94
|
| Rate for Payer: Quartz Beloit One Network |
$366.40
|
| Rate for Payer: Quartz Commercial |
$486.04
|
| Rate for Payer: Quartz Medicare Advantage |
$448.66
|
| Rate for Payer: The Alliance Commercial |
$373.88
|
| Rate for Payer: WEA Trust Commercial |
$411.27
|
| Rate for Payer: WPS Commercial |
$553.85
|
|
|
PACKING NASAL 5.5 UNILATERAL RR550
|
Facility
|
OP
|
$642.00
|
|
| Hospital Charge Code |
2973425
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$186.95 |
| Max. Negotiated Rate |
$614.27 |
| Rate for Payer: Aetna Commercial |
$600.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.20
|
| Rate for Payer: Aetna Managed Medicare |
$186.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$433.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$333.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$320.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$353.87
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$614.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$373.64
|
| Rate for Payer: Health EOS Commercial |
$594.24
|
| Rate for Payer: HFN Commercial |
$614.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$500.76
|
| Rate for Payer: Multiplan Commercial |
$534.14
|
| Rate for Payer: NAPHCARE Commercial |
$400.61
|
| Rate for Payer: Preferred Network Access Commercial |
$614.27
|
| Rate for Payer: Quartz Beloit One Network |
$327.16
|
| Rate for Payer: Quartz Commercial |
$433.99
|
| Rate for Payer: Quartz Medicare Advantage |
$400.61
|
| Rate for Payer: The Alliance Commercial |
$333.84
|
| Rate for Payer: WEA Trust Commercial |
$367.22
|
| Rate for Payer: WPS Commercial |
$494.53
|
|
|
PACKING NASAL 5.5 UNILATERAL RR550
|
Facility
|
IP
|
$642.00
|
|
| Hospital Charge Code |
2973425
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$327.16 |
| Max. Negotiated Rate |
$614.27 |
| Rate for Payer: Aetna Commercial |
$600.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$574.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$353.87
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$614.27
|
| Rate for Payer: Health EOS Commercial |
$594.24
|
| Rate for Payer: HFN Commercial |
$614.27
|
| Rate for Payer: Multiplan Commercial |
$534.14
|
| Rate for Payer: Preferred Network Access Commercial |
$614.27
|
| Rate for Payer: Quartz Beloit One Network |
$327.16
|
| Rate for Payer: Quartz Commercial |
$400.61
|
| Rate for Payer: WEA Trust Commercial |
$367.22
|
| Rate for Payer: WPS Commercial |
$494.53
|
|
|
PACKING NASAL RAPID RHINO RR 751
|
Facility
|
OP
|
$719.00
|
|
| Hospital Charge Code |
2964722
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$209.37 |
| Max. Negotiated Rate |
$687.94 |
| Rate for Payer: Aetna Commercial |
$672.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.07
|
| Rate for Payer: Aetna Managed Medicare |
$209.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$486.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$373.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$358.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.31
|
| Rate for Payer: Cash Price |
$215.70
|
| Rate for Payer: Cigna Commercial |
$687.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$418.46
|
| Rate for Payer: Health EOS Commercial |
$665.51
|
| Rate for Payer: HFN Commercial |
$687.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$560.82
|
| Rate for Payer: Multiplan Commercial |
$598.21
|
| Rate for Payer: NAPHCARE Commercial |
$448.66
|
| Rate for Payer: Preferred Network Access Commercial |
$687.94
|
| Rate for Payer: Quartz Beloit One Network |
$366.40
|
| Rate for Payer: Quartz Commercial |
$486.04
|
| Rate for Payer: Quartz Medicare Advantage |
$448.66
|
| Rate for Payer: The Alliance Commercial |
$373.88
|
| Rate for Payer: WEA Trust Commercial |
$411.27
|
| Rate for Payer: WPS Commercial |
$553.85
|
|
|
PACKING NASAL RAPID RHINO RR 751
|
Facility
|
IP
|
$719.00
|
|
| Hospital Charge Code |
2964722
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$366.40 |
| Max. Negotiated Rate |
$687.94 |
| Rate for Payer: Aetna Commercial |
$672.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.31
|
| Rate for Payer: Cash Price |
$215.70
|
| Rate for Payer: Cigna Commercial |
$687.94
|
| Rate for Payer: Health EOS Commercial |
$665.51
|
| Rate for Payer: HFN Commercial |
$687.94
|
| Rate for Payer: Multiplan Commercial |
$598.21
|
| Rate for Payer: Preferred Network Access Commercial |
$687.94
|
| Rate for Payer: Quartz Beloit One Network |
$366.40
|
| Rate for Payer: Quartz Commercial |
$448.66
|
| Rate for Payer: WEA Trust Commercial |
$411.27
|
| Rate for Payer: WPS Commercial |
$553.85
|
|
|
PACKING PLAIN 1
|
Facility
|
OP
|
$97.00
|
|
| Hospital Charge Code |
2968999
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$28.25 |
| Max. Negotiated Rate |
$92.81 |
| Rate for Payer: Aetna Commercial |
$90.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.76
|
| Rate for Payer: Aetna Managed Medicare |
$28.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$65.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.47
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cigna Commercial |
$92.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$56.45
|
| Rate for Payer: Health EOS Commercial |
$89.78
|
| Rate for Payer: HFN Commercial |
$92.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$75.66
|
| Rate for Payer: Multiplan Commercial |
$80.70
|
| Rate for Payer: NAPHCARE Commercial |
$60.53
|
| Rate for Payer: Preferred Network Access Commercial |
$92.81
|
| Rate for Payer: Quartz Beloit One Network |
$49.43
|
| Rate for Payer: Quartz Commercial |
$65.57
|
| Rate for Payer: Quartz Medicare Advantage |
$60.53
|
| Rate for Payer: The Alliance Commercial |
$50.44
|
| Rate for Payer: WEA Trust Commercial |
$55.48
|
| Rate for Payer: WPS Commercial |
$74.72
|
|
|
PACKING PLAIN 1
|
Facility
|
IP
|
$97.00
|
|
| Hospital Charge Code |
2968999
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.43 |
| Max. Negotiated Rate |
$92.81 |
| Rate for Payer: Aetna Commercial |
$90.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.47
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Cigna Commercial |
$92.81
|
| Rate for Payer: Health EOS Commercial |
$89.78
|
| Rate for Payer: HFN Commercial |
$92.81
|
| Rate for Payer: Multiplan Commercial |
$80.70
|
| Rate for Payer: Preferred Network Access Commercial |
$92.81
|
| Rate for Payer: Quartz Beloit One Network |
$49.43
|
| Rate for Payer: Quartz Commercial |
$60.53
|
| Rate for Payer: WEA Trust Commercial |
$55.48
|
| Rate for Payer: WPS Commercial |
$74.72
|
|
|
PACKING PLAIN 1/2 X 5
|
Facility
|
OP
|
$88.00
|
|
| Hospital Charge Code |
2964057
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.63 |
| Max. Negotiated Rate |
$84.20 |
| Rate for Payer: Aetna Commercial |
$82.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$78.71
|
| Rate for Payer: Aetna Managed Medicare |
$25.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.51
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$84.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.22
|
| Rate for Payer: Health EOS Commercial |
$81.45
|
| Rate for Payer: HFN Commercial |
$84.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.64
|
| Rate for Payer: Multiplan Commercial |
$73.22
|
| Rate for Payer: NAPHCARE Commercial |
$54.91
|
| Rate for Payer: Preferred Network Access Commercial |
$84.20
|
| Rate for Payer: Quartz Beloit One Network |
$44.84
|
| Rate for Payer: Quartz Commercial |
$59.49
|
| Rate for Payer: Quartz Medicare Advantage |
$54.91
|
| Rate for Payer: The Alliance Commercial |
$45.76
|
| Rate for Payer: WEA Trust Commercial |
$50.34
|
| Rate for Payer: WPS Commercial |
$67.79
|
|
|
PACKING PLAIN 1/2 X 5
|
Facility
|
IP
|
$88.00
|
|
| Hospital Charge Code |
2964057
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$44.84 |
| Max. Negotiated Rate |
$84.20 |
| Rate for Payer: Aetna Commercial |
$82.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$78.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.51
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$84.20
|
| Rate for Payer: Health EOS Commercial |
$81.45
|
| Rate for Payer: HFN Commercial |
$84.20
|
| Rate for Payer: Multiplan Commercial |
$73.22
|
| Rate for Payer: Preferred Network Access Commercial |
$84.20
|
| Rate for Payer: Quartz Beloit One Network |
$44.84
|
| Rate for Payer: Quartz Commercial |
$54.91
|
| Rate for Payer: WEA Trust Commercial |
$50.34
|
| Rate for Payer: WPS Commercial |
$67.79
|
|
|
PACKING PLAIN 1/4
|
Facility
|
IP
|
$86.00
|
|
| Hospital Charge Code |
2969446
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.83 |
| Max. Negotiated Rate |
$82.28 |
| Rate for Payer: Aetna Commercial |
$80.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.40
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$82.28
|
| Rate for Payer: Health EOS Commercial |
$79.60
|
| Rate for Payer: HFN Commercial |
$82.28
|
| Rate for Payer: Multiplan Commercial |
$71.55
|
| Rate for Payer: Preferred Network Access Commercial |
$82.28
|
| Rate for Payer: Quartz Beloit One Network |
$43.83
|
| Rate for Payer: Quartz Commercial |
$53.66
|
| Rate for Payer: WEA Trust Commercial |
$49.19
|
| Rate for Payer: WPS Commercial |
$66.25
|
|
|
PACKING PLAIN 1/4
|
Facility
|
OP
|
$86.00
|
|
| Hospital Charge Code |
2969446
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.04 |
| Max. Negotiated Rate |
$82.28 |
| Rate for Payer: Aetna Commercial |
$80.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.92
|
| Rate for Payer: Aetna Managed Medicare |
$25.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.40
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$82.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.05
|
| Rate for Payer: Health EOS Commercial |
$79.60
|
| Rate for Payer: HFN Commercial |
$82.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.08
|
| Rate for Payer: Multiplan Commercial |
$71.55
|
| Rate for Payer: NAPHCARE Commercial |
$53.66
|
| Rate for Payer: Preferred Network Access Commercial |
$82.28
|
| Rate for Payer: Quartz Beloit One Network |
$43.83
|
| Rate for Payer: Quartz Commercial |
$58.14
|
| Rate for Payer: Quartz Medicare Advantage |
$53.66
|
| Rate for Payer: The Alliance Commercial |
$44.72
|
| Rate for Payer: WEA Trust Commercial |
$49.19
|
| Rate for Payer: WPS Commercial |
$66.25
|
|
|
PACKING STRIPS 1/2 CURITY AMD
|
Facility
|
IP
|
$101.00
|
|
| Hospital Charge Code |
2969225
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.47 |
| Max. Negotiated Rate |
$96.64 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.67
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$96.64
|
| Rate for Payer: Health EOS Commercial |
$93.49
|
| Rate for Payer: HFN Commercial |
$96.64
|
| Rate for Payer: Multiplan Commercial |
$84.03
|
| Rate for Payer: Preferred Network Access Commercial |
$96.64
|
| Rate for Payer: Quartz Beloit One Network |
$51.47
|
| Rate for Payer: Quartz Commercial |
$63.02
|
| Rate for Payer: WEA Trust Commercial |
$57.77
|
| Rate for Payer: WPS Commercial |
$77.80
|
|
|
PACKING STRIPS 1/2 CURITY AMD
|
Facility
|
OP
|
$101.00
|
|
| Hospital Charge Code |
2969225
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$29.41 |
| Max. Negotiated Rate |
$96.64 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.33
|
| Rate for Payer: Aetna Managed Medicare |
$29.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.67
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$96.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.78
|
| Rate for Payer: Health EOS Commercial |
$93.49
|
| Rate for Payer: HFN Commercial |
$96.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.78
|
| Rate for Payer: Multiplan Commercial |
$84.03
|
| Rate for Payer: NAPHCARE Commercial |
$63.02
|
| Rate for Payer: Preferred Network Access Commercial |
$96.64
|
| Rate for Payer: Quartz Beloit One Network |
$51.47
|
| Rate for Payer: Quartz Commercial |
$68.28
|
| Rate for Payer: Quartz Medicare Advantage |
$63.02
|
| Rate for Payer: The Alliance Commercial |
$52.52
|
| Rate for Payer: WEA Trust Commercial |
$57.77
|
| Rate for Payer: WPS Commercial |
$77.80
|
|
|
PACKING STRIPS 1/4 X 1YRD AMD
|
Facility
|
OP
|
$105.00
|
|
| Hospital Charge Code |
2963595
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.58 |
| Max. Negotiated Rate |
$100.46 |
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Aetna Managed Medicare |
$30.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.88
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$100.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.11
|
| Rate for Payer: Health EOS Commercial |
$97.19
|
| Rate for Payer: HFN Commercial |
$100.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.90
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: NAPHCARE Commercial |
$65.52
|
| Rate for Payer: Preferred Network Access Commercial |
$100.46
|
| Rate for Payer: Quartz Beloit One Network |
$53.51
|
| Rate for Payer: Quartz Commercial |
$70.98
|
| Rate for Payer: Quartz Medicare Advantage |
$65.52
|
| Rate for Payer: The Alliance Commercial |
$54.60
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$80.88
|
|
|
PACKING STRIPS 1/4 X 1YRD AMD
|
Facility
|
IP
|
$105.00
|
|
| Hospital Charge Code |
2963595
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.51 |
| Max. Negotiated Rate |
$100.46 |
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.88
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$100.46
|
| Rate for Payer: Health EOS Commercial |
$97.19
|
| Rate for Payer: HFN Commercial |
$100.46
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: Preferred Network Access Commercial |
$100.46
|
| Rate for Payer: Quartz Beloit One Network |
$53.51
|
| Rate for Payer: Quartz Commercial |
$65.52
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$80.88
|
|
|
Packing strips charge
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
2844922
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$65.74 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$80.50
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
Packing strips charge
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
2844922
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Aetna Managed Medicare |
$37.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$87.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$67.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.08
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.62
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: NAPHCARE Commercial |
$80.50
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$87.20
|
| Rate for Payer: Quartz Medicare Advantage |
$80.50
|
| Rate for Payer: The Alliance Commercial |
$67.08
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
PACK LAPAROSCOPY w/GOWN 88222
|
Facility
|
OP
|
$532.00
|
|
| Hospital Charge Code |
2963186
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$154.92 |
| Max. Negotiated Rate |
$509.02 |
| Rate for Payer: Aetna Commercial |
$497.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.82
|
| Rate for Payer: Aetna Managed Medicare |
$154.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$359.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$276.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$265.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.24
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$509.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$309.62
|
| Rate for Payer: Health EOS Commercial |
$492.42
|
| Rate for Payer: HFN Commercial |
$509.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$414.96
|
| Rate for Payer: Multiplan Commercial |
$442.62
|
| Rate for Payer: NAPHCARE Commercial |
$331.97
|
| Rate for Payer: Preferred Network Access Commercial |
$509.02
|
| Rate for Payer: Quartz Beloit One Network |
$271.11
|
| Rate for Payer: Quartz Commercial |
$359.63
|
| Rate for Payer: Quartz Medicare Advantage |
$331.97
|
| Rate for Payer: The Alliance Commercial |
$276.64
|
| Rate for Payer: WEA Trust Commercial |
$304.30
|
| Rate for Payer: WPS Commercial |
$409.80
|
|
|
PACK LAPAROSCOPY w/GOWN 88222
|
Facility
|
IP
|
$532.00
|
|
| Hospital Charge Code |
2963186
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$271.11 |
| Max. Negotiated Rate |
$509.02 |
| Rate for Payer: Aetna Commercial |
$497.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.24
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$509.02
|
| Rate for Payer: Health EOS Commercial |
$492.42
|
| Rate for Payer: HFN Commercial |
$509.02
|
| Rate for Payer: Multiplan Commercial |
$442.62
|
| Rate for Payer: Preferred Network Access Commercial |
$509.02
|
| Rate for Payer: Quartz Beloit One Network |
$271.11
|
| Rate for Payer: Quartz Commercial |
$331.97
|
| Rate for Payer: WEA Trust Commercial |
$304.30
|
| Rate for Payer: WPS Commercial |
$409.80
|
|
|
PACK LINE INSERTION BARRIER
|
Facility
|
IP
|
$431.00
|
|
| Hospital Charge Code |
2962938
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$219.64 |
| Max. Negotiated Rate |
$412.38 |
| Rate for Payer: Aetna Commercial |
$403.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$385.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$237.57
|
| Rate for Payer: Cash Price |
$129.30
|
| Rate for Payer: Cigna Commercial |
$412.38
|
| Rate for Payer: Health EOS Commercial |
$398.93
|
| Rate for Payer: HFN Commercial |
$412.38
|
| Rate for Payer: Multiplan Commercial |
$358.59
|
| Rate for Payer: Preferred Network Access Commercial |
$412.38
|
| Rate for Payer: Quartz Beloit One Network |
$219.64
|
| Rate for Payer: Quartz Commercial |
$268.94
|
| Rate for Payer: WEA Trust Commercial |
$246.53
|
| Rate for Payer: WPS Commercial |
$332.00
|
|
|
PACK LINE INSERTION BARRIER
|
Facility
|
OP
|
$431.00
|
|
| Hospital Charge Code |
2962938
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$125.51 |
| Max. Negotiated Rate |
$412.38 |
| Rate for Payer: Aetna Commercial |
$403.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$385.49
|
| Rate for Payer: Aetna Managed Medicare |
$125.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$291.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$224.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$215.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$237.57
|
| Rate for Payer: Cash Price |
$129.30
|
| Rate for Payer: Cigna Commercial |
$412.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.84
|
| Rate for Payer: Health EOS Commercial |
$398.93
|
| Rate for Payer: HFN Commercial |
$412.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$336.18
|
| Rate for Payer: Multiplan Commercial |
$358.59
|
| Rate for Payer: NAPHCARE Commercial |
$268.94
|
| Rate for Payer: Preferred Network Access Commercial |
$412.38
|
| Rate for Payer: Quartz Beloit One Network |
$219.64
|
| Rate for Payer: Quartz Commercial |
$291.36
|
| Rate for Payer: Quartz Medicare Advantage |
$268.94
|
| Rate for Payer: The Alliance Commercial |
$224.12
|
| Rate for Payer: WEA Trust Commercial |
$246.53
|
| Rate for Payer: WPS Commercial |
$332.00
|
|
|
PACK LITHOTOMY PERI-GYNE IV 88541
|
Facility
|
OP
|
$246.00
|
|
| Hospital Charge Code |
2962813
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.64 |
| Max. Negotiated Rate |
$235.37 |
| Rate for Payer: Aetna Commercial |
$230.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$220.02
|
| Rate for Payer: Aetna Managed Medicare |
$71.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$166.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$127.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$122.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.60
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$235.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$143.17
|
| Rate for Payer: Health EOS Commercial |
$227.70
|
| Rate for Payer: HFN Commercial |
$235.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$191.88
|
| Rate for Payer: Multiplan Commercial |
$204.67
|
| Rate for Payer: NAPHCARE Commercial |
$153.50
|
| Rate for Payer: Preferred Network Access Commercial |
$235.37
|
| Rate for Payer: Quartz Beloit One Network |
$125.36
|
| Rate for Payer: Quartz Commercial |
$166.30
|
| Rate for Payer: Quartz Medicare Advantage |
$153.50
|
| Rate for Payer: The Alliance Commercial |
$127.92
|
| Rate for Payer: WEA Trust Commercial |
$140.71
|
| Rate for Payer: WPS Commercial |
$189.49
|
|
