|
PACK CARDIOPLEGIA 027770201
|
Facility
|
OP
|
$1,691.00
|
|
| Hospital Charge Code |
2962886
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$492.42 |
| Max. Negotiated Rate |
$1,617.95 |
| Rate for Payer: Aetna Commercial |
$1,582.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,512.43
|
| Rate for Payer: Aetna Managed Medicare |
$492.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,143.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$879.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$844.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$932.08
|
| Rate for Payer: Cash Price |
$507.30
|
| Rate for Payer: Cigna Commercial |
$1,617.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$984.16
|
| Rate for Payer: Health EOS Commercial |
$1,565.19
|
| Rate for Payer: HFN Commercial |
$1,617.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,318.98
|
| Rate for Payer: Multiplan Commercial |
$1,406.91
|
| Rate for Payer: NAPHCARE Commercial |
$1,055.18
|
| Rate for Payer: Preferred Network Access Commercial |
$1,617.95
|
| Rate for Payer: Quartz Beloit One Network |
$861.73
|
| Rate for Payer: Quartz Commercial |
$1,143.12
|
| Rate for Payer: Quartz Medicare Advantage |
$1,055.18
|
| Rate for Payer: The Alliance Commercial |
$879.32
|
| Rate for Payer: WEA Trust Commercial |
$967.25
|
| Rate for Payer: WPS Commercial |
$1,302.58
|
|
|
PACK CATARACT BASIC AS10572
|
Facility
|
OP
|
$4,344.00
|
|
| Hospital Charge Code |
2962933
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,264.97 |
| Max. Negotiated Rate |
$4,156.34 |
| Rate for Payer: Aetna Commercial |
$4,065.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,885.27
|
| Rate for Payer: Aetna Managed Medicare |
$1,264.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,936.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,258.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,168.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,394.41
|
| Rate for Payer: Cash Price |
$1,303.20
|
| Rate for Payer: Cigna Commercial |
$4,156.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,528.21
|
| Rate for Payer: Health EOS Commercial |
$4,020.81
|
| Rate for Payer: HFN Commercial |
$4,156.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,388.32
|
| Rate for Payer: Multiplan Commercial |
$3,614.21
|
| Rate for Payer: NAPHCARE Commercial |
$2,710.66
|
| Rate for Payer: Preferred Network Access Commercial |
$4,156.34
|
| Rate for Payer: Quartz Beloit One Network |
$2,213.70
|
| Rate for Payer: Quartz Commercial |
$2,936.54
|
| Rate for Payer: Quartz Medicare Advantage |
$2,710.66
|
| Rate for Payer: The Alliance Commercial |
$2,258.88
|
| Rate for Payer: WEA Trust Commercial |
$2,484.77
|
| Rate for Payer: WPS Commercial |
$3,346.18
|
|
|
PACK CATARACT BASIC AS10572
|
Facility
|
IP
|
$4,344.00
|
|
| Hospital Charge Code |
2962933
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,213.70 |
| Max. Negotiated Rate |
$4,156.34 |
| Rate for Payer: Aetna Commercial |
$4,065.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,885.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,394.41
|
| Rate for Payer: Cash Price |
$1,303.20
|
| Rate for Payer: Cigna Commercial |
$4,156.34
|
| Rate for Payer: Health EOS Commercial |
$4,020.81
|
| Rate for Payer: HFN Commercial |
$4,156.34
|
| Rate for Payer: Multiplan Commercial |
$3,614.21
|
| Rate for Payer: Preferred Network Access Commercial |
$4,156.34
|
| Rate for Payer: Quartz Beloit One Network |
$2,213.70
|
| Rate for Payer: Quartz Commercial |
$2,710.66
|
| Rate for Payer: WEA Trust Commercial |
$2,484.77
|
| Rate for Payer: WPS Commercial |
$3,346.18
|
|
|
PACK CATARACT FRIEDRICHS AS18176
|
Facility
|
OP
|
$3,969.00
|
|
| Hospital Charge Code |
5459618
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,155.77 |
| Max. Negotiated Rate |
$3,797.54 |
| Rate for Payer: Aetna Commercial |
$3,714.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,549.87
|
| Rate for Payer: Aetna Managed Medicare |
$1,155.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,683.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,063.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,981.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,187.71
|
| Rate for Payer: Cash Price |
$1,190.70
|
| Rate for Payer: Cigna Commercial |
$3,797.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,309.96
|
| Rate for Payer: Health EOS Commercial |
$3,673.71
|
| Rate for Payer: HFN Commercial |
$3,797.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,095.82
|
| Rate for Payer: Multiplan Commercial |
$3,302.21
|
| Rate for Payer: NAPHCARE Commercial |
$2,476.66
|
| Rate for Payer: Preferred Network Access Commercial |
$3,797.54
|
| Rate for Payer: Quartz Beloit One Network |
$2,022.60
|
| Rate for Payer: Quartz Commercial |
$2,683.04
|
| Rate for Payer: Quartz Medicare Advantage |
$2,476.66
|
| Rate for Payer: The Alliance Commercial |
$2,063.88
|
| Rate for Payer: WEA Trust Commercial |
$2,270.27
|
| Rate for Payer: WPS Commercial |
$3,057.32
|
|
|
PACK CATARACT FRIEDRICHS AS18176
|
Facility
|
IP
|
$3,969.00
|
|
| Hospital Charge Code |
5459618
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,022.60 |
| Max. Negotiated Rate |
$3,797.54 |
| Rate for Payer: Aetna Commercial |
$3,714.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,549.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,187.71
|
| Rate for Payer: Cash Price |
$1,190.70
|
| Rate for Payer: Cigna Commercial |
$3,797.54
|
| Rate for Payer: Health EOS Commercial |
$3,673.71
|
| Rate for Payer: HFN Commercial |
$3,797.54
|
| Rate for Payer: Multiplan Commercial |
$3,302.21
|
| Rate for Payer: Preferred Network Access Commercial |
$3,797.54
|
| Rate for Payer: Quartz Beloit One Network |
$2,022.60
|
| Rate for Payer: Quartz Commercial |
$2,476.66
|
| Rate for Payer: WEA Trust Commercial |
$2,270.27
|
| Rate for Payer: WPS Commercial |
$3,057.32
|
|
|
PACK CLOSUREFAST PROCEDURE CFP
|
Facility
|
IP
|
$1,637.00
|
|
| Hospital Charge Code |
4069310
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$834.22 |
| Max. Negotiated Rate |
$1,566.28 |
| Rate for Payer: Aetna Commercial |
$1,532.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,464.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$902.31
|
| Rate for Payer: Cash Price |
$491.10
|
| Rate for Payer: Cigna Commercial |
$1,566.28
|
| Rate for Payer: Health EOS Commercial |
$1,515.21
|
| Rate for Payer: HFN Commercial |
$1,566.28
|
| Rate for Payer: Multiplan Commercial |
$1,361.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,566.28
|
| Rate for Payer: Quartz Beloit One Network |
$834.22
|
| Rate for Payer: Quartz Commercial |
$1,021.49
|
| Rate for Payer: WEA Trust Commercial |
$936.36
|
| Rate for Payer: WPS Commercial |
$1,260.98
|
|
|
PACK CLOSUREFAST PROCEDURE CFP
|
Facility
|
OP
|
$1,637.00
|
|
| Hospital Charge Code |
4069310
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$476.69 |
| Max. Negotiated Rate |
$1,566.28 |
| Rate for Payer: Aetna Commercial |
$1,532.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,464.13
|
| Rate for Payer: Aetna Managed Medicare |
$476.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,106.61
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$851.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$817.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$902.31
|
| Rate for Payer: Cash Price |
$491.10
|
| Rate for Payer: Cigna Commercial |
$1,566.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$952.73
|
| Rate for Payer: Health EOS Commercial |
$1,515.21
|
| Rate for Payer: HFN Commercial |
$1,566.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,276.86
|
| Rate for Payer: Multiplan Commercial |
$1,361.98
|
| Rate for Payer: NAPHCARE Commercial |
$1,021.49
|
| Rate for Payer: Preferred Network Access Commercial |
$1,566.28
|
| Rate for Payer: Quartz Beloit One Network |
$834.22
|
| Rate for Payer: Quartz Commercial |
$1,106.61
|
| Rate for Payer: Quartz Medicare Advantage |
$1,021.49
|
| Rate for Payer: The Alliance Commercial |
$851.24
|
| Rate for Payer: WEA Trust Commercial |
$936.36
|
| Rate for Payer: WPS Commercial |
$1,260.98
|
|
|
PACK CV HEART DRAPE CUSTOM DYNJ30558
|
Facility
|
OP
|
$5,767.00
|
|
| Hospital Charge Code |
2962889
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,679.35 |
| Max. Negotiated Rate |
$5,517.87 |
| Rate for Payer: Aetna Commercial |
$5,397.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,158.00
|
| Rate for Payer: Aetna Managed Medicare |
$1,679.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,898.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,998.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,878.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,178.77
|
| Rate for Payer: Cash Price |
$1,730.10
|
| Rate for Payer: Cigna Commercial |
$5,517.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,356.39
|
| Rate for Payer: Health EOS Commercial |
$5,337.94
|
| Rate for Payer: HFN Commercial |
$5,517.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,498.26
|
| Rate for Payer: Multiplan Commercial |
$4,798.14
|
| Rate for Payer: NAPHCARE Commercial |
$3,598.61
|
| Rate for Payer: Preferred Network Access Commercial |
$5,517.87
|
| Rate for Payer: Quartz Beloit One Network |
$2,938.86
|
| Rate for Payer: Quartz Commercial |
$3,898.49
|
| Rate for Payer: Quartz Medicare Advantage |
$3,598.61
|
| Rate for Payer: The Alliance Commercial |
$2,998.84
|
| Rate for Payer: WEA Trust Commercial |
$3,298.72
|
| Rate for Payer: WPS Commercial |
$4,442.32
|
|
|
PACK CV HEART DRAPE CUSTOM DYNJ30558
|
Facility
|
IP
|
$5,767.00
|
|
| Hospital Charge Code |
2962889
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,938.86 |
| Max. Negotiated Rate |
$5,517.87 |
| Rate for Payer: Aetna Commercial |
$5,397.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,158.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,178.77
|
| Rate for Payer: Cash Price |
$1,730.10
|
| Rate for Payer: Cigna Commercial |
$5,517.87
|
| Rate for Payer: Health EOS Commercial |
$5,337.94
|
| Rate for Payer: HFN Commercial |
$5,517.87
|
| Rate for Payer: Multiplan Commercial |
$4,798.14
|
| Rate for Payer: Preferred Network Access Commercial |
$5,517.87
|
| Rate for Payer: Quartz Beloit One Network |
$2,938.86
|
| Rate for Payer: Quartz Commercial |
$3,598.61
|
| Rate for Payer: WEA Trust Commercial |
$3,298.72
|
| Rate for Payer: WPS Commercial |
$4,442.32
|
|
|
PACK GENERAL ORTHOPEDIC 88411
|
Facility
|
IP
|
$484.00
|
|
| Hospital Charge Code |
2963230
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$246.65 |
| Max. Negotiated Rate |
$463.09 |
| Rate for Payer: Aetna Commercial |
$453.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$432.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$266.78
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cigna Commercial |
$463.09
|
| Rate for Payer: Health EOS Commercial |
$447.99
|
| Rate for Payer: HFN Commercial |
$463.09
|
| Rate for Payer: Multiplan Commercial |
$402.69
|
| Rate for Payer: Preferred Network Access Commercial |
$463.09
|
| Rate for Payer: Quartz Beloit One Network |
$246.65
|
| Rate for Payer: Quartz Commercial |
$302.02
|
| Rate for Payer: WEA Trust Commercial |
$276.85
|
| Rate for Payer: WPS Commercial |
$372.83
|
|
|
PACK GENERAL ORTHOPEDIC 88411
|
Facility
|
OP
|
$484.00
|
|
| Hospital Charge Code |
2963230
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$140.94 |
| Max. Negotiated Rate |
$463.09 |
| Rate for Payer: Aetna Commercial |
$453.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$432.89
|
| Rate for Payer: Aetna Managed Medicare |
$140.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$327.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$251.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$241.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$266.78
|
| Rate for Payer: Cash Price |
$145.20
|
| Rate for Payer: Cigna Commercial |
$463.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$281.69
|
| Rate for Payer: Health EOS Commercial |
$447.99
|
| Rate for Payer: HFN Commercial |
$463.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$377.52
|
| Rate for Payer: Multiplan Commercial |
$402.69
|
| Rate for Payer: NAPHCARE Commercial |
$302.02
|
| Rate for Payer: Preferred Network Access Commercial |
$463.09
|
| Rate for Payer: Quartz Beloit One Network |
$246.65
|
| Rate for Payer: Quartz Commercial |
$327.18
|
| Rate for Payer: Quartz Medicare Advantage |
$302.02
|
| Rate for Payer: The Alliance Commercial |
$251.68
|
| Rate for Payer: WEA Trust Commercial |
$276.85
|
| Rate for Payer: WPS Commercial |
$372.83
|
|
|
PACK HEAD AND NECK EENT 88716
|
Facility
|
OP
|
$447.00
|
|
| Hospital Charge Code |
2963812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$130.17 |
| Max. Negotiated Rate |
$427.69 |
| Rate for Payer: Aetna Commercial |
$418.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$399.80
|
| Rate for Payer: Aetna Managed Medicare |
$130.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$302.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$232.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$223.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$246.39
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$427.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$260.15
|
| Rate for Payer: Health EOS Commercial |
$413.74
|
| Rate for Payer: HFN Commercial |
$427.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$348.66
|
| Rate for Payer: Multiplan Commercial |
$371.90
|
| Rate for Payer: NAPHCARE Commercial |
$278.93
|
| Rate for Payer: Preferred Network Access Commercial |
$427.69
|
| Rate for Payer: Quartz Beloit One Network |
$227.79
|
| Rate for Payer: Quartz Commercial |
$302.17
|
| Rate for Payer: Quartz Medicare Advantage |
$278.93
|
| Rate for Payer: The Alliance Commercial |
$232.44
|
| Rate for Payer: WEA Trust Commercial |
$255.68
|
| Rate for Payer: WPS Commercial |
$344.32
|
|
|
PACK HEAD AND NECK EENT 88716
|
Facility
|
IP
|
$447.00
|
|
| Hospital Charge Code |
2963812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.79 |
| Max. Negotiated Rate |
$427.69 |
| Rate for Payer: Aetna Commercial |
$418.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$399.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$246.39
|
| Rate for Payer: Cash Price |
$134.10
|
| Rate for Payer: Cigna Commercial |
$427.69
|
| Rate for Payer: Health EOS Commercial |
$413.74
|
| Rate for Payer: HFN Commercial |
$427.69
|
| Rate for Payer: Multiplan Commercial |
$371.90
|
| Rate for Payer: Preferred Network Access Commercial |
$427.69
|
| Rate for Payer: Quartz Beloit One Network |
$227.79
|
| Rate for Payer: Quartz Commercial |
$278.93
|
| Rate for Payer: WEA Trust Commercial |
$255.68
|
| Rate for Payer: WPS Commercial |
$344.32
|
|
|
PACKING 1 STRIPS CURITY AMD 7833AMD
|
Facility
|
OP
|
$120.00
|
|
| Hospital Charge Code |
2969224
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.94 |
| Max. Negotiated Rate |
$114.82 |
| Rate for Payer: Aetna Commercial |
$112.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Aetna Managed Medicare |
$34.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$59.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.14
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.84
|
| Rate for Payer: Health EOS Commercial |
$111.07
|
| Rate for Payer: HFN Commercial |
$114.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.60
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: NAPHCARE Commercial |
$74.88
|
| Rate for Payer: Preferred Network Access Commercial |
$114.82
|
| Rate for Payer: Quartz Beloit One Network |
$61.15
|
| Rate for Payer: Quartz Commercial |
$81.12
|
| Rate for Payer: Quartz Medicare Advantage |
$74.88
|
| Rate for Payer: The Alliance Commercial |
$62.40
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$92.44
|
|
|
PACKING 1 STRIPS CURITY AMD 7833AMD
|
Facility
|
IP
|
$120.00
|
|
| Hospital Charge Code |
2969224
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$61.15 |
| Max. Negotiated Rate |
$114.82 |
| Rate for Payer: Aetna Commercial |
$112.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.14
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.82
|
| Rate for Payer: Health EOS Commercial |
$111.07
|
| Rate for Payer: HFN Commercial |
$114.82
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: Preferred Network Access Commercial |
$114.82
|
| Rate for Payer: Quartz Beloit One Network |
$61.15
|
| Rate for Payer: Quartz Commercial |
$74.88
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$92.44
|
|
|
PACKING IODOFORM 1/2 X 5 YRDS
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
HCPCS A6266
|
| Hospital Charge Code |
2964050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.88 |
| Max. Negotiated Rate |
$88.03 |
| Rate for Payer: Aetna Commercial |
$86.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.71
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$88.03
|
| Rate for Payer: Health EOS Commercial |
$85.16
|
| Rate for Payer: HFN Commercial |
$88.03
|
| Rate for Payer: Multiplan Commercial |
$76.54
|
| Rate for Payer: Preferred Network Access Commercial |
$88.03
|
| Rate for Payer: Quartz Beloit One Network |
$46.88
|
| Rate for Payer: Quartz Commercial |
$57.41
|
| Rate for Payer: WEA Trust Commercial |
$52.62
|
| Rate for Payer: WPS Commercial |
$70.87
|
|
|
PACKING IODOFORM 1/2 X 5 YRDS
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
HCPCS A6266
|
| Hospital Charge Code |
2964050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$88.03 |
| Rate for Payer: Aetna Commercial |
$86.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.28
|
| Rate for Payer: Aetna Managed Medicare |
$26.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$47.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$45.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.71
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$88.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.54
|
| Rate for Payer: Health EOS Commercial |
$85.16
|
| Rate for Payer: HFN Commercial |
$88.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.76
|
| Rate for Payer: Multiplan Commercial |
$76.54
|
| Rate for Payer: NAPHCARE Commercial |
$57.41
|
| Rate for Payer: Preferred Network Access Commercial |
$88.03
|
| Rate for Payer: Quartz Beloit One Network |
$46.88
|
| Rate for Payer: Quartz Commercial |
$62.19
|
| Rate for Payer: Quartz Medicare Advantage |
$57.41
|
| Rate for Payer: The Alliance Commercial |
$11.32
|
| Rate for Payer: WEA Trust Commercial |
$52.62
|
| Rate for Payer: WPS Commercial |
$70.87
|
|
|
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 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 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 5.5cm 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 5.5 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 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 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
|
|
