|
PAD SENSA T.R.A.C. (TUBING CLAMP & CONNECTOR) M8275057/10
|
Facility
|
OP
|
$493.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
4020640
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.79 |
| Max. Negotiated Rate |
$471.70 |
| Rate for Payer: Aetna Commercial |
$461.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$440.94
|
| Rate for Payer: Aetna Managed Medicare |
$143.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$333.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$256.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$271.74
|
| Rate for Payer: Cash Price |
$147.90
|
| Rate for Payer: Cash Price |
$147.90
|
| Rate for Payer: Cigna Commercial |
$471.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$286.93
|
| Rate for Payer: Health EOS Commercial |
$456.32
|
| Rate for Payer: HFN Commercial |
$471.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$384.54
|
| Rate for Payer: Multiplan Commercial |
$410.18
|
| Rate for Payer: NAPHCARE Commercial |
$307.63
|
| Rate for Payer: Preferred Network Access Commercial |
$471.70
|
| Rate for Payer: Quartz Beloit One Network |
$251.23
|
| Rate for Payer: Quartz Commercial |
$333.27
|
| Rate for Payer: Quartz Medicare Advantage |
$307.63
|
| Rate for Payer: The Alliance Commercial |
$132.79
|
| Rate for Payer: WEA Trust Commercial |
$282.00
|
| Rate for Payer: WPS Commercial |
$379.76
|
|
|
PADS JODEE BRA SIZE 34B
|
Facility
|
IP
|
$192.00
|
|
| Hospital Charge Code |
2970633
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$97.84 |
| Max. Negotiated Rate |
$183.71 |
| Rate for Payer: Aetna Commercial |
$179.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.83
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$183.71
|
| Rate for Payer: Health EOS Commercial |
$177.72
|
| Rate for Payer: HFN Commercial |
$183.71
|
| Rate for Payer: Multiplan Commercial |
$159.74
|
| Rate for Payer: Preferred Network Access Commercial |
$183.71
|
| Rate for Payer: Quartz Beloit One Network |
$97.84
|
| Rate for Payer: Quartz Commercial |
$119.81
|
| Rate for Payer: WEA Trust Commercial |
$109.82
|
| Rate for Payer: WPS Commercial |
$147.90
|
|
|
PADS JODEE BRA SIZE 34B
|
Facility
|
OP
|
$192.00
|
|
| Hospital Charge Code |
2970633
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$55.91 |
| Max. Negotiated Rate |
$183.71 |
| Rate for Payer: Aetna Commercial |
$179.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.72
|
| Rate for Payer: Aetna Managed Medicare |
$55.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$129.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$95.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.83
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$183.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.74
|
| Rate for Payer: Health EOS Commercial |
$177.72
|
| Rate for Payer: HFN Commercial |
$183.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$149.76
|
| Rate for Payer: Multiplan Commercial |
$159.74
|
| Rate for Payer: NAPHCARE Commercial |
$119.81
|
| Rate for Payer: Preferred Network Access Commercial |
$183.71
|
| Rate for Payer: Quartz Beloit One Network |
$97.84
|
| Rate for Payer: Quartz Commercial |
$129.79
|
| Rate for Payer: Quartz Medicare Advantage |
$119.81
|
| Rate for Payer: The Alliance Commercial |
$99.84
|
| Rate for Payer: WEA Trust Commercial |
$109.82
|
| Rate for Payer: WPS Commercial |
$147.90
|
|
|
PADS JODEE BRA SIZE 36B
|
Facility
|
IP
|
$192.00
|
|
| Hospital Charge Code |
2970634
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$97.84 |
| Max. Negotiated Rate |
$183.71 |
| Rate for Payer: Aetna Commercial |
$179.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.83
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$183.71
|
| Rate for Payer: Health EOS Commercial |
$177.72
|
| Rate for Payer: HFN Commercial |
$183.71
|
| Rate for Payer: Multiplan Commercial |
$159.74
|
| Rate for Payer: Preferred Network Access Commercial |
$183.71
|
| Rate for Payer: Quartz Beloit One Network |
$97.84
|
| Rate for Payer: Quartz Commercial |
$119.81
|
| Rate for Payer: WEA Trust Commercial |
$109.82
|
| Rate for Payer: WPS Commercial |
$147.90
|
|
|
PADS JODEE BRA SIZE 36B
|
Facility
|
OP
|
$192.00
|
|
| Hospital Charge Code |
2970634
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$55.91 |
| Max. Negotiated Rate |
$183.71 |
| Rate for Payer: Aetna Commercial |
$179.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.72
|
| Rate for Payer: Aetna Managed Medicare |
$55.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$129.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$95.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.83
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$183.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.74
|
| Rate for Payer: Health EOS Commercial |
$177.72
|
| Rate for Payer: HFN Commercial |
$183.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$149.76
|
| Rate for Payer: Multiplan Commercial |
$159.74
|
| Rate for Payer: NAPHCARE Commercial |
$119.81
|
| Rate for Payer: Preferred Network Access Commercial |
$183.71
|
| Rate for Payer: Quartz Beloit One Network |
$97.84
|
| Rate for Payer: Quartz Commercial |
$129.79
|
| Rate for Payer: Quartz Medicare Advantage |
$119.81
|
| Rate for Payer: The Alliance Commercial |
$99.84
|
| Rate for Payer: WEA Trust Commercial |
$109.82
|
| Rate for Payer: WPS Commercial |
$147.90
|
|
|
PADS JODEE BRA SIZE 38C
|
Facility
|
OP
|
$192.00
|
|
| Hospital Charge Code |
2970635
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$55.91 |
| Max. Negotiated Rate |
$183.71 |
| Rate for Payer: Aetna Commercial |
$179.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.72
|
| Rate for Payer: Aetna Managed Medicare |
$55.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$129.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$95.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.83
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$183.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.74
|
| Rate for Payer: Health EOS Commercial |
$177.72
|
| Rate for Payer: HFN Commercial |
$183.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$149.76
|
| Rate for Payer: Multiplan Commercial |
$159.74
|
| Rate for Payer: NAPHCARE Commercial |
$119.81
|
| Rate for Payer: Preferred Network Access Commercial |
$183.71
|
| Rate for Payer: Quartz Beloit One Network |
$97.84
|
| Rate for Payer: Quartz Commercial |
$129.79
|
| Rate for Payer: Quartz Medicare Advantage |
$119.81
|
| Rate for Payer: The Alliance Commercial |
$99.84
|
| Rate for Payer: WEA Trust Commercial |
$109.82
|
| Rate for Payer: WPS Commercial |
$147.90
|
|
|
PADS JODEE BRA SIZE 38C
|
Facility
|
IP
|
$192.00
|
|
| Hospital Charge Code |
2970635
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$97.84 |
| Max. Negotiated Rate |
$183.71 |
| Rate for Payer: Aetna Commercial |
$179.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.83
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$183.71
|
| Rate for Payer: Health EOS Commercial |
$177.72
|
| Rate for Payer: HFN Commercial |
$183.71
|
| Rate for Payer: Multiplan Commercial |
$159.74
|
| Rate for Payer: Preferred Network Access Commercial |
$183.71
|
| Rate for Payer: Quartz Beloit One Network |
$97.84
|
| Rate for Payer: Quartz Commercial |
$119.81
|
| Rate for Payer: WEA Trust Commercial |
$109.82
|
| Rate for Payer: WPS Commercial |
$147.90
|
|
|
PADS JODEE BRA SIZE 40D
|
Facility
|
IP
|
$192.00
|
|
| Hospital Charge Code |
2970636
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$97.84 |
| Max. Negotiated Rate |
$183.71 |
| Rate for Payer: Aetna Commercial |
$179.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.83
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$183.71
|
| Rate for Payer: Health EOS Commercial |
$177.72
|
| Rate for Payer: HFN Commercial |
$183.71
|
| Rate for Payer: Multiplan Commercial |
$159.74
|
| Rate for Payer: Preferred Network Access Commercial |
$183.71
|
| Rate for Payer: Quartz Beloit One Network |
$97.84
|
| Rate for Payer: Quartz Commercial |
$119.81
|
| Rate for Payer: WEA Trust Commercial |
$109.82
|
| Rate for Payer: WPS Commercial |
$147.90
|
|
|
PADS JODEE BRA SIZE 40D
|
Facility
|
OP
|
$192.00
|
|
| Hospital Charge Code |
2970636
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$55.91 |
| Max. Negotiated Rate |
$183.71 |
| Rate for Payer: Aetna Commercial |
$179.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.72
|
| Rate for Payer: Aetna Managed Medicare |
$55.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$129.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$95.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.83
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$183.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.74
|
| Rate for Payer: Health EOS Commercial |
$177.72
|
| Rate for Payer: HFN Commercial |
$183.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$149.76
|
| Rate for Payer: Multiplan Commercial |
$159.74
|
| Rate for Payer: NAPHCARE Commercial |
$119.81
|
| Rate for Payer: Preferred Network Access Commercial |
$183.71
|
| Rate for Payer: Quartz Beloit One Network |
$97.84
|
| Rate for Payer: Quartz Commercial |
$129.79
|
| Rate for Payer: Quartz Medicare Advantage |
$119.81
|
| Rate for Payer: The Alliance Commercial |
$99.84
|
| Rate for Payer: WEA Trust Commercial |
$109.82
|
| Rate for Payer: WPS Commercial |
$147.90
|
|
|
PADS JODEE BRA SIZE 42D
|
Facility
|
OP
|
$192.00
|
|
| Hospital Charge Code |
2970630
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$55.91 |
| Max. Negotiated Rate |
$183.71 |
| Rate for Payer: Aetna Commercial |
$179.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.72
|
| Rate for Payer: Aetna Managed Medicare |
$55.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$129.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$95.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.83
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$183.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.74
|
| Rate for Payer: Health EOS Commercial |
$177.72
|
| Rate for Payer: HFN Commercial |
$183.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$149.76
|
| Rate for Payer: Multiplan Commercial |
$159.74
|
| Rate for Payer: NAPHCARE Commercial |
$119.81
|
| Rate for Payer: Preferred Network Access Commercial |
$183.71
|
| Rate for Payer: Quartz Beloit One Network |
$97.84
|
| Rate for Payer: Quartz Commercial |
$129.79
|
| Rate for Payer: Quartz Medicare Advantage |
$119.81
|
| Rate for Payer: The Alliance Commercial |
$99.84
|
| Rate for Payer: WEA Trust Commercial |
$109.82
|
| Rate for Payer: WPS Commercial |
$147.90
|
|
|
PADS JODEE BRA SIZE 42D
|
Facility
|
IP
|
$192.00
|
|
| Hospital Charge Code |
2970630
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$97.84 |
| Max. Negotiated Rate |
$183.71 |
| Rate for Payer: Aetna Commercial |
$179.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.83
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$183.71
|
| Rate for Payer: Health EOS Commercial |
$177.72
|
| Rate for Payer: HFN Commercial |
$183.71
|
| Rate for Payer: Multiplan Commercial |
$159.74
|
| Rate for Payer: Preferred Network Access Commercial |
$183.71
|
| Rate for Payer: Quartz Beloit One Network |
$97.84
|
| Rate for Payer: Quartz Commercial |
$119.81
|
| Rate for Payer: WEA Trust Commercial |
$109.82
|
| Rate for Payer: WPS Commercial |
$147.90
|
|
|
PAD VERSATILE LEG HOLDER (SINGLE USE) 3757
|
Facility
|
OP
|
$373.00
|
|
| Hospital Charge Code |
4403603
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$108.62 |
| Max. Negotiated Rate |
$356.89 |
| Rate for Payer: Aetna Commercial |
$349.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$333.61
|
| Rate for Payer: Aetna Managed Medicare |
$108.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$252.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$193.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$186.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$205.60
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cigna Commercial |
$356.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$217.09
|
| Rate for Payer: Health EOS Commercial |
$345.25
|
| Rate for Payer: HFN Commercial |
$356.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$290.94
|
| Rate for Payer: Multiplan Commercial |
$310.34
|
| Rate for Payer: NAPHCARE Commercial |
$232.75
|
| Rate for Payer: Preferred Network Access Commercial |
$356.89
|
| Rate for Payer: Quartz Beloit One Network |
$190.08
|
| Rate for Payer: Quartz Commercial |
$252.15
|
| Rate for Payer: Quartz Medicare Advantage |
$232.75
|
| Rate for Payer: The Alliance Commercial |
$193.96
|
| Rate for Payer: WEA Trust Commercial |
$213.36
|
| Rate for Payer: WPS Commercial |
$287.32
|
|
|
PAD VERSATILE LEG HOLDER (SINGLE USE) 3757
|
Facility
|
IP
|
$373.00
|
|
| Hospital Charge Code |
4403603
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$190.08 |
| Max. Negotiated Rate |
$356.89 |
| Rate for Payer: Aetna Commercial |
$349.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$333.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$205.60
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cigna Commercial |
$356.89
|
| Rate for Payer: Health EOS Commercial |
$345.25
|
| Rate for Payer: HFN Commercial |
$356.89
|
| Rate for Payer: Multiplan Commercial |
$310.34
|
| Rate for Payer: Preferred Network Access Commercial |
$356.89
|
| Rate for Payer: Quartz Beloit One Network |
$190.08
|
| Rate for Payer: Quartz Commercial |
$232.75
|
| Rate for Payer: WEA Trust Commercial |
$213.36
|
| Rate for Payer: WPS Commercial |
$287.32
|
|
|
PAD XXL BODY PREVALON AIRTAP 7260
|
Facility
|
IP
|
$495.00
|
|
| Hospital Charge Code |
5414960
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$252.25 |
| Max. Negotiated Rate |
$473.62 |
| Rate for Payer: Aetna Commercial |
$463.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.84
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$473.62
|
| Rate for Payer: Health EOS Commercial |
$458.17
|
| Rate for Payer: HFN Commercial |
$473.62
|
| Rate for Payer: Multiplan Commercial |
$411.84
|
| Rate for Payer: Preferred Network Access Commercial |
$473.62
|
| Rate for Payer: Quartz Beloit One Network |
$252.25
|
| Rate for Payer: Quartz Commercial |
$308.88
|
| Rate for Payer: WEA Trust Commercial |
$283.14
|
| Rate for Payer: WPS Commercial |
$381.30
|
|
|
PAD XXL BODY PREVALON AIRTAP 7260
|
Facility
|
OP
|
$495.00
|
|
| Hospital Charge Code |
5414960
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$144.14 |
| Max. Negotiated Rate |
$473.62 |
| Rate for Payer: Aetna Commercial |
$463.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.73
|
| Rate for Payer: Aetna Managed Medicare |
$144.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$334.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$257.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$247.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.84
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$473.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$288.09
|
| Rate for Payer: Health EOS Commercial |
$458.17
|
| Rate for Payer: HFN Commercial |
$473.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$386.10
|
| Rate for Payer: Multiplan Commercial |
$411.84
|
| Rate for Payer: NAPHCARE Commercial |
$308.88
|
| Rate for Payer: Preferred Network Access Commercial |
$473.62
|
| Rate for Payer: Quartz Beloit One Network |
$252.25
|
| Rate for Payer: Quartz Commercial |
$334.62
|
| Rate for Payer: Quartz Medicare Advantage |
$308.88
|
| Rate for Payer: The Alliance Commercial |
$257.40
|
| Rate for Payer: WEA Trust Commercial |
$283.14
|
| Rate for Payer: WPS Commercial |
$381.30
|
|
|
PAI-A INTRODUCTORY KIT
|
Facility
|
IP
|
$3,843.00
|
|
| Hospital Charge Code |
2973444
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,958.39 |
| Max. Negotiated Rate |
$3,676.98 |
| Rate for Payer: Aetna Commercial |
$3,597.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,437.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,118.26
|
| Rate for Payer: Cash Price |
$1,152.90
|
| Rate for Payer: Cigna Commercial |
$3,676.98
|
| Rate for Payer: Health EOS Commercial |
$3,557.08
|
| Rate for Payer: HFN Commercial |
$3,676.98
|
| Rate for Payer: Multiplan Commercial |
$3,197.38
|
| Rate for Payer: Preferred Network Access Commercial |
$3,676.98
|
| Rate for Payer: Quartz Beloit One Network |
$1,958.39
|
| Rate for Payer: Quartz Commercial |
$2,398.03
|
| Rate for Payer: WEA Trust Commercial |
$2,198.20
|
| Rate for Payer: WPS Commercial |
$2,960.26
|
|
|
PAI-A INTRODUCTORY KIT
|
Facility
|
OP
|
$3,843.00
|
|
| Hospital Charge Code |
2973444
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,119.08 |
| Max. Negotiated Rate |
$3,676.98 |
| Rate for Payer: Aetna Commercial |
$3,597.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,437.18
|
| Rate for Payer: Aetna Managed Medicare |
$1,119.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,597.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,998.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,918.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,118.26
|
| Rate for Payer: Cash Price |
$1,152.90
|
| Rate for Payer: Cigna Commercial |
$3,676.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,236.63
|
| Rate for Payer: Health EOS Commercial |
$3,557.08
|
| Rate for Payer: HFN Commercial |
$3,676.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,997.54
|
| Rate for Payer: Multiplan Commercial |
$3,197.38
|
| Rate for Payer: NAPHCARE Commercial |
$2,398.03
|
| Rate for Payer: Preferred Network Access Commercial |
$3,676.98
|
| Rate for Payer: Quartz Beloit One Network |
$1,958.39
|
| Rate for Payer: Quartz Commercial |
$2,597.87
|
| Rate for Payer: Quartz Medicare Advantage |
$2,398.03
|
| Rate for Payer: The Alliance Commercial |
$1,998.36
|
| Rate for Payer: WEA Trust Commercial |
$2,198.20
|
| Rate for Payer: WPS Commercial |
$2,960.26
|
|
|
PAIN
|
Facility
|
OP
|
$29.89
|
|
|
Service Code
|
EAPG 00663
|
| Min. Negotiated Rate |
$28.74 |
| Max. Negotiated Rate |
$29.89 |
| Rate for Payer: Anthem Medicaid |
$28.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$28.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.74
|
| Rate for Payer: Dean Health Medicaid |
$28.74
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$28.74
|
| Rate for Payer: Managed Health Services Medicaid |
$29.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.74
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$28.74
|
| Rate for Payer: United Healthcare Medicaid |
$28.74
|
|
|
Pain Management Profile 1, Urine
|
Professional
|
Both
|
$291.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
5358629
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.63 |
| Max. Negotiated Rate |
$287.51 |
| Rate for Payer: Aetna Commercial |
$287.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$260.27
|
| Rate for Payer: Aetna Managed Medicare |
$64.63
|
| Rate for Payer: Anthem Medicare Advantage |
$64.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$64.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$64.63
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$287.51
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$151.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.63
|
| Rate for Payer: Health EOS Commercial |
$275.40
|
| Rate for Payer: HFN Commercial |
$287.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$228.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$228.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$64.63
|
| Rate for Payer: Multiplan Commercial |
$242.11
|
| Rate for Payer: NAPHCARE Commercial |
$96.94
|
| Rate for Payer: Preferred Network Access Commercial |
$287.51
|
| Rate for Payer: Quartz Beloit One Network |
$133.16
|
| Rate for Payer: Quartz Commercial |
$172.50
|
| Rate for Payer: Quartz Medicare Advantage |
$64.63
|
| Rate for Payer: The Alliance Commercial |
$255.27
|
| Rate for Payer: United Healthcare Medicare Advantage |
$64.63
|
| Rate for Payer: WEA Trust Commercial |
$166.45
|
| Rate for Payer: WPS Commercial |
$284.35
|
|
|
Pain Management Profile 1, Urine
|
Facility
|
IP
|
$291.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
5358629
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$148.29 |
| Max. Negotiated Rate |
$278.43 |
| Rate for Payer: Aetna Commercial |
$272.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$260.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.40
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$278.43
|
| Rate for Payer: Health EOS Commercial |
$269.35
|
| Rate for Payer: HFN Commercial |
$278.43
|
| Rate for Payer: Multiplan Commercial |
$242.11
|
| Rate for Payer: Preferred Network Access Commercial |
$278.43
|
| Rate for Payer: Quartz Beloit One Network |
$148.29
|
| Rate for Payer: Quartz Commercial |
$181.58
|
| Rate for Payer: WEA Trust Commercial |
$166.45
|
| Rate for Payer: WPS Commercial |
$224.16
|
|
|
Pain Management Profile 1, Urine
|
Facility
|
OP
|
$291.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
5358629
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.63 |
| Max. Negotiated Rate |
$278.43 |
| Rate for Payer: Aetna Commercial |
$272.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$260.27
|
| Rate for Payer: Aetna Managed Medicare |
$64.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$242.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$113.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$107.28
|
| Rate for Payer: Anthem Medicare Advantage |
$64.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$64.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$64.63
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$278.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$64.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$169.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$64.63
|
| Rate for Payer: Health EOS Commercial |
$269.35
|
| Rate for Payer: HFN Commercial |
$278.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$240.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$64.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$64.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$64.63
|
| Rate for Payer: Multiplan Commercial |
$242.11
|
| Rate for Payer: NAPHCARE Commercial |
$96.94
|
| Rate for Payer: Preferred Network Access Commercial |
$278.43
|
| Rate for Payer: Quartz Beloit One Network |
$148.29
|
| Rate for Payer: Quartz Commercial |
$196.72
|
| Rate for Payer: Quartz Medicare Advantage |
$64.63
|
| Rate for Payer: The Alliance Commercial |
$258.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$64.63
|
| Rate for Payer: United Healthcare PPO |
$226.98
|
| Rate for Payer: WEA Trust Commercial |
$166.45
|
| Rate for Payer: Wellcare Medicare |
$64.63
|
| Rate for Payer: WPS Commercial |
$224.16
|
|
|
*** PAIN PUMP 275ML 4ML FIXED RATE MC0040LYK5-CP*** DISC ***
|
Facility
|
IP
|
$2,844.00
|
|
| Hospital Charge Code |
2965273
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,449.30 |
| Max. Negotiated Rate |
$2,721.14 |
| Rate for Payer: Aetna Commercial |
$2,661.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,543.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,567.61
|
| Rate for Payer: Cash Price |
$853.20
|
| Rate for Payer: Cigna Commercial |
$2,721.14
|
| Rate for Payer: Health EOS Commercial |
$2,632.41
|
| Rate for Payer: HFN Commercial |
$2,721.14
|
| Rate for Payer: Multiplan Commercial |
$2,366.21
|
| Rate for Payer: Preferred Network Access Commercial |
$2,721.14
|
| Rate for Payer: Quartz Beloit One Network |
$1,449.30
|
| Rate for Payer: Quartz Commercial |
$1,774.66
|
| Rate for Payer: WEA Trust Commercial |
$1,626.77
|
| Rate for Payer: WPS Commercial |
$2,190.73
|
|
|
*** PAIN PUMP 275ML 4ML FIXED RATE MC0040LYK5-CP*** DISC ***
|
Facility
|
OP
|
$2,844.00
|
|
| Hospital Charge Code |
2965273
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$828.17 |
| Max. Negotiated Rate |
$2,721.14 |
| Rate for Payer: Aetna Commercial |
$2,661.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,543.67
|
| Rate for Payer: Aetna Managed Medicare |
$828.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,922.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,478.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,419.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,567.61
|
| Rate for Payer: Cash Price |
$853.20
|
| Rate for Payer: Cigna Commercial |
$2,721.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,655.21
|
| Rate for Payer: Health EOS Commercial |
$2,632.41
|
| Rate for Payer: HFN Commercial |
$2,721.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,218.32
|
| Rate for Payer: Multiplan Commercial |
$2,366.21
|
| Rate for Payer: NAPHCARE Commercial |
$1,774.66
|
| Rate for Payer: Preferred Network Access Commercial |
$2,721.14
|
| Rate for Payer: Quartz Beloit One Network |
$1,449.30
|
| Rate for Payer: Quartz Commercial |
$1,922.54
|
| Rate for Payer: Quartz Medicare Advantage |
$1,774.66
|
| Rate for Payer: The Alliance Commercial |
$1,478.88
|
| Rate for Payer: WEA Trust Commercial |
$1,626.77
|
| Rate for Payer: WPS Commercial |
$2,190.73
|
|
|
PAIN PUMP 275ML 4ML FIXED RATE WITH 2ML BOLUS WITH 60 MIN RELOAD MT4060LYK5-CP
|
Facility
|
OP
|
$1,920.00
|
|
| Hospital Charge Code |
5577698
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$559.10 |
| Max. Negotiated Rate |
$1,837.06 |
| Rate for Payer: Aetna Commercial |
$1,797.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,717.25
|
| Rate for Payer: Aetna Managed Medicare |
$559.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,297.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$998.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$958.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,058.30
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Cigna Commercial |
$1,837.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,117.44
|
| Rate for Payer: Health EOS Commercial |
$1,777.15
|
| Rate for Payer: HFN Commercial |
$1,837.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,497.60
|
| Rate for Payer: Multiplan Commercial |
$1,597.44
|
| Rate for Payer: NAPHCARE Commercial |
$1,198.08
|
| Rate for Payer: Preferred Network Access Commercial |
$1,837.06
|
| Rate for Payer: Quartz Beloit One Network |
$978.43
|
| Rate for Payer: Quartz Commercial |
$1,297.92
|
| Rate for Payer: Quartz Medicare Advantage |
$1,198.08
|
| Rate for Payer: The Alliance Commercial |
$998.40
|
| Rate for Payer: WEA Trust Commercial |
$1,098.24
|
| Rate for Payer: WPS Commercial |
$1,478.98
|
|
|
PAIN PUMP 275ML 4ML FIXED RATE WITH 2ML BOLUS WITH 60 MIN RELOAD MT4060LYK5-CP
|
Facility
|
IP
|
$1,920.00
|
|
| Hospital Charge Code |
5577698
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$978.43 |
| Max. Negotiated Rate |
$1,837.06 |
| Rate for Payer: Aetna Commercial |
$1,797.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,717.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,058.30
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Cigna Commercial |
$1,837.06
|
| Rate for Payer: Health EOS Commercial |
$1,777.15
|
| Rate for Payer: HFN Commercial |
$1,837.06
|
| Rate for Payer: Multiplan Commercial |
$1,597.44
|
| Rate for Payer: Preferred Network Access Commercial |
$1,837.06
|
| Rate for Payer: Quartz Beloit One Network |
$978.43
|
| Rate for Payer: Quartz Commercial |
$1,198.08
|
| Rate for Payer: WEA Trust Commercial |
$1,098.24
|
| Rate for Payer: WPS Commercial |
$1,478.98
|
|
