|
PRINCIPAL CARE MGMT SVC 1ST 30 PHYS/QHP CAL MO 99424
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
CPT 99424
|
| Hospital Charge Code |
6230820
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$88.00 |
| Max. Negotiated Rate |
$190.00 |
| Rate for Payer: Aetna Commercial |
$190.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$190.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$100.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$120.00
|
| Rate for Payer: Health EOS Commercial |
$182.00
|
| Rate for Payer: HFN Commercial |
$190.00
|
| Rate for Payer: Multiplan Commercial |
$160.00
|
| Rate for Payer: Preferred Network Access Commercial |
$190.00
|
| Rate for Payer: Quartz Beloit One Network |
$88.00
|
| Rate for Payer: Quartz Commercial |
$114.00
|
| Rate for Payer: The Alliance Commercial |
$100.00
|
| Rate for Payer: WEA Trust Commercial |
$110.00
|
| Rate for Payer: WPS Commercial |
$148.14
|
|
|
PRINCIPAL CARE MGMT SVC 1ST 30 STAFF CAL MO 99426
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
CPT 99426
|
| Hospital Charge Code |
6230822
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$142.50 |
| Rate for Payer: Aetna Commercial |
$142.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$142.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.00
|
| Rate for Payer: Health EOS Commercial |
$136.50
|
| Rate for Payer: HFN Commercial |
$142.50
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: Preferred Network Access Commercial |
$142.50
|
| Rate for Payer: Quartz Beloit One Network |
$66.00
|
| Rate for Payer: Quartz Commercial |
$85.50
|
| Rate for Payer: The Alliance Commercial |
$75.00
|
| Rate for Payer: WEA Trust Commercial |
$82.50
|
| Rate for Payer: WPS Commercial |
$111.10
|
|
|
PRINCIPAL CARE MGMT SVC EA ADDL 30 STAFF CAL MO 99427
|
Professional
|
Both
|
$116.00
|
|
|
Service Code
|
CPT 99427
|
| Hospital Charge Code |
6230823
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.04 |
| Max. Negotiated Rate |
$110.20 |
| Rate for Payer: Aetna Commercial |
$110.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$99.76
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$110.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$58.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.60
|
| Rate for Payer: Health EOS Commercial |
$105.56
|
| Rate for Payer: HFN Commercial |
$110.20
|
| Rate for Payer: Multiplan Commercial |
$92.80
|
| Rate for Payer: Preferred Network Access Commercial |
$110.20
|
| Rate for Payer: Quartz Beloit One Network |
$51.04
|
| Rate for Payer: Quartz Commercial |
$66.12
|
| Rate for Payer: The Alliance Commercial |
$58.00
|
| Rate for Payer: WEA Trust Commercial |
$63.80
|
| Rate for Payer: WPS Commercial |
$85.92
|
|
|
PRINCIPAL CARE MGMT SVC EA ADL 30 PHY/QHP CAL MO 99425
|
Professional
|
Both
|
$142.00
|
|
|
Service Code
|
CPT 99425
|
| Hospital Charge Code |
6230821
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.48 |
| Max. Negotiated Rate |
$134.90 |
| Rate for Payer: Aetna Commercial |
$134.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$122.12
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cigna Commercial |
$134.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$71.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85.20
|
| Rate for Payer: Health EOS Commercial |
$129.22
|
| Rate for Payer: HFN Commercial |
$134.90
|
| Rate for Payer: Multiplan Commercial |
$113.60
|
| Rate for Payer: Preferred Network Access Commercial |
$134.90
|
| Rate for Payer: Quartz Beloit One Network |
$62.48
|
| Rate for Payer: Quartz Commercial |
$80.94
|
| Rate for Payer: The Alliance Commercial |
$71.00
|
| Rate for Payer: WEA Trust Commercial |
$78.10
|
| Rate for Payer: WPS Commercial |
$105.18
|
|
|
PRISM DISPOSABLE GONIO IPRISM S SGL1
|
Facility
|
OP
|
$1,280.00
|
|
| Hospital Charge Code |
5349363
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$358.40 |
| Max. Negotiated Rate |
$5,120.00 |
| Rate for Payer: Aetna Commercial |
$1,152.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,100.80
|
| Rate for Payer: Aetna Managed Medicare |
$358.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$832.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$640.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$614.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$678.40
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$1,177.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$716.29
|
| Rate for Payer: Health EOS Commercial |
$1,139.20
|
| Rate for Payer: HFN Commercial |
$1,177.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$960.00
|
| Rate for Payer: Multiplan Commercial |
$1,024.00
|
| Rate for Payer: NAPHCARE Commercial |
$768.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,177.60
|
| Rate for Payer: Quartz Beloit One Network |
$627.20
|
| Rate for Payer: Quartz Commercial |
$832.00
|
| Rate for Payer: Quartz Medicare Advantage |
$768.00
|
| Rate for Payer: The Alliance Commercial |
$5,120.00
|
| Rate for Payer: WEA Trust Commercial |
$704.00
|
| Rate for Payer: WPS Commercial |
$948.10
|
|
|
PRISM DISPOSABLE GONIO IPRISM S SGL1
|
Facility
|
IP
|
$1,280.00
|
|
| Hospital Charge Code |
5349363
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$627.20 |
| Max. Negotiated Rate |
$1,177.60 |
| Rate for Payer: Aetna Commercial |
$1,152.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,100.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$678.40
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$1,177.60
|
| Rate for Payer: Health EOS Commercial |
$1,139.20
|
| Rate for Payer: HFN Commercial |
$1,177.60
|
| Rate for Payer: Multiplan Commercial |
$1,024.00
|
| Rate for Payer: NAPHCARE Commercial |
$768.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,177.60
|
| Rate for Payer: Quartz Beloit One Network |
$627.20
|
| Rate for Payer: Quartz Commercial |
$768.00
|
| Rate for Payer: WEA Trust Commercial |
$704.00
|
| Rate for Payer: WPS Commercial |
$948.10
|
|
|
PROBE 5FR EHL 2280.1515
|
Facility
|
IP
|
$1,429.00
|
|
| Hospital Charge Code |
2974884
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$700.21 |
| Max. Negotiated Rate |
$1,314.68 |
| Rate for Payer: Aetna Commercial |
$1,286.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,228.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$757.37
|
| Rate for Payer: Cash Price |
$428.70
|
| Rate for Payer: Cigna Commercial |
$1,314.68
|
| Rate for Payer: Health EOS Commercial |
$1,271.81
|
| Rate for Payer: HFN Commercial |
$1,314.68
|
| Rate for Payer: Multiplan Commercial |
$1,143.20
|
| Rate for Payer: NAPHCARE Commercial |
$857.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,314.68
|
| Rate for Payer: Quartz Beloit One Network |
$700.21
|
| Rate for Payer: Quartz Commercial |
$857.40
|
| Rate for Payer: WEA Trust Commercial |
$785.95
|
| Rate for Payer: WPS Commercial |
$1,058.46
|
|
|
PROBE 5FR EHL 2280.1515
|
Facility
|
OP
|
$1,429.00
|
|
| Hospital Charge Code |
2974884
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$400.12 |
| Max. Negotiated Rate |
$5,716.00 |
| Rate for Payer: Aetna Commercial |
$1,286.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,228.94
|
| Rate for Payer: Aetna Managed Medicare |
$400.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$928.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$714.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$685.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$757.37
|
| Rate for Payer: Cash Price |
$428.70
|
| Rate for Payer: Cigna Commercial |
$1,314.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$799.67
|
| Rate for Payer: Health EOS Commercial |
$1,271.81
|
| Rate for Payer: HFN Commercial |
$1,314.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,071.75
|
| Rate for Payer: Multiplan Commercial |
$1,143.20
|
| Rate for Payer: NAPHCARE Commercial |
$857.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,314.68
|
| Rate for Payer: Quartz Beloit One Network |
$700.21
|
| Rate for Payer: Quartz Commercial |
$928.85
|
| Rate for Payer: Quartz Medicare Advantage |
$857.40
|
| Rate for Payer: The Alliance Commercial |
$5,716.00
|
| Rate for Payer: WEA Trust Commercial |
$785.95
|
| Rate for Payer: WPS Commercial |
$1,058.46
|
|
|
PROBE 9FR EHL 2280.0915***DISC 3/17
|
Facility
|
OP
|
$1,429.00
|
|
| Hospital Charge Code |
2974883
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$400.12 |
| Max. Negotiated Rate |
$5,716.00 |
| Rate for Payer: Aetna Commercial |
$1,286.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,228.94
|
| Rate for Payer: Aetna Managed Medicare |
$400.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$928.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$714.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$685.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$757.37
|
| Rate for Payer: Cash Price |
$428.70
|
| Rate for Payer: Cigna Commercial |
$1,314.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$799.67
|
| Rate for Payer: Health EOS Commercial |
$1,271.81
|
| Rate for Payer: HFN Commercial |
$1,314.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,071.75
|
| Rate for Payer: Multiplan Commercial |
$1,143.20
|
| Rate for Payer: NAPHCARE Commercial |
$857.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,314.68
|
| Rate for Payer: Quartz Beloit One Network |
$700.21
|
| Rate for Payer: Quartz Commercial |
$928.85
|
| Rate for Payer: Quartz Medicare Advantage |
$857.40
|
| Rate for Payer: The Alliance Commercial |
$5,716.00
|
| Rate for Payer: WEA Trust Commercial |
$785.95
|
| Rate for Payer: WPS Commercial |
$1,058.46
|
|
|
PROBE 9FR EHL 2280.0915***DISC 3/17
|
Facility
|
IP
|
$1,429.00
|
|
| Hospital Charge Code |
2974883
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$700.21 |
| Max. Negotiated Rate |
$1,314.68 |
| Rate for Payer: Aetna Commercial |
$1,286.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,228.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$757.37
|
| Rate for Payer: Cash Price |
$428.70
|
| Rate for Payer: Cigna Commercial |
$1,314.68
|
| Rate for Payer: Health EOS Commercial |
$1,271.81
|
| Rate for Payer: HFN Commercial |
$1,314.68
|
| Rate for Payer: Multiplan Commercial |
$1,143.20
|
| Rate for Payer: NAPHCARE Commercial |
$857.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,314.68
|
| Rate for Payer: Quartz Beloit One Network |
$700.21
|
| Rate for Payer: Quartz Commercial |
$857.40
|
| Rate for Payer: WEA Trust Commercial |
$785.95
|
| Rate for Payer: WPS Commercial |
$1,058.46
|
|
|
PROBE ARGON BEAMER COLON 2.3MM 320CM A-BEAM-4
|
Facility
|
OP
|
$2,618.00
|
|
| Hospital Charge Code |
5240746
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$733.04 |
| Max. Negotiated Rate |
$10,472.00 |
| Rate for Payer: Aetna Commercial |
$2,356.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,251.48
|
| Rate for Payer: Aetna Managed Medicare |
$733.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,701.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,309.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,256.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,387.54
|
| Rate for Payer: Cash Price |
$785.40
|
| Rate for Payer: Cigna Commercial |
$2,408.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,465.03
|
| Rate for Payer: Health EOS Commercial |
$2,330.02
|
| Rate for Payer: HFN Commercial |
$2,408.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,963.50
|
| Rate for Payer: Multiplan Commercial |
$2,094.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,570.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,408.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,282.82
|
| Rate for Payer: Quartz Commercial |
$1,701.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,570.80
|
| Rate for Payer: The Alliance Commercial |
$10,472.00
|
| Rate for Payer: WEA Trust Commercial |
$1,439.90
|
| Rate for Payer: WPS Commercial |
$1,939.15
|
|
|
PROBE ARGON BEAMER COLON 2.3MM 320CM A-BEAM-4
|
Facility
|
IP
|
$2,618.00
|
|
| Hospital Charge Code |
5240746
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,282.82 |
| Max. Negotiated Rate |
$2,408.56 |
| Rate for Payer: Aetna Commercial |
$2,356.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,251.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,387.54
|
| Rate for Payer: Cash Price |
$785.40
|
| Rate for Payer: Cigna Commercial |
$2,408.56
|
| Rate for Payer: Health EOS Commercial |
$2,330.02
|
| Rate for Payer: HFN Commercial |
$2,408.56
|
| Rate for Payer: Multiplan Commercial |
$2,094.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,570.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,408.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,282.82
|
| Rate for Payer: Quartz Commercial |
$1,570.80
|
| Rate for Payer: WEA Trust Commercial |
$1,439.90
|
| Rate for Payer: WPS Commercial |
$1,939.15
|
|
|
PROBE ARGON BEAMER ENDO 1.8MM 320CM A-BEAM-2
|
Facility
|
IP
|
$2,618.00
|
|
| Hospital Charge Code |
5240743
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,282.82 |
| Max. Negotiated Rate |
$2,408.56 |
| Rate for Payer: Aetna Commercial |
$2,356.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,251.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,387.54
|
| Rate for Payer: Cash Price |
$785.40
|
| Rate for Payer: Cigna Commercial |
$2,408.56
|
| Rate for Payer: Health EOS Commercial |
$2,330.02
|
| Rate for Payer: HFN Commercial |
$2,408.56
|
| Rate for Payer: Multiplan Commercial |
$2,094.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,570.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,408.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,282.82
|
| Rate for Payer: Quartz Commercial |
$1,570.80
|
| Rate for Payer: WEA Trust Commercial |
$1,439.90
|
| Rate for Payer: WPS Commercial |
$1,939.15
|
|
|
PROBE ARGON BEAMER ENDO 1.8MM 320CM A-BEAM-2
|
Facility
|
OP
|
$2,618.00
|
|
| Hospital Charge Code |
5240743
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$733.04 |
| Max. Negotiated Rate |
$10,472.00 |
| Rate for Payer: Aetna Commercial |
$2,356.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,251.48
|
| Rate for Payer: Aetna Managed Medicare |
$733.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,701.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,309.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,256.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,387.54
|
| Rate for Payer: Cash Price |
$785.40
|
| Rate for Payer: Cigna Commercial |
$2,408.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,465.03
|
| Rate for Payer: Health EOS Commercial |
$2,330.02
|
| Rate for Payer: HFN Commercial |
$2,408.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,963.50
|
| Rate for Payer: Multiplan Commercial |
$2,094.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,570.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,408.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,282.82
|
| Rate for Payer: Quartz Commercial |
$1,701.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,570.80
|
| Rate for Payer: The Alliance Commercial |
$10,472.00
|
| Rate for Payer: WEA Trust Commercial |
$1,439.90
|
| Rate for Payer: WPS Commercial |
$1,939.15
|
|
|
PROBE AR SCOPE MEASUREMENT 220MM60 AR-4070-01
|
Facility
|
OP
|
$2,926.00
|
|
| Hospital Charge Code |
5611601
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$819.28 |
| Max. Negotiated Rate |
$11,704.00 |
| Rate for Payer: Aetna Commercial |
$2,633.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,516.36
|
| Rate for Payer: Aetna Managed Medicare |
$819.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,901.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,463.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,404.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,550.78
|
| Rate for Payer: Cash Price |
$877.80
|
| Rate for Payer: Cigna Commercial |
$2,691.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,637.39
|
| Rate for Payer: Health EOS Commercial |
$2,604.14
|
| Rate for Payer: HFN Commercial |
$2,691.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,194.50
|
| Rate for Payer: Multiplan Commercial |
$2,340.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,755.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,691.92
|
| Rate for Payer: Quartz Beloit One Network |
$1,433.74
|
| Rate for Payer: Quartz Commercial |
$1,901.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,755.60
|
| Rate for Payer: The Alliance Commercial |
$11,704.00
|
| Rate for Payer: WEA Trust Commercial |
$1,609.30
|
| Rate for Payer: WPS Commercial |
$2,167.29
|
|
|
PROBE AR SCOPE MEASUREMENT 220MM60 AR-4070-01
|
Facility
|
IP
|
$2,926.00
|
|
| Hospital Charge Code |
5611601
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,433.74 |
| Max. Negotiated Rate |
$2,691.92 |
| Rate for Payer: Aetna Commercial |
$2,633.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,516.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,550.78
|
| Rate for Payer: Cash Price |
$877.80
|
| Rate for Payer: Cigna Commercial |
$2,691.92
|
| Rate for Payer: Health EOS Commercial |
$2,604.14
|
| Rate for Payer: HFN Commercial |
$2,691.92
|
| Rate for Payer: Multiplan Commercial |
$2,340.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,755.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,691.92
|
| Rate for Payer: Quartz Beloit One Network |
$1,433.74
|
| Rate for Payer: Quartz Commercial |
$1,755.60
|
| Rate for Payer: WEA Trust Commercial |
$1,609.30
|
| Rate for Payer: WPS Commercial |
$2,167.29
|
|
|
PROBE BILIARY BALLOON 5 FR
|
Facility
|
IP
|
$1,172.00
|
|
| Hospital Charge Code |
2963300
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$574.28 |
| Max. Negotiated Rate |
$1,078.24 |
| Rate for Payer: Aetna Commercial |
$1,054.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,007.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$621.16
|
| Rate for Payer: Cash Price |
$351.60
|
| Rate for Payer: Cigna Commercial |
$1,078.24
|
| Rate for Payer: Health EOS Commercial |
$1,043.08
|
| Rate for Payer: HFN Commercial |
$1,078.24
|
| Rate for Payer: Multiplan Commercial |
$937.60
|
| Rate for Payer: NAPHCARE Commercial |
$703.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,078.24
|
| Rate for Payer: Quartz Beloit One Network |
$574.28
|
| Rate for Payer: Quartz Commercial |
$703.20
|
| Rate for Payer: WEA Trust Commercial |
$644.60
|
| Rate for Payer: WPS Commercial |
$868.10
|
|
|
PROBE BILIARY BALLOON 5 FR
|
Facility
|
OP
|
$1,172.00
|
|
| Hospital Charge Code |
2963300
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$328.16 |
| Max. Negotiated Rate |
$4,688.00 |
| Rate for Payer: Aetna Commercial |
$1,054.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,007.92
|
| Rate for Payer: Aetna Managed Medicare |
$328.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$761.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$562.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$621.16
|
| Rate for Payer: Cash Price |
$351.60
|
| Rate for Payer: Cigna Commercial |
$1,078.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$655.85
|
| Rate for Payer: Health EOS Commercial |
$1,043.08
|
| Rate for Payer: HFN Commercial |
$1,078.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$879.00
|
| Rate for Payer: Multiplan Commercial |
$937.60
|
| Rate for Payer: NAPHCARE Commercial |
$703.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,078.24
|
| Rate for Payer: Quartz Beloit One Network |
$574.28
|
| Rate for Payer: Quartz Commercial |
$761.80
|
| Rate for Payer: Quartz Medicare Advantage |
$703.20
|
| Rate for Payer: The Alliance Commercial |
$4,688.00
|
| Rate for Payer: WEA Trust Commercial |
$644.60
|
| Rate for Payer: WPS Commercial |
$868.10
|
|
|
PROBE BILIARY BALLOON 6 FRENCH
|
Facility
|
OP
|
$1,129.00
|
|
| Hospital Charge Code |
2963299
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$316.12 |
| Max. Negotiated Rate |
$4,516.00 |
| Rate for Payer: Aetna Commercial |
$1,016.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$970.94
|
| Rate for Payer: Aetna Managed Medicare |
$316.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$733.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$564.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$598.37
|
| Rate for Payer: Cash Price |
$338.70
|
| Rate for Payer: Cigna Commercial |
$1,038.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$631.79
|
| Rate for Payer: Health EOS Commercial |
$1,004.81
|
| Rate for Payer: HFN Commercial |
$1,038.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$846.75
|
| Rate for Payer: Multiplan Commercial |
$903.20
|
| Rate for Payer: NAPHCARE Commercial |
$677.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,038.68
|
| Rate for Payer: Quartz Beloit One Network |
$553.21
|
| Rate for Payer: Quartz Commercial |
$733.85
|
| Rate for Payer: Quartz Medicare Advantage |
$677.40
|
| Rate for Payer: The Alliance Commercial |
$4,516.00
|
| Rate for Payer: WEA Trust Commercial |
$620.95
|
| Rate for Payer: WPS Commercial |
$836.25
|
|
|
PROBE BILIARY BALLOON 6 FRENCH
|
Facility
|
IP
|
$1,129.00
|
|
| Hospital Charge Code |
2963299
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$553.21 |
| Max. Negotiated Rate |
$1,038.68 |
| Rate for Payer: Aetna Commercial |
$1,016.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$970.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$598.37
|
| Rate for Payer: Cash Price |
$338.70
|
| Rate for Payer: Cigna Commercial |
$1,038.68
|
| Rate for Payer: Health EOS Commercial |
$1,004.81
|
| Rate for Payer: HFN Commercial |
$1,038.68
|
| Rate for Payer: Multiplan Commercial |
$903.20
|
| Rate for Payer: NAPHCARE Commercial |
$677.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,038.68
|
| Rate for Payer: Quartz Beloit One Network |
$553.21
|
| Rate for Payer: Quartz Commercial |
$677.40
|
| Rate for Payer: WEA Trust Commercial |
$620.95
|
| Rate for Payer: WPS Commercial |
$836.25
|
|
|
PROBE CIRCUMFERENTIAL FIRE APC 20132-218
|
Facility
|
OP
|
$2,300.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
5685801
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$644.00 |
| Max. Negotiated Rate |
$9,200.00 |
| Rate for Payer: Aetna Commercial |
$2,070.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,978.00
|
| Rate for Payer: Aetna Managed Medicare |
$644.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,495.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,150.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,104.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,219.00
|
| Rate for Payer: Cash Price |
$690.00
|
| Rate for Payer: Cigna Commercial |
$2,116.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,287.08
|
| Rate for Payer: Health EOS Commercial |
$2,047.00
|
| Rate for Payer: HFN Commercial |
$2,116.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,725.00
|
| Rate for Payer: Multiplan Commercial |
$1,840.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,380.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,116.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,127.00
|
| Rate for Payer: Quartz Commercial |
$1,495.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,380.00
|
| Rate for Payer: The Alliance Commercial |
$9,200.00
|
| Rate for Payer: WEA Trust Commercial |
$1,265.00
|
| Rate for Payer: WPS Commercial |
$1,703.61
|
|
|
PROBE CIRCUMFERENTIAL FIRE APC 20132-218
|
Facility
|
IP
|
$2,300.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
5685801
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,127.00 |
| Max. Negotiated Rate |
$2,116.00 |
| Rate for Payer: Aetna Commercial |
$2,070.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,978.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,219.00
|
| Rate for Payer: Cash Price |
$690.00
|
| Rate for Payer: Cigna Commercial |
$2,116.00
|
| Rate for Payer: Health EOS Commercial |
$2,047.00
|
| Rate for Payer: HFN Commercial |
$2,116.00
|
| Rate for Payer: Multiplan Commercial |
$1,840.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,380.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,116.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,127.00
|
| Rate for Payer: Quartz Commercial |
$1,380.00
|
| Rate for Payer: WEA Trust Commercial |
$1,265.00
|
| Rate for Payer: WPS Commercial |
$1,703.61
|
|
|
PROBE CRYO-ABLATION 20MM CRYO2
|
Facility
|
OP
|
$15,713.00
|
|
| Hospital Charge Code |
2964755
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,399.64 |
| Max. Negotiated Rate |
$62,852.00 |
| Rate for Payer: Aetna Commercial |
$14,141.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,513.18
|
| Rate for Payer: Aetna Managed Medicare |
$4,399.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,213.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,856.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,542.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,327.89
|
| Rate for Payer: Cash Price |
$4,713.90
|
| Rate for Payer: Cigna Commercial |
$14,455.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,792.99
|
| Rate for Payer: Health EOS Commercial |
$13,984.57
|
| Rate for Payer: HFN Commercial |
$14,455.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,784.75
|
| Rate for Payer: Multiplan Commercial |
$12,570.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,427.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,455.96
|
| Rate for Payer: Quartz Beloit One Network |
$7,699.37
|
| Rate for Payer: Quartz Commercial |
$10,213.45
|
| Rate for Payer: Quartz Medicare Advantage |
$9,427.80
|
| Rate for Payer: The Alliance Commercial |
$62,852.00
|
| Rate for Payer: WEA Trust Commercial |
$8,642.15
|
| Rate for Payer: WPS Commercial |
$11,638.62
|
|
|
PROBE CRYO-ABLATION 20MM CRYO2
|
Facility
|
IP
|
$15,713.00
|
|
| Hospital Charge Code |
2964755
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7,699.37 |
| Max. Negotiated Rate |
$14,455.96 |
| Rate for Payer: Aetna Commercial |
$14,141.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,513.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,327.89
|
| Rate for Payer: Cash Price |
$4,713.90
|
| Rate for Payer: Cigna Commercial |
$14,455.96
|
| Rate for Payer: Health EOS Commercial |
$13,984.57
|
| Rate for Payer: HFN Commercial |
$14,455.96
|
| Rate for Payer: Multiplan Commercial |
$12,570.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,427.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,455.96
|
| Rate for Payer: Quartz Beloit One Network |
$7,699.37
|
| Rate for Payer: Quartz Commercial |
$9,427.80
|
| Rate for Payer: WEA Trust Commercial |
$8,642.15
|
| Rate for Payer: WPS Commercial |
$11,638.62
|
|
|
PROBE ENDOCARE CRYOPROBE PCS-17
|
Facility
|
IP
|
$6,117.00
|
|
|
Service Code
|
HCPCS C2618
|
| Hospital Charge Code |
5307097
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,997.33 |
| Max. Negotiated Rate |
$5,627.64 |
| Rate for Payer: Aetna Commercial |
$5,505.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,260.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,242.01
|
| Rate for Payer: Cash Price |
$1,835.10
|
| Rate for Payer: Cigna Commercial |
$5,627.64
|
| Rate for Payer: Health EOS Commercial |
$5,444.13
|
| Rate for Payer: HFN Commercial |
$5,627.64
|
| Rate for Payer: Multiplan Commercial |
$4,893.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,670.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,627.64
|
| Rate for Payer: Quartz Beloit One Network |
$2,997.33
|
| Rate for Payer: Quartz Commercial |
$3,670.20
|
| Rate for Payer: WEA Trust Commercial |
$3,364.35
|
| Rate for Payer: WPS Commercial |
$4,530.86
|
|
