|
ProtÈgÈ 9mm x 20mm 80cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548890
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,840.71 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 20mm 80cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548890
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$39,516.00 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: The Alliance Commercial |
$39,516.00
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 20mm 80cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548890
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.76 |
| Max. Negotiated Rate |
$9,385.05 |
| Rate for Payer: Aetna Commercial |
$9,385.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,385.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,939.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.40
|
| Rate for Payer: Health EOS Commercial |
$8,989.89
|
| Rate for Payer: HFN Commercial |
$9,385.05
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,385.05
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.76
|
| Rate for Payer: Quartz Commercial |
$5,631.03
|
| Rate for Payer: The Alliance Commercial |
$4,939.50
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 40mm 120cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548956
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,840.71 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 40mm 120cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548956
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.76 |
| Max. Negotiated Rate |
$9,385.05 |
| Rate for Payer: Aetna Commercial |
$9,385.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,385.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,939.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.40
|
| Rate for Payer: Health EOS Commercial |
$8,989.89
|
| Rate for Payer: HFN Commercial |
$9,385.05
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,385.05
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.76
|
| Rate for Payer: Quartz Commercial |
$5,631.03
|
| Rate for Payer: The Alliance Commercial |
$4,939.50
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 40mm 120cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548956
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$39,516.00 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: The Alliance Commercial |
$39,516.00
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 40mm 80cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548892
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$39,516.00 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: The Alliance Commercial |
$39,516.00
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 40mm 80cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548892
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.76 |
| Max. Negotiated Rate |
$9,385.05 |
| Rate for Payer: Aetna Commercial |
$9,385.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,385.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,939.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.40
|
| Rate for Payer: Health EOS Commercial |
$8,989.89
|
| Rate for Payer: HFN Commercial |
$9,385.05
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,385.05
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.76
|
| Rate for Payer: Quartz Commercial |
$5,631.03
|
| Rate for Payer: The Alliance Commercial |
$4,939.50
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 40mm 80cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548892
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,840.71 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 60mm 120cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548958
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.76 |
| Max. Negotiated Rate |
$9,385.05 |
| Rate for Payer: Aetna Commercial |
$9,385.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,385.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,939.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.40
|
| Rate for Payer: Health EOS Commercial |
$8,989.89
|
| Rate for Payer: HFN Commercial |
$9,385.05
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,385.05
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.76
|
| Rate for Payer: Quartz Commercial |
$5,631.03
|
| Rate for Payer: The Alliance Commercial |
$4,939.50
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 60mm 120cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548958
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$39,516.00 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: The Alliance Commercial |
$39,516.00
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 60mm 120cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548958
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,840.71 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 60mm 80cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548894
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,840.71 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 60mm 80cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548894
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$39,516.00 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: The Alliance Commercial |
$39,516.00
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 60mm 80cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548894
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.76 |
| Max. Negotiated Rate |
$9,385.05 |
| Rate for Payer: Aetna Commercial |
$9,385.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,385.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,939.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.40
|
| Rate for Payer: Health EOS Commercial |
$8,989.89
|
| Rate for Payer: HFN Commercial |
$9,385.05
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,385.05
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.76
|
| Rate for Payer: Quartz Commercial |
$5,631.03
|
| Rate for Payer: The Alliance Commercial |
$4,939.50
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 80mm 120cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548960
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.76 |
| Max. Negotiated Rate |
$9,385.05 |
| Rate for Payer: Aetna Commercial |
$9,385.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,385.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,939.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.40
|
| Rate for Payer: Health EOS Commercial |
$8,989.89
|
| Rate for Payer: HFN Commercial |
$9,385.05
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,385.05
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.76
|
| Rate for Payer: Quartz Commercial |
$5,631.03
|
| Rate for Payer: The Alliance Commercial |
$4,939.50
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 80mm 120cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548960
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,840.71 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 80mm 120cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548960
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$39,516.00 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: The Alliance Commercial |
$39,516.00
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 80mm 80cm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548896
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.76 |
| Max. Negotiated Rate |
$9,385.05 |
| Rate for Payer: Aetna Commercial |
$9,385.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,385.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,939.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.40
|
| Rate for Payer: Health EOS Commercial |
$8,989.89
|
| Rate for Payer: HFN Commercial |
$9,385.05
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,385.05
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.76
|
| Rate for Payer: Quartz Commercial |
$5,631.03
|
| Rate for Payer: The Alliance Commercial |
$4,939.50
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 80mm 80cm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548896
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$39,516.00 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: The Alliance Commercial |
$39,516.00
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
ProtÈgÈ 9mm x 80mm 80cm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548896
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,840.71 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
Protein 24 Hour Urine
|
Facility
|
OP
|
$101.00
|
|
|
Service Code
|
CPT 84156
|
| Hospital Charge Code |
633811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$92.92 |
| Rate for Payer: Aetna Commercial |
$90.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.86
|
| Rate for Payer: Aetna Managed Medicare |
$3.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6.09
|
| Rate for Payer: Anthem Medicaid |
$3.79
|
| Rate for Payer: Anthem Medicare Advantage |
$3.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.67
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$92.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$56.52
|
| Rate for Payer: Dean Health Medicaid |
$3.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3.67
|
| Rate for Payer: Health EOS Commercial |
$89.89
|
| Rate for Payer: HFN Commercial |
$92.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.67
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3.79
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.67
|
| Rate for Payer: Managed Health Services Medicaid |
$3.94
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3.67
|
| Rate for Payer: Multiplan Commercial |
$80.80
|
| Rate for Payer: NAPHCARE Commercial |
$5.50
|
| Rate for Payer: Preferred Network Access Commercial |
$92.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3.79
|
| Rate for Payer: Quartz Beloit One Network |
$49.49
|
| Rate for Payer: Quartz Commercial |
$65.65
|
| Rate for Payer: Quartz Medicare Advantage |
$3.67
|
| Rate for Payer: The Alliance Commercial |
$14.68
|
| Rate for Payer: United Healthcare Medicaid |
$3.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.67
|
| Rate for Payer: United Healthcare PPO |
$75.75
|
| Rate for Payer: WEA Trust Commercial |
$55.55
|
| Rate for Payer: Wellcare Medicare |
$3.67
|
| Rate for Payer: WMAP Medicaid |
$3.79
|
| Rate for Payer: WPS Commercial |
$74.81
|
|
|
Protein 24 Hour Urine
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
CPT 84156
|
| Hospital Charge Code |
633811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.49 |
| Max. Negotiated Rate |
$92.92 |
| Rate for Payer: Aetna Commercial |
$90.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.53
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$92.92
|
| Rate for Payer: Health EOS Commercial |
$89.89
|
| Rate for Payer: HFN Commercial |
$92.92
|
| Rate for Payer: Multiplan Commercial |
$80.80
|
| Rate for Payer: NAPHCARE Commercial |
$60.60
|
| Rate for Payer: Preferred Network Access Commercial |
$92.92
|
| Rate for Payer: Quartz Beloit One Network |
$49.49
|
| Rate for Payer: Quartz Commercial |
$60.60
|
| Rate for Payer: WEA Trust Commercial |
$55.55
|
| Rate for Payer: WPS Commercial |
$74.81
|
|
|
Protein 24 Hour Urine
|
Professional
|
Both
|
$101.00
|
|
|
Service Code
|
CPT 84156
|
| Hospital Charge Code |
633811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.96 |
| Max. Negotiated Rate |
$95.95 |
| Rate for Payer: Aetna Commercial |
$95.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.86
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$95.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.60
|
| Rate for Payer: Health EOS Commercial |
$91.91
|
| Rate for Payer: HFN Commercial |
$95.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.96
|
| Rate for Payer: Multiplan Commercial |
$80.80
|
| Rate for Payer: Preferred Network Access Commercial |
$95.95
|
| Rate for Payer: Quartz Beloit One Network |
$44.44
|
| Rate for Payer: Quartz Commercial |
$57.57
|
| Rate for Payer: The Alliance Commercial |
$50.50
|
| Rate for Payer: WEA Trust Commercial |
$55.55
|
| Rate for Payer: WPS Commercial |
$74.81
|
|
|
Proteinase-3 Ab
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86021
|
| Hospital Charge Code |
5438977
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$108.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Health EOS Commercial |
$106.80
|
| Rate for Payer: HFN Commercial |
$110.40
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: NAPHCARE Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$110.40
|
| Rate for Payer: Quartz Beloit One Network |
$58.80
|
| Rate for Payer: Quartz Commercial |
$72.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
