|
Pump tubing - Peripheral IV Equipment:
|
Facility
|
OP
|
$154.00
|
|
| Hospital Charge Code |
3003556
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$43.12 |
| Max. Negotiated Rate |
$616.00 |
| Rate for Payer: Aetna Commercial |
$138.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.44
|
| Rate for Payer: Aetna Managed Medicare |
$43.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$100.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$77.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$73.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.62
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$141.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$86.18
|
| Rate for Payer: Health EOS Commercial |
$137.06
|
| Rate for Payer: HFN Commercial |
$141.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.50
|
| Rate for Payer: Multiplan Commercial |
$123.20
|
| Rate for Payer: NAPHCARE Commercial |
$92.40
|
| Rate for Payer: Preferred Network Access Commercial |
$141.68
|
| Rate for Payer: Quartz Beloit One Network |
$75.46
|
| Rate for Payer: Quartz Commercial |
$100.10
|
| Rate for Payer: Quartz Medicare Advantage |
$92.40
|
| Rate for Payer: The Alliance Commercial |
$616.00
|
| Rate for Payer: WEA Trust Commercial |
$84.70
|
| Rate for Payer: WPS Commercial |
$114.07
|
|
|
Pump tubing - Peripheral IV Equipment:
|
Facility
|
IP
|
$154.00
|
|
| Hospital Charge Code |
3003556
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$75.46 |
| Max. Negotiated Rate |
$141.68 |
| Rate for Payer: Aetna Commercial |
$138.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.62
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$141.68
|
| Rate for Payer: Health EOS Commercial |
$137.06
|
| Rate for Payer: HFN Commercial |
$141.68
|
| Rate for Payer: Multiplan Commercial |
$123.20
|
| Rate for Payer: NAPHCARE Commercial |
$92.40
|
| Rate for Payer: Preferred Network Access Commercial |
$141.68
|
| Rate for Payer: Quartz Beloit One Network |
$75.46
|
| Rate for Payer: Quartz Commercial |
$92.40
|
| Rate for Payer: WEA Trust Commercial |
$84.70
|
| Rate for Payer: WPS Commercial |
$114.07
|
|
|
PUMP TUBING SET 152cm #PS-360/10
|
Facility
|
IP
|
$274.00
|
|
| Hospital Charge Code |
2972475
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$134.26 |
| Max. Negotiated Rate |
$252.08 |
| Rate for Payer: Aetna Commercial |
$246.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$235.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.22
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$252.08
|
| Rate for Payer: Health EOS Commercial |
$243.86
|
| Rate for Payer: HFN Commercial |
$252.08
|
| Rate for Payer: Multiplan Commercial |
$219.20
|
| Rate for Payer: NAPHCARE Commercial |
$164.40
|
| Rate for Payer: Preferred Network Access Commercial |
$252.08
|
| Rate for Payer: Quartz Beloit One Network |
$134.26
|
| Rate for Payer: Quartz Commercial |
$164.40
|
| Rate for Payer: WEA Trust Commercial |
$150.70
|
| Rate for Payer: WPS Commercial |
$202.95
|
|
|
PUMP TUBING SET 152cm #PS-360/10
|
Facility
|
OP
|
$274.00
|
|
| Hospital Charge Code |
2972475
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$76.72 |
| Max. Negotiated Rate |
$1,096.00 |
| Rate for Payer: Aetna Commercial |
$246.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$235.64
|
| Rate for Payer: Aetna Managed Medicare |
$76.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$178.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$137.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$131.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.22
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$252.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$153.33
|
| Rate for Payer: Health EOS Commercial |
$243.86
|
| Rate for Payer: HFN Commercial |
$252.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$205.50
|
| Rate for Payer: Multiplan Commercial |
$219.20
|
| Rate for Payer: NAPHCARE Commercial |
$164.40
|
| Rate for Payer: Preferred Network Access Commercial |
$252.08
|
| Rate for Payer: Quartz Beloit One Network |
$134.26
|
| Rate for Payer: Quartz Commercial |
$178.10
|
| Rate for Payer: Quartz Medicare Advantage |
$164.40
|
| Rate for Payer: The Alliance Commercial |
$1,096.00
|
| Rate for Payer: WEA Trust Commercial |
$150.70
|
| Rate for Payer: WPS Commercial |
$202.95
|
|
|
PUNCH AORTIC 4.0 RCL40
|
Facility
|
OP
|
$421.00
|
|
| Hospital Charge Code |
2965939
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$117.88 |
| Max. Negotiated Rate |
$1,684.00 |
| Rate for Payer: Aetna Commercial |
$378.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.06
|
| Rate for Payer: Aetna Managed Medicare |
$117.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$273.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$210.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$202.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.13
|
| Rate for Payer: Cash Price |
$126.30
|
| Rate for Payer: Cigna Commercial |
$387.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$235.59
|
| Rate for Payer: Health EOS Commercial |
$374.69
|
| Rate for Payer: HFN Commercial |
$387.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$315.75
|
| Rate for Payer: Multiplan Commercial |
$336.80
|
| Rate for Payer: NAPHCARE Commercial |
$252.60
|
| Rate for Payer: Preferred Network Access Commercial |
$387.32
|
| Rate for Payer: Quartz Beloit One Network |
$206.29
|
| Rate for Payer: Quartz Commercial |
$273.65
|
| Rate for Payer: Quartz Medicare Advantage |
$252.60
|
| Rate for Payer: The Alliance Commercial |
$1,684.00
|
| Rate for Payer: WEA Trust Commercial |
$231.55
|
| Rate for Payer: WPS Commercial |
$311.83
|
|
|
PUNCH AORTIC 4.0 RCL40
|
Facility
|
IP
|
$421.00
|
|
| Hospital Charge Code |
2965939
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$206.29 |
| Max. Negotiated Rate |
$387.32 |
| Rate for Payer: Aetna Commercial |
$378.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.13
|
| Rate for Payer: Cash Price |
$126.30
|
| Rate for Payer: Cigna Commercial |
$387.32
|
| Rate for Payer: Health EOS Commercial |
$374.69
|
| Rate for Payer: HFN Commercial |
$387.32
|
| Rate for Payer: Multiplan Commercial |
$336.80
|
| Rate for Payer: NAPHCARE Commercial |
$252.60
|
| Rate for Payer: Preferred Network Access Commercial |
$387.32
|
| Rate for Payer: Quartz Beloit One Network |
$206.29
|
| Rate for Payer: Quartz Commercial |
$252.60
|
| Rate for Payer: WEA Trust Commercial |
$231.55
|
| Rate for Payer: WPS Commercial |
$311.83
|
|
|
PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION
|
Facility
|
OP
|
$4,218.22
|
|
|
Service Code
|
CPT 11104
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$394.12 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Managed Medicare |
$394.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$394.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$394.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$394.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$394.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$394.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,466.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$394.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$394.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$394.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$394.12
|
| Rate for Payer: NAPHCARE Commercial |
$591.18
|
| Rate for Payer: Quartz Medicare Advantage |
$394.12
|
| Rate for Payer: The Alliance Commercial |
$1,576.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$394.12
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$394.12
|
|
|
Punch Biopsy Skin Ea Sep/Additional Lesion 11105
|
Professional
|
Both
|
$124.00
|
|
|
Service Code
|
CPT 11105
|
| Hospital Charge Code |
5454808
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$47.25 |
| Max. Negotiated Rate |
$117.80 |
| Rate for Payer: Aetna Commercial |
$117.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$106.64
|
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Cigna Commercial |
$117.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$47.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.40
|
| Rate for Payer: Health EOS Commercial |
$112.84
|
| Rate for Payer: HFN Commercial |
$117.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$86.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$86.27
|
| Rate for Payer: Multiplan Commercial |
$99.20
|
| Rate for Payer: Preferred Network Access Commercial |
$117.80
|
| Rate for Payer: Quartz Beloit One Network |
$54.56
|
| Rate for Payer: Quartz Commercial |
$70.68
|
| Rate for Payer: The Alliance Commercial |
$62.00
|
| Rate for Payer: United Healthcare Medicaid |
$47.25
|
| Rate for Payer: WEA Trust Commercial |
$68.20
|
| Rate for Payer: WPS Commercial |
$91.85
|
|
|
Punch Biopsy Skin Single Lesion 11104
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
CPT 11104
|
| Hospital Charge Code |
5454809
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$96.25 |
| Max. Negotiated Rate |
$380.00 |
| Rate for Payer: Aetna Commercial |
$380.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$380.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$96.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$240.00
|
| Rate for Payer: Health EOS Commercial |
$364.00
|
| Rate for Payer: HFN Commercial |
$380.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$158.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$158.89
|
| Rate for Payer: Multiplan Commercial |
$320.00
|
| Rate for Payer: Preferred Network Access Commercial |
$380.00
|
| Rate for Payer: Quartz Beloit One Network |
$176.00
|
| Rate for Payer: Quartz Commercial |
$228.00
|
| Rate for Payer: The Alliance Commercial |
$200.00
|
| Rate for Payer: United Healthcare Medicaid |
$96.25
|
| Rate for Payer: WEA Trust Commercial |
$220.00
|
| Rate for Payer: WPS Commercial |
$296.28
|
|
|
Puncture aspiration of abscess, hematoma, bulla, or cyst 10160
|
Professional
|
Both
|
$362.00
|
|
|
Service Code
|
CPT 10160
|
| Hospital Charge Code |
3013508
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.17 |
| Max. Negotiated Rate |
$343.90 |
| Rate for Payer: Aetna Commercial |
$343.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$311.32
|
| Rate for Payer: Cash Price |
$108.60
|
| Rate for Payer: Cash Price |
$108.60
|
| Rate for Payer: Cash Price |
$108.60
|
| Rate for Payer: Cigna Commercial |
$343.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$217.20
|
| Rate for Payer: Health EOS Commercial |
$329.42
|
| Rate for Payer: HFN Commercial |
$343.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$318.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$318.41
|
| Rate for Payer: Multiplan Commercial |
$289.60
|
| Rate for Payer: Preferred Network Access Commercial |
$343.90
|
| Rate for Payer: Quartz Beloit One Network |
$159.28
|
| Rate for Payer: Quartz Commercial |
$206.34
|
| Rate for Payer: The Alliance Commercial |
$181.00
|
| Rate for Payer: United Healthcare Medicaid |
$30.17
|
| Rate for Payer: WEA Trust Commercial |
$199.10
|
| Rate for Payer: WPS Commercial |
$268.13
|
|
|
Puncture Aspiration Of Cyst Of Breast 19000
|
Professional
|
Both
|
$395.00
|
|
|
Service Code
|
CPT 19000
|
| Hospital Charge Code |
2572831
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.65 |
| Max. Negotiated Rate |
$375.25 |
| Rate for Payer: Aetna Commercial |
$375.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$339.70
|
| Rate for Payer: Cash Price |
$118.50
|
| Rate for Payer: Cash Price |
$118.50
|
| Rate for Payer: Cash Price |
$118.50
|
| Rate for Payer: Cigna Commercial |
$375.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$237.00
|
| Rate for Payer: Health EOS Commercial |
$359.45
|
| Rate for Payer: HFN Commercial |
$375.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$143.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$143.46
|
| Rate for Payer: Multiplan Commercial |
$316.00
|
| Rate for Payer: Preferred Network Access Commercial |
$375.25
|
| Rate for Payer: Quartz Beloit One Network |
$173.80
|
| Rate for Payer: Quartz Commercial |
$225.15
|
| Rate for Payer: The Alliance Commercial |
$197.50
|
| Rate for Payer: United Healthcare Medicaid |
$36.65
|
| Rate for Payer: WEA Trust Commercial |
$217.25
|
| Rate for Payer: WPS Commercial |
$292.58
|
|
|
Puncture Aspiration Of Cyst Of Breast, Each Add'l 19001
|
Professional
|
Both
|
$114.00
|
|
|
Service Code
|
CPT 19001
|
| Hospital Charge Code |
2572832
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$20.92 |
| Max. Negotiated Rate |
$108.30 |
| Rate for Payer: Aetna Commercial |
$108.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.04
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$108.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.40
|
| Rate for Payer: Health EOS Commercial |
$103.74
|
| Rate for Payer: HFN Commercial |
$108.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$70.95
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: Preferred Network Access Commercial |
$108.30
|
| Rate for Payer: Quartz Beloit One Network |
$50.16
|
| Rate for Payer: Quartz Commercial |
$64.98
|
| Rate for Payer: The Alliance Commercial |
$57.00
|
| Rate for Payer: United Healthcare Medicaid |
$20.92
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR WITHOUT INJECTION OF MEDICATION
|
Facility
|
OP
|
$4,218.22
|
|
|
Service Code
|
CPT 55000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$695.42 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Managed Medicare |
$695.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$695.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$695.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$695.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$695.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$695.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,586.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$695.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$695.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$695.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$695.42
|
| Rate for Payer: NAPHCARE Commercial |
$1,043.13
|
| Rate for Payer: Quartz Medicare Advantage |
$695.42
|
| Rate for Payer: The Alliance Commercial |
$2,781.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$695.42
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$695.42
|
|
|
PURAPLY AM 1.6 CM DISC (1.6 SQ CM)
|
Facility
|
OP
|
$4,787.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
5456980
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.81 |
| Max. Negotiated Rate |
$19,148.00 |
| Rate for Payer: Aetna Commercial |
$4,308.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,116.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,340.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,111.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,393.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,297.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,537.11
|
| Rate for Payer: Cash Price |
$1,436.10
|
| Rate for Payer: Cash Price |
$1,436.10
|
| Rate for Payer: Cigna Commercial |
$4,404.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.81
|
| Rate for Payer: Health EOS Commercial |
$4,260.43
|
| Rate for Payer: HFN Commercial |
$4,404.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,590.25
|
| Rate for Payer: Multiplan Commercial |
$3,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,872.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,404.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,345.63
|
| Rate for Payer: Quartz Commercial |
$3,111.55
|
| Rate for Payer: Quartz Medicare Advantage |
$2,872.20
|
| Rate for Payer: The Alliance Commercial |
$19,148.00
|
| Rate for Payer: WEA Trust Commercial |
$2,632.85
|
| Rate for Payer: WPS Commercial |
$260.41
|
|
|
PURAPLY AM 1.6 CM DISC (1.6 SQ CM)
|
Facility
|
IP
|
$4,787.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
5456980
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,345.63 |
| Max. Negotiated Rate |
$4,404.04 |
| Rate for Payer: Aetna Commercial |
$4,308.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,116.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,537.11
|
| Rate for Payer: Cash Price |
$1,436.10
|
| Rate for Payer: Cigna Commercial |
$4,404.04
|
| Rate for Payer: Health EOS Commercial |
$4,260.43
|
| Rate for Payer: HFN Commercial |
$4,404.04
|
| Rate for Payer: Multiplan Commercial |
$3,829.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,872.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,404.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,345.63
|
| Rate for Payer: Quartz Commercial |
$2,872.20
|
| Rate for Payer: WEA Trust Commercial |
$2,632.85
|
| Rate for Payer: WPS Commercial |
$3,545.73
|
|
|
PURAPLY AM 2X2 (4 SQ CM) PURAPLYAM-COM 2X2
|
Facility
|
IP
|
$5,984.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
4520548
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,932.16 |
| Max. Negotiated Rate |
$5,505.28 |
| Rate for Payer: Aetna Commercial |
$5,385.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,146.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,171.52
|
| Rate for Payer: Cash Price |
$1,795.20
|
| Rate for Payer: Cigna Commercial |
$5,505.28
|
| Rate for Payer: Health EOS Commercial |
$5,325.76
|
| Rate for Payer: HFN Commercial |
$5,505.28
|
| Rate for Payer: Multiplan Commercial |
$4,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,590.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,505.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,932.16
|
| Rate for Payer: Quartz Commercial |
$3,590.40
|
| Rate for Payer: WEA Trust Commercial |
$3,291.20
|
| Rate for Payer: WPS Commercial |
$4,432.35
|
|
|
PURAPLY AM 2X2 (4 SQ CM) PURAPLYAM-COM 2X2
|
Facility
|
OP
|
$5,984.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
4520548
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.81 |
| Max. Negotiated Rate |
$23,936.00 |
| Rate for Payer: Aetna Commercial |
$5,385.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,146.24
|
| Rate for Payer: Aetna Managed Medicare |
$1,675.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,889.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,992.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,872.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,171.52
|
| Rate for Payer: Cash Price |
$1,795.20
|
| Rate for Payer: Cash Price |
$1,795.20
|
| Rate for Payer: Cigna Commercial |
$5,505.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.81
|
| Rate for Payer: Health EOS Commercial |
$5,325.76
|
| Rate for Payer: HFN Commercial |
$5,505.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,488.00
|
| Rate for Payer: Multiplan Commercial |
$4,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,590.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,505.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,932.16
|
| Rate for Payer: Quartz Commercial |
$3,889.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,590.40
|
| Rate for Payer: The Alliance Commercial |
$23,936.00
|
| Rate for Payer: WEA Trust Commercial |
$3,291.20
|
| Rate for Payer: WPS Commercial |
$260.41
|
|
|
PURAPLY AM 2X4 (8 SQ CM) PURAPLYAM-COM 2X4
|
Facility
|
IP
|
$7,181.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
4520549
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,518.69 |
| Max. Negotiated Rate |
$6,606.52 |
| Rate for Payer: Aetna Commercial |
$6,462.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,175.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,805.93
|
| Rate for Payer: Cash Price |
$2,154.30
|
| Rate for Payer: Cigna Commercial |
$6,606.52
|
| Rate for Payer: Health EOS Commercial |
$6,391.09
|
| Rate for Payer: HFN Commercial |
$6,606.52
|
| Rate for Payer: Multiplan Commercial |
$5,744.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,308.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,606.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,518.69
|
| Rate for Payer: Quartz Commercial |
$4,308.60
|
| Rate for Payer: WEA Trust Commercial |
$3,949.55
|
| Rate for Payer: WPS Commercial |
$5,318.97
|
|
|
PURAPLY AM 2X4 (8 SQ CM) PURAPLYAM-COM 2X4
|
Facility
|
OP
|
$7,181.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
4520549
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.81 |
| Max. Negotiated Rate |
$28,724.00 |
| Rate for Payer: Aetna Commercial |
$6,462.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,175.66
|
| Rate for Payer: Aetna Managed Medicare |
$2,010.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,667.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,590.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,446.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,805.93
|
| Rate for Payer: Cash Price |
$2,154.30
|
| Rate for Payer: Cash Price |
$2,154.30
|
| Rate for Payer: Cigna Commercial |
$6,606.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.81
|
| Rate for Payer: Health EOS Commercial |
$6,391.09
|
| Rate for Payer: HFN Commercial |
$6,606.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,385.75
|
| Rate for Payer: Multiplan Commercial |
$5,744.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,308.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6,606.52
|
| Rate for Payer: Quartz Beloit One Network |
$3,518.69
|
| Rate for Payer: Quartz Commercial |
$4,667.65
|
| Rate for Payer: Quartz Medicare Advantage |
$4,308.60
|
| Rate for Payer: The Alliance Commercial |
$28,724.00
|
| Rate for Payer: WEA Trust Commercial |
$3,949.55
|
| Rate for Payer: WPS Commercial |
$260.41
|
|
|
PURAPLY AM 5X5 (25 SQ CM) PURAPLYAM-COM 5X5
|
Facility
|
IP
|
$13,829.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
4520546
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,776.21 |
| Max. Negotiated Rate |
$12,722.68 |
| Rate for Payer: Aetna Commercial |
$12,446.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,892.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,329.37
|
| Rate for Payer: Cash Price |
$4,148.70
|
| Rate for Payer: Cigna Commercial |
$12,722.68
|
| Rate for Payer: Health EOS Commercial |
$12,307.81
|
| Rate for Payer: HFN Commercial |
$12,722.68
|
| Rate for Payer: Multiplan Commercial |
$11,063.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,297.40
|
| Rate for Payer: Preferred Network Access Commercial |
$12,722.68
|
| Rate for Payer: Quartz Beloit One Network |
$6,776.21
|
| Rate for Payer: Quartz Commercial |
$8,297.40
|
| Rate for Payer: WEA Trust Commercial |
$7,605.95
|
| Rate for Payer: WPS Commercial |
$10,243.14
|
|
|
PURAPLY AM 5X5 (25 SQ CM) PURAPLYAM-COM 5X5
|
Facility
|
OP
|
$13,829.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
4520546
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.81 |
| Max. Negotiated Rate |
$55,316.00 |
| Rate for Payer: Aetna Commercial |
$12,446.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,892.94
|
| Rate for Payer: Aetna Managed Medicare |
$3,872.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,988.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,914.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,637.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,329.37
|
| Rate for Payer: Cash Price |
$4,148.70
|
| Rate for Payer: Cash Price |
$4,148.70
|
| Rate for Payer: Cigna Commercial |
$12,722.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.81
|
| Rate for Payer: Health EOS Commercial |
$12,307.81
|
| Rate for Payer: HFN Commercial |
$12,722.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,371.75
|
| Rate for Payer: Multiplan Commercial |
$11,063.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,297.40
|
| Rate for Payer: Preferred Network Access Commercial |
$12,722.68
|
| Rate for Payer: Quartz Beloit One Network |
$6,776.21
|
| Rate for Payer: Quartz Commercial |
$8,988.85
|
| Rate for Payer: Quartz Medicare Advantage |
$8,297.40
|
| Rate for Payer: The Alliance Commercial |
$55,316.00
|
| Rate for Payer: WEA Trust Commercial |
$7,605.95
|
| Rate for Payer: WPS Commercial |
$260.41
|
|
|
PURAPLY AM 6X9 (54 SQ CM) PURAPLYAM-COM 6X9
|
Facility
|
IP
|
$26,236.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
4520551
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,855.64 |
| Max. Negotiated Rate |
$24,137.12 |
| Rate for Payer: Aetna Commercial |
$23,612.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,562.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,905.08
|
| Rate for Payer: Cash Price |
$7,870.80
|
| Rate for Payer: Cigna Commercial |
$24,137.12
|
| Rate for Payer: Health EOS Commercial |
$23,350.04
|
| Rate for Payer: HFN Commercial |
$24,137.12
|
| Rate for Payer: Multiplan Commercial |
$20,988.80
|
| Rate for Payer: NAPHCARE Commercial |
$15,741.60
|
| Rate for Payer: Preferred Network Access Commercial |
$24,137.12
|
| Rate for Payer: Quartz Beloit One Network |
$12,855.64
|
| Rate for Payer: Quartz Commercial |
$15,741.60
|
| Rate for Payer: WEA Trust Commercial |
$14,429.80
|
| Rate for Payer: WPS Commercial |
$19,433.01
|
|
|
PURAPLY AM 6X9 (54 SQ CM) PURAPLYAM-COM 6X9
|
Facility
|
OP
|
$26,236.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
4520551
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.81 |
| Max. Negotiated Rate |
$104,944.00 |
| Rate for Payer: Aetna Commercial |
$23,612.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22,562.96
|
| Rate for Payer: Aetna Managed Medicare |
$7,346.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,053.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,118.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,593.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13,905.08
|
| Rate for Payer: Cash Price |
$7,870.80
|
| Rate for Payer: Cash Price |
$7,870.80
|
| Rate for Payer: Cigna Commercial |
$24,137.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.81
|
| Rate for Payer: Health EOS Commercial |
$23,350.04
|
| Rate for Payer: HFN Commercial |
$24,137.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19,677.00
|
| Rate for Payer: Multiplan Commercial |
$20,988.80
|
| Rate for Payer: NAPHCARE Commercial |
$15,741.60
|
| Rate for Payer: Preferred Network Access Commercial |
$24,137.12
|
| Rate for Payer: Quartz Beloit One Network |
$12,855.64
|
| Rate for Payer: Quartz Commercial |
$17,053.40
|
| Rate for Payer: Quartz Medicare Advantage |
$15,741.60
|
| Rate for Payer: The Alliance Commercial |
$104,944.00
|
| Rate for Payer: WEA Trust Commercial |
$14,429.80
|
| Rate for Payer: WPS Commercial |
$260.41
|
|
|
PURAPLY AM 8X16 (128 SQ CM) PURAPLYAM-COM 8X16
|
Facility
|
OP
|
$68,083.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
5107211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.81 |
| Max. Negotiated Rate |
$272,332.00 |
| Rate for Payer: Aetna Commercial |
$61,274.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$58,551.38
|
| Rate for Payer: Aetna Managed Medicare |
$19,063.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44,253.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34,041.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32,679.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36,083.99
|
| Rate for Payer: Cash Price |
$20,424.90
|
| Rate for Payer: Cash Price |
$20,424.90
|
| Rate for Payer: Cigna Commercial |
$62,636.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.81
|
| Rate for Payer: Health EOS Commercial |
$60,593.87
|
| Rate for Payer: HFN Commercial |
$62,636.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51,062.25
|
| Rate for Payer: Multiplan Commercial |
$54,466.40
|
| Rate for Payer: NAPHCARE Commercial |
$40,849.80
|
| Rate for Payer: Preferred Network Access Commercial |
$62,636.36
|
| Rate for Payer: Quartz Beloit One Network |
$33,360.67
|
| Rate for Payer: Quartz Commercial |
$44,253.95
|
| Rate for Payer: Quartz Medicare Advantage |
$40,849.80
|
| Rate for Payer: The Alliance Commercial |
$272,332.00
|
| Rate for Payer: WEA Trust Commercial |
$37,445.65
|
| Rate for Payer: WPS Commercial |
$260.41
|
|
|
PURAPLY AM 8X16 (128 SQ CM) PURAPLYAM-COM 8X16
|
Facility
|
IP
|
$68,083.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
5107211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33,360.67 |
| Max. Negotiated Rate |
$62,636.36 |
| Rate for Payer: Aetna Commercial |
$61,274.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$58,551.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36,083.99
|
| Rate for Payer: Cash Price |
$20,424.90
|
| Rate for Payer: Cigna Commercial |
$62,636.36
|
| Rate for Payer: Health EOS Commercial |
$60,593.87
|
| Rate for Payer: HFN Commercial |
$62,636.36
|
| Rate for Payer: Multiplan Commercial |
$54,466.40
|
| Rate for Payer: NAPHCARE Commercial |
$40,849.80
|
| Rate for Payer: Preferred Network Access Commercial |
$62,636.36
|
| Rate for Payer: Quartz Beloit One Network |
$33,360.67
|
| Rate for Payer: Quartz Commercial |
$40,849.80
|
| Rate for Payer: WEA Trust Commercial |
$37,445.65
|
| Rate for Payer: WPS Commercial |
$50,429.08
|
|
