|
Primewire J 300cm
|
Facility
|
IP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550932
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$204.35 |
| Max. Negotiated Rate |
$383.68 |
| Rate for Payer: Aetna Commercial |
$375.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.03
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$383.68
|
| Rate for Payer: Health EOS Commercial |
$371.17
|
| Rate for Payer: HFN Commercial |
$383.68
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: Preferred Network Access Commercial |
$383.68
|
| Rate for Payer: Quartz Beloit One Network |
$204.35
|
| Rate for Payer: Quartz Commercial |
$250.22
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primewire J 300cm
|
Facility
|
OP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550932
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.77 |
| Max. Negotiated Rate |
$383.68 |
| Rate for Payer: Aetna Commercial |
$375.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Aetna Managed Medicare |
$116.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$271.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$208.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$200.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.03
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$383.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$233.38
|
| Rate for Payer: Health EOS Commercial |
$371.17
|
| Rate for Payer: HFN Commercial |
$383.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$312.78
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: NAPHCARE Commercial |
$250.22
|
| Rate for Payer: Preferred Network Access Commercial |
$383.68
|
| Rate for Payer: Quartz Beloit One Network |
$204.35
|
| Rate for Payer: Quartz Commercial |
$271.08
|
| Rate for Payer: Quartz Medicare Advantage |
$250.22
|
| Rate for Payer: The Alliance Commercial |
$208.52
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primewire ST 185cm
|
Facility
|
IP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550990
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$204.35 |
| Max. Negotiated Rate |
$383.68 |
| Rate for Payer: Aetna Commercial |
$375.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.03
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$383.68
|
| Rate for Payer: Health EOS Commercial |
$371.17
|
| Rate for Payer: HFN Commercial |
$383.68
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: Preferred Network Access Commercial |
$383.68
|
| Rate for Payer: Quartz Beloit One Network |
$204.35
|
| Rate for Payer: Quartz Commercial |
$250.22
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primewire ST 185cm
|
Facility
|
OP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550990
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.77 |
| Max. Negotiated Rate |
$383.68 |
| Rate for Payer: Aetna Commercial |
$375.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Aetna Managed Medicare |
$116.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$271.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$208.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$200.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.03
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$383.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$233.38
|
| Rate for Payer: Health EOS Commercial |
$371.17
|
| Rate for Payer: HFN Commercial |
$383.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$312.78
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: NAPHCARE Commercial |
$250.22
|
| Rate for Payer: Preferred Network Access Commercial |
$383.68
|
| Rate for Payer: Quartz Beloit One Network |
$204.35
|
| Rate for Payer: Quartz Commercial |
$271.08
|
| Rate for Payer: Quartz Medicare Advantage |
$250.22
|
| Rate for Payer: The Alliance Commercial |
$208.52
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primewire ST 185cm
|
Professional
|
Both
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550990
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$183.50 |
| Max. Negotiated Rate |
$396.19 |
| Rate for Payer: Aetna Commercial |
$396.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$396.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$208.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.22
|
| Rate for Payer: Health EOS Commercial |
$379.51
|
| Rate for Payer: HFN Commercial |
$396.19
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: Preferred Network Access Commercial |
$396.19
|
| Rate for Payer: Quartz Beloit One Network |
$183.50
|
| Rate for Payer: Quartz Commercial |
$237.71
|
| Rate for Payer: The Alliance Commercial |
$208.52
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primewire ST 300cm
|
Facility
|
OP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550934
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.77 |
| Max. Negotiated Rate |
$383.68 |
| Rate for Payer: Aetna Commercial |
$375.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Aetna Managed Medicare |
$116.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$271.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$208.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$200.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.03
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$383.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$233.38
|
| Rate for Payer: Health EOS Commercial |
$371.17
|
| Rate for Payer: HFN Commercial |
$383.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$312.78
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: NAPHCARE Commercial |
$250.22
|
| Rate for Payer: Preferred Network Access Commercial |
$383.68
|
| Rate for Payer: Quartz Beloit One Network |
$204.35
|
| Rate for Payer: Quartz Commercial |
$271.08
|
| Rate for Payer: Quartz Medicare Advantage |
$250.22
|
| Rate for Payer: The Alliance Commercial |
$208.52
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primewire ST 300cm
|
Facility
|
IP
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550934
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$204.35 |
| Max. Negotiated Rate |
$383.68 |
| Rate for Payer: Aetna Commercial |
$375.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.03
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$383.68
|
| Rate for Payer: Health EOS Commercial |
$371.17
|
| Rate for Payer: HFN Commercial |
$383.68
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: Preferred Network Access Commercial |
$383.68
|
| Rate for Payer: Quartz Beloit One Network |
$204.35
|
| Rate for Payer: Quartz Commercial |
$250.22
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primewire ST 300cm
|
Professional
|
Both
|
$401.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
2550934
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$183.50 |
| Max. Negotiated Rate |
$396.19 |
| Rate for Payer: Aetna Commercial |
$396.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.65
|
| Rate for Payer: Cash Price |
$120.30
|
| Rate for Payer: Cigna Commercial |
$396.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$208.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.22
|
| Rate for Payer: Health EOS Commercial |
$379.51
|
| Rate for Payer: HFN Commercial |
$396.19
|
| Rate for Payer: Multiplan Commercial |
$333.63
|
| Rate for Payer: Preferred Network Access Commercial |
$396.19
|
| Rate for Payer: Quartz Beloit One Network |
$183.50
|
| Rate for Payer: Quartz Commercial |
$237.71
|
| Rate for Payer: The Alliance Commercial |
$208.52
|
| Rate for Payer: WEA Trust Commercial |
$229.37
|
| Rate for Payer: WPS Commercial |
$308.89
|
|
|
Primidone & Phenobarbital Level
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 80188
|
| Hospital Charge Code |
978044
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.56 |
| Max. Negotiated Rate |
$55.49 |
| Rate for Payer: Aetna Commercial |
$54.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.97
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.49
|
| Rate for Payer: Health EOS Commercial |
$53.68
|
| Rate for Payer: HFN Commercial |
$55.49
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: Preferred Network Access Commercial |
$55.49
|
| Rate for Payer: Quartz Beloit One Network |
$29.56
|
| Rate for Payer: Quartz Commercial |
$36.19
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: WPS Commercial |
$44.68
|
|
|
Primidone & Phenobarbital Level
|
Professional
|
Both
|
$58.00
|
|
|
Service Code
|
CPT 80188
|
| Hospital Charge Code |
978044
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.25 |
| Max. Negotiated Rate |
$75.92 |
| Rate for Payer: Aetna Commercial |
$57.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Aetna Managed Medicare |
$17.25
|
| Rate for Payer: Anthem Medicare Advantage |
$17.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.25
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$57.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.25
|
| Rate for Payer: Health EOS Commercial |
$54.89
|
| Rate for Payer: HFN Commercial |
$57.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.25
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: NAPHCARE Commercial |
$25.88
|
| Rate for Payer: Preferred Network Access Commercial |
$57.30
|
| Rate for Payer: Quartz Beloit One Network |
$26.54
|
| Rate for Payer: Quartz Commercial |
$34.38
|
| Rate for Payer: Quartz Medicare Advantage |
$17.25
|
| Rate for Payer: The Alliance Commercial |
$68.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.25
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: WPS Commercial |
$75.92
|
|
|
Primidone & Phenobarbital Level
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 80188
|
| Hospital Charge Code |
978044
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.25 |
| Max. Negotiated Rate |
$69.01 |
| Rate for Payer: Aetna Commercial |
$54.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Aetna Managed Medicare |
$17.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.19
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.64
|
| Rate for Payer: Anthem Medicare Advantage |
$17.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.25
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.25
|
| Rate for Payer: Health EOS Commercial |
$53.68
|
| Rate for Payer: HFN Commercial |
$55.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.25
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.25
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.25
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: NAPHCARE Commercial |
$25.88
|
| Rate for Payer: Preferred Network Access Commercial |
$55.49
|
| Rate for Payer: Quartz Beloit One Network |
$29.56
|
| Rate for Payer: Quartz Commercial |
$39.21
|
| Rate for Payer: Quartz Medicare Advantage |
$17.25
|
| Rate for Payer: The Alliance Commercial |
$69.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.25
|
| Rate for Payer: United Healthcare PPO |
$45.24
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: Wellcare Medicare |
$17.25
|
| Rate for Payer: WPS Commercial |
$44.68
|
|
|
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 |
$64.19 |
| Max. Negotiated Rate |
$197.60 |
| Rate for Payer: Aetna Commercial |
$197.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Aetna Managed Medicare |
$64.19
|
| Rate for Payer: Anthem Medicare Advantage |
$64.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$64.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$64.19
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$197.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$104.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.19
|
| Rate for Payer: Health EOS Commercial |
$189.28
|
| Rate for Payer: HFN Commercial |
$197.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$64.19
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: NAPHCARE Commercial |
$96.28
|
| Rate for Payer: Preferred Network Access Commercial |
$197.60
|
| Rate for Payer: Quartz Beloit One Network |
$91.52
|
| Rate for Payer: Quartz Commercial |
$118.56
|
| Rate for Payer: Quartz Medicare Advantage |
$64.19
|
| Rate for Payer: The Alliance Commercial |
$154.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$64.19
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$176.52
|
|
|
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 |
$43.80 |
| Max. Negotiated Rate |
$148.20 |
| Rate for Payer: Aetna Commercial |
$148.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Aetna Managed Medicare |
$43.80
|
| Rate for Payer: Anthem Medicare Advantage |
$43.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$43.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$43.80
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$148.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$78.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.80
|
| Rate for Payer: Health EOS Commercial |
$141.96
|
| Rate for Payer: HFN Commercial |
$148.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$43.80
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: NAPHCARE Commercial |
$65.71
|
| Rate for Payer: Preferred Network Access Commercial |
$148.20
|
| Rate for Payer: Quartz Beloit One Network |
$68.64
|
| Rate for Payer: Quartz Commercial |
$88.92
|
| Rate for Payer: Quartz Medicare Advantage |
$43.80
|
| Rate for Payer: The Alliance Commercial |
$105.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.80
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$120.46
|
|
|
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 |
$31.19 |
| Max. Negotiated Rate |
$114.61 |
| Rate for Payer: Aetna Commercial |
$114.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.75
|
| Rate for Payer: Aetna Managed Medicare |
$31.19
|
| Rate for Payer: Anthem Medicare Advantage |
$31.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$31.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$31.19
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$114.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.19
|
| Rate for Payer: Health EOS Commercial |
$109.78
|
| Rate for Payer: HFN Commercial |
$114.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$31.19
|
| Rate for Payer: Multiplan Commercial |
$96.51
|
| Rate for Payer: NAPHCARE Commercial |
$46.78
|
| Rate for Payer: Preferred Network Access Commercial |
$114.61
|
| Rate for Payer: Quartz Beloit One Network |
$53.08
|
| Rate for Payer: Quartz Commercial |
$68.76
|
| Rate for Payer: Quartz Medicare Advantage |
$31.19
|
| Rate for Payer: The Alliance Commercial |
$74.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$31.19
|
| Rate for Payer: WEA Trust Commercial |
$66.35
|
| Rate for Payer: WPS Commercial |
$85.77
|
|
|
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 |
$43.80 |
| Max. Negotiated Rate |
$140.30 |
| Rate for Payer: Aetna Commercial |
$140.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.00
|
| Rate for Payer: Aetna Managed Medicare |
$43.80
|
| Rate for Payer: Anthem Medicare Advantage |
$43.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$43.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$43.80
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cigna Commercial |
$140.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$73.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.80
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$140.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$43.80
|
| Rate for Payer: Multiplan Commercial |
$118.14
|
| Rate for Payer: NAPHCARE Commercial |
$65.71
|
| Rate for Payer: Preferred Network Access Commercial |
$140.30
|
| Rate for Payer: Quartz Beloit One Network |
$64.98
|
| Rate for Payer: Quartz Commercial |
$84.18
|
| Rate for Payer: Quartz Medicare Advantage |
$43.80
|
| Rate for Payer: The Alliance Commercial |
$105.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.80
|
| Rate for Payer: WEA Trust Commercial |
$81.22
|
| Rate for Payer: WPS Commercial |
$120.46
|
|
|
PRISM DISPOSABLE GONIO IPRISM S SGL1
|
Facility
|
IP
|
$1,280.00
|
|
| Hospital Charge Code |
5349363
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$652.29 |
| Max. Negotiated Rate |
$1,224.70 |
| Rate for Payer: Aetna Commercial |
$1,198.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,144.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$705.54
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$1,224.70
|
| Rate for Payer: Health EOS Commercial |
$1,184.77
|
| Rate for Payer: HFN Commercial |
$1,224.70
|
| Rate for Payer: Multiplan Commercial |
$1,064.96
|
| Rate for Payer: Preferred Network Access Commercial |
$1,224.70
|
| Rate for Payer: Quartz Beloit One Network |
$652.29
|
| Rate for Payer: Quartz Commercial |
$798.72
|
| Rate for Payer: WEA Trust Commercial |
$732.16
|
| Rate for Payer: WPS Commercial |
$985.98
|
|
|
PRISM DISPOSABLE GONIO IPRISM S SGL1
|
Facility
|
OP
|
$1,280.00
|
|
| Hospital Charge Code |
5349363
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$372.74 |
| Max. Negotiated Rate |
$1,224.70 |
| Rate for Payer: Aetna Commercial |
$1,198.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,144.83
|
| Rate for Payer: Aetna Managed Medicare |
$372.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$865.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$665.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$638.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$705.54
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$1,224.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$744.96
|
| Rate for Payer: Health EOS Commercial |
$1,184.77
|
| Rate for Payer: HFN Commercial |
$1,224.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$998.40
|
| Rate for Payer: Multiplan Commercial |
$1,064.96
|
| Rate for Payer: NAPHCARE Commercial |
$798.72
|
| Rate for Payer: Preferred Network Access Commercial |
$1,224.70
|
| Rate for Payer: Quartz Beloit One Network |
$652.29
|
| Rate for Payer: Quartz Commercial |
$865.28
|
| Rate for Payer: Quartz Medicare Advantage |
$798.72
|
| Rate for Payer: The Alliance Commercial |
$665.60
|
| Rate for Payer: WEA Trust Commercial |
$732.16
|
| Rate for Payer: WPS Commercial |
$985.98
|
|
|
PROBE 5FR EHL 2280.1515
|
Facility
|
IP
|
$1,429.00
|
|
| Hospital Charge Code |
2974884
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$728.22 |
| Max. Negotiated Rate |
$1,367.27 |
| Rate for Payer: Aetna Commercial |
$1,337.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,278.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$787.66
|
| Rate for Payer: Cash Price |
$428.70
|
| Rate for Payer: Cigna Commercial |
$1,367.27
|
| Rate for Payer: Health EOS Commercial |
$1,322.68
|
| Rate for Payer: HFN Commercial |
$1,367.27
|
| Rate for Payer: Multiplan Commercial |
$1,188.93
|
| Rate for Payer: Preferred Network Access Commercial |
$1,367.27
|
| Rate for Payer: Quartz Beloit One Network |
$728.22
|
| Rate for Payer: Quartz Commercial |
$891.70
|
| Rate for Payer: WEA Trust Commercial |
$817.39
|
| Rate for Payer: WPS Commercial |
$1,100.76
|
|
|
PROBE 5FR EHL 2280.1515
|
Facility
|
OP
|
$1,429.00
|
|
| Hospital Charge Code |
2974884
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$416.12 |
| Max. Negotiated Rate |
$1,367.27 |
| Rate for Payer: Aetna Commercial |
$1,337.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,278.10
|
| Rate for Payer: Aetna Managed Medicare |
$416.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$966.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$743.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$713.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$787.66
|
| Rate for Payer: Cash Price |
$428.70
|
| Rate for Payer: Cigna Commercial |
$1,367.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$831.68
|
| Rate for Payer: Health EOS Commercial |
$1,322.68
|
| Rate for Payer: HFN Commercial |
$1,367.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,114.62
|
| Rate for Payer: Multiplan Commercial |
$1,188.93
|
| Rate for Payer: NAPHCARE Commercial |
$891.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,367.27
|
| Rate for Payer: Quartz Beloit One Network |
$728.22
|
| Rate for Payer: Quartz Commercial |
$966.00
|
| Rate for Payer: Quartz Medicare Advantage |
$891.70
|
| Rate for Payer: The Alliance Commercial |
$743.08
|
| Rate for Payer: WEA Trust Commercial |
$817.39
|
| Rate for Payer: WPS Commercial |
$1,100.76
|
|
|
PROBE 9FR EHL 2280.0915***DISC 3/17
|
Facility
|
OP
|
$1,429.00
|
|
| Hospital Charge Code |
2974883
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$416.12 |
| Max. Negotiated Rate |
$1,367.27 |
| Rate for Payer: Aetna Commercial |
$1,337.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,278.10
|
| Rate for Payer: Aetna Managed Medicare |
$416.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$966.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$743.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$713.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$787.66
|
| Rate for Payer: Cash Price |
$428.70
|
| Rate for Payer: Cigna Commercial |
$1,367.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$831.68
|
| Rate for Payer: Health EOS Commercial |
$1,322.68
|
| Rate for Payer: HFN Commercial |
$1,367.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,114.62
|
| Rate for Payer: Multiplan Commercial |
$1,188.93
|
| Rate for Payer: NAPHCARE Commercial |
$891.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,367.27
|
| Rate for Payer: Quartz Beloit One Network |
$728.22
|
| Rate for Payer: Quartz Commercial |
$966.00
|
| Rate for Payer: Quartz Medicare Advantage |
$891.70
|
| Rate for Payer: The Alliance Commercial |
$743.08
|
| Rate for Payer: WEA Trust Commercial |
$817.39
|
| Rate for Payer: WPS Commercial |
$1,100.76
|
|
|
PROBE 9FR EHL 2280.0915***DISC 3/17
|
Facility
|
IP
|
$1,429.00
|
|
| Hospital Charge Code |
2974883
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$728.22 |
| Max. Negotiated Rate |
$1,367.27 |
| Rate for Payer: Aetna Commercial |
$1,337.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,278.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$787.66
|
| Rate for Payer: Cash Price |
$428.70
|
| Rate for Payer: Cigna Commercial |
$1,367.27
|
| Rate for Payer: Health EOS Commercial |
$1,322.68
|
| Rate for Payer: HFN Commercial |
$1,367.27
|
| Rate for Payer: Multiplan Commercial |
$1,188.93
|
| Rate for Payer: Preferred Network Access Commercial |
$1,367.27
|
| Rate for Payer: Quartz Beloit One Network |
$728.22
|
| Rate for Payer: Quartz Commercial |
$891.70
|
| Rate for Payer: WEA Trust Commercial |
$817.39
|
| Rate for Payer: WPS Commercial |
$1,100.76
|
|
|
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 |
$762.36 |
| Max. Negotiated Rate |
$2,504.90 |
| Rate for Payer: Aetna Commercial |
$2,450.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,341.54
|
| Rate for Payer: Aetna Managed Medicare |
$762.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,769.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,361.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,306.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,443.04
|
| Rate for Payer: Cash Price |
$785.40
|
| Rate for Payer: Cigna Commercial |
$2,504.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,523.68
|
| Rate for Payer: Health EOS Commercial |
$2,423.22
|
| Rate for Payer: HFN Commercial |
$2,504.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,042.04
|
| Rate for Payer: Multiplan Commercial |
$2,178.18
|
| Rate for Payer: NAPHCARE Commercial |
$1,633.63
|
| Rate for Payer: Preferred Network Access Commercial |
$2,504.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,334.13
|
| Rate for Payer: Quartz Commercial |
$1,769.77
|
| Rate for Payer: Quartz Medicare Advantage |
$1,633.63
|
| Rate for Payer: The Alliance Commercial |
$1,361.36
|
| Rate for Payer: WEA Trust Commercial |
$1,497.50
|
| Rate for Payer: WPS Commercial |
$2,016.65
|
|
|
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 |
$1,334.13 |
| Max. Negotiated Rate |
$2,504.90 |
| Rate for Payer: Aetna Commercial |
$2,450.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,341.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,443.04
|
| Rate for Payer: Cash Price |
$785.40
|
| Rate for Payer: Cigna Commercial |
$2,504.90
|
| Rate for Payer: Health EOS Commercial |
$2,423.22
|
| Rate for Payer: HFN Commercial |
$2,504.90
|
| Rate for Payer: Multiplan Commercial |
$2,178.18
|
| Rate for Payer: Preferred Network Access Commercial |
$2,504.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,334.13
|
| Rate for Payer: Quartz Commercial |
$1,633.63
|
| Rate for Payer: WEA Trust Commercial |
$1,497.50
|
| Rate for Payer: WPS Commercial |
$2,016.65
|
|
|
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 |
$1,334.13 |
| Max. Negotiated Rate |
$2,504.90 |
| Rate for Payer: Aetna Commercial |
$2,450.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,341.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,443.04
|
| Rate for Payer: Cash Price |
$785.40
|
| Rate for Payer: Cigna Commercial |
$2,504.90
|
| Rate for Payer: Health EOS Commercial |
$2,423.22
|
| Rate for Payer: HFN Commercial |
$2,504.90
|
| Rate for Payer: Multiplan Commercial |
$2,178.18
|
| Rate for Payer: Preferred Network Access Commercial |
$2,504.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,334.13
|
| Rate for Payer: Quartz Commercial |
$1,633.63
|
| Rate for Payer: WEA Trust Commercial |
$1,497.50
|
| Rate for Payer: WPS Commercial |
$2,016.65
|
|
|
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 |
$762.36 |
| Max. Negotiated Rate |
$2,504.90 |
| Rate for Payer: Aetna Commercial |
$2,450.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,341.54
|
| Rate for Payer: Aetna Managed Medicare |
$762.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,769.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,361.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,306.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,443.04
|
| Rate for Payer: Cash Price |
$785.40
|
| Rate for Payer: Cigna Commercial |
$2,504.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,523.68
|
| Rate for Payer: Health EOS Commercial |
$2,423.22
|
| Rate for Payer: HFN Commercial |
$2,504.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,042.04
|
| Rate for Payer: Multiplan Commercial |
$2,178.18
|
| Rate for Payer: NAPHCARE Commercial |
$1,633.63
|
| Rate for Payer: Preferred Network Access Commercial |
$2,504.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,334.13
|
| Rate for Payer: Quartz Commercial |
$1,769.77
|
| Rate for Payer: Quartz Medicare Advantage |
$1,633.63
|
| Rate for Payer: The Alliance Commercial |
$1,361.36
|
| Rate for Payer: WEA Trust Commercial |
$1,497.50
|
| Rate for Payer: WPS Commercial |
$2,016.65
|
|
