|
REINFORCEMENT GORE SEAMGUARD ETHICON PROXIMATE 75 12OBSGPROX75
|
Facility
|
IP
|
$12,314.00
|
|
| Hospital Charge Code |
4640790
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6,033.86 |
| Max. Negotiated Rate |
$11,328.88 |
| Rate for Payer: Aetna Commercial |
$11,082.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,590.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,526.42
|
| Rate for Payer: Cash Price |
$3,694.20
|
| Rate for Payer: Cigna Commercial |
$11,328.88
|
| Rate for Payer: Health EOS Commercial |
$10,959.46
|
| Rate for Payer: HFN Commercial |
$11,328.88
|
| Rate for Payer: Multiplan Commercial |
$9,851.20
|
| Rate for Payer: NAPHCARE Commercial |
$7,388.40
|
| Rate for Payer: Preferred Network Access Commercial |
$11,328.88
|
| Rate for Payer: Quartz Beloit One Network |
$6,033.86
|
| Rate for Payer: Quartz Commercial |
$7,388.40
|
| Rate for Payer: WEA Trust Commercial |
$6,772.70
|
| Rate for Payer: WPS Commercial |
$9,120.98
|
|
|
REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT
|
Facility
|
OP
|
$28,284.48
|
|
|
Service Code
|
CPT 24342
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,546.14 |
| Max. Negotiated Rate |
$28,284.48 |
| Rate for Payer: Aetna Managed Medicare |
$7,071.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,483.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,081.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,278.00
|
| Rate for Payer: Anthem Medicare Advantage |
$7,071.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,071.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,071.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,071.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,071.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,304.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,071.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,071.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,071.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,071.12
|
| Rate for Payer: NAPHCARE Commercial |
$10,606.68
|
| Rate for Payer: Quartz Medicare Advantage |
$7,071.12
|
| Rate for Payer: The Alliance Commercial |
$28,284.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,071.12
|
| Rate for Payer: United Healthcare PPO |
$8,452.00
|
| Rate for Payer: Wellcare Medicare |
$7,071.12
|
|
|
RELEASE OF BIG TOE 28240
|
Professional
|
Both
|
$1,310.00
|
|
|
Service Code
|
CPT 28240
|
| Hospital Charge Code |
3014224
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,244.50 |
| Rate for Payer: Aetna Commercial |
$1,244.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,126.60
|
| Rate for Payer: Cash Price |
$393.00
|
| Rate for Payer: Cash Price |
$393.00
|
| Rate for Payer: Cash Price |
$393.00
|
| Rate for Payer: Cigna Commercial |
$1,244.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$226.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$786.00
|
| Rate for Payer: Health EOS Commercial |
$1,192.10
|
| Rate for Payer: HFN Commercial |
$1,244.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$992.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$992.88
|
| Rate for Payer: Multiplan Commercial |
$1,048.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,244.50
|
| Rate for Payer: Quartz Beloit One Network |
$576.40
|
| Rate for Payer: Quartz Commercial |
$746.70
|
| Rate for Payer: The Alliance Commercial |
$655.00
|
| Rate for Payer: United Healthcare Medicaid |
$226.00
|
| Rate for Payer: WEA Trust Commercial |
$720.50
|
| Rate for Payer: WPS Commercial |
$970.32
|
|
|
RELEASE OF FOOT CONTRACTURE 28270
|
Professional
|
Both
|
$1,145.00
|
|
|
Service Code
|
CPT 28270
|
| Hospital Charge Code |
3014226
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$503.80 |
| Max. Negotiated Rate |
$1,128.29 |
| Rate for Payer: Aetna Commercial |
$1,087.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$984.70
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cigna Commercial |
$1,087.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$538.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$687.00
|
| Rate for Payer: Health EOS Commercial |
$1,041.95
|
| Rate for Payer: HFN Commercial |
$1,087.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,128.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,128.29
|
| Rate for Payer: Multiplan Commercial |
$916.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,087.75
|
| Rate for Payer: Quartz Beloit One Network |
$503.80
|
| Rate for Payer: Quartz Commercial |
$652.65
|
| Rate for Payer: The Alliance Commercial |
$572.50
|
| Rate for Payer: United Healthcare Medicaid |
$538.00
|
| Rate for Payer: WEA Trust Commercial |
$629.75
|
| Rate for Payer: WPS Commercial |
$848.10
|
|
|
RELEASE OF FOOT TENDON 28220
|
Professional
|
Both
|
$1,858.00
|
|
|
Service Code
|
CPT 28220
|
| Hospital Charge Code |
3014218
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$376.66 |
| Max. Negotiated Rate |
$1,765.10 |
| Rate for Payer: Aetna Commercial |
$1,765.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,597.88
|
| Rate for Payer: Cash Price |
$557.40
|
| Rate for Payer: Cash Price |
$557.40
|
| Rate for Payer: Cash Price |
$557.40
|
| Rate for Payer: Cigna Commercial |
$1,765.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$376.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,114.80
|
| Rate for Payer: Health EOS Commercial |
$1,690.78
|
| Rate for Payer: HFN Commercial |
$1,765.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,024.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,024.83
|
| Rate for Payer: Multiplan Commercial |
$1,486.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,765.10
|
| Rate for Payer: Quartz Beloit One Network |
$817.52
|
| Rate for Payer: Quartz Commercial |
$1,059.06
|
| Rate for Payer: The Alliance Commercial |
$929.00
|
| Rate for Payer: United Healthcare Medicaid |
$376.66
|
| Rate for Payer: WEA Trust Commercial |
$1,021.90
|
| Rate for Payer: WPS Commercial |
$1,376.22
|
|
|
RELEASE OF FOOT TENDON 28225
|
Professional
|
Both
|
$1,424.00
|
|
|
Service Code
|
CPT 28225
|
| Hospital Charge Code |
3014219
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$110.44 |
| Max. Negotiated Rate |
$1,352.80 |
| Rate for Payer: Aetna Commercial |
$1,352.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,224.64
|
| Rate for Payer: Cash Price |
$427.20
|
| Rate for Payer: Cash Price |
$427.20
|
| Rate for Payer: Cash Price |
$427.20
|
| Rate for Payer: Cigna Commercial |
$1,352.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$110.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$854.40
|
| Rate for Payer: Health EOS Commercial |
$1,295.84
|
| Rate for Payer: HFN Commercial |
$1,352.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$891.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$891.64
|
| Rate for Payer: Multiplan Commercial |
$1,139.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,352.80
|
| Rate for Payer: Quartz Beloit One Network |
$626.56
|
| Rate for Payer: Quartz Commercial |
$811.68
|
| Rate for Payer: The Alliance Commercial |
$712.00
|
| Rate for Payer: United Healthcare Medicaid |
$110.44
|
| Rate for Payer: WEA Trust Commercial |
$783.20
|
| Rate for Payer: WPS Commercial |
$1,054.76
|
|
|
RELEASE OF TOE JOINT, EACH 28272
|
Professional
|
Both
|
$950.00
|
|
|
Service Code
|
CPT 28272
|
| Hospital Charge Code |
3014227
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$235.52 |
| Max. Negotiated Rate |
$902.50 |
| Rate for Payer: Aetna Commercial |
$902.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$817.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$902.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$235.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$570.00
|
| Rate for Payer: Health EOS Commercial |
$864.50
|
| Rate for Payer: HFN Commercial |
$902.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$850.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$850.34
|
| Rate for Payer: Multiplan Commercial |
$760.00
|
| Rate for Payer: Preferred Network Access Commercial |
$902.50
|
| Rate for Payer: Quartz Beloit One Network |
$418.00
|
| Rate for Payer: Quartz Commercial |
$541.50
|
| Rate for Payer: The Alliance Commercial |
$475.00
|
| Rate for Payer: United Healthcare Medicaid |
$235.52
|
| Rate for Payer: WEA Trust Commercial |
$522.50
|
| Rate for Payer: WPS Commercial |
$703.66
|
|
|
Release Palm Contracture 26040
|
Professional
|
Both
|
$1,991.00
|
|
|
Service Code
|
CPT 26040
|
| Hospital Charge Code |
4590637
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$150.66 |
| Max. Negotiated Rate |
$1,891.45 |
| Rate for Payer: Aetna Commercial |
$1,891.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,712.26
|
| Rate for Payer: Cash Price |
$597.30
|
| Rate for Payer: Cash Price |
$597.30
|
| Rate for Payer: Cash Price |
$597.30
|
| Rate for Payer: Cigna Commercial |
$1,891.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$150.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,194.60
|
| Rate for Payer: Health EOS Commercial |
$1,811.81
|
| Rate for Payer: HFN Commercial |
$1,891.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,060.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,060.24
|
| Rate for Payer: Multiplan Commercial |
$1,592.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,891.45
|
| Rate for Payer: Quartz Beloit One Network |
$876.04
|
| Rate for Payer: Quartz Commercial |
$1,134.87
|
| Rate for Payer: The Alliance Commercial |
$995.50
|
| Rate for Payer: United Healthcare Medicaid |
$150.66
|
| Rate for Payer: WEA Trust Commercial |
$1,095.05
|
| Rate for Payer: WPS Commercial |
$1,474.73
|
|
|
Release Palm Contracture 2604050
|
Professional
|
Both
|
$3,755.00
|
|
|
Service Code
|
CPT 26040 50
|
| Hospital Charge Code |
5442684
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$150.66 |
| Max. Negotiated Rate |
$3,567.25 |
| Rate for Payer: Aetna Commercial |
$3,567.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,229.30
|
| Rate for Payer: Cash Price |
$1,126.50
|
| Rate for Payer: Cash Price |
$1,126.50
|
| Rate for Payer: Cash Price |
$1,126.50
|
| Rate for Payer: Cigna Commercial |
$3,567.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$150.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,253.00
|
| Rate for Payer: Health EOS Commercial |
$3,417.05
|
| Rate for Payer: HFN Commercial |
$3,567.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,060.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,060.24
|
| Rate for Payer: Multiplan Commercial |
$3,004.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,567.25
|
| Rate for Payer: Quartz Beloit One Network |
$1,652.20
|
| Rate for Payer: Quartz Commercial |
$2,140.35
|
| Rate for Payer: The Alliance Commercial |
$1,877.50
|
| Rate for Payer: United Healthcare Medicaid |
$150.66
|
| Rate for Payer: WEA Trust Commercial |
$2,065.25
|
| Rate for Payer: WPS Commercial |
$2,781.33
|
|
|
RELOAD #0 POLYSORB ENDO STITCH 48 VIOLET 170052"
|
Facility
|
IP
|
$996.00
|
|
| Hospital Charge Code |
5382987
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$488.04 |
| Max. Negotiated Rate |
$916.32 |
| Rate for Payer: Aetna Commercial |
$896.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$856.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$527.88
|
| Rate for Payer: Cash Price |
$298.80
|
| Rate for Payer: Cigna Commercial |
$916.32
|
| Rate for Payer: Health EOS Commercial |
$886.44
|
| Rate for Payer: HFN Commercial |
$916.32
|
| Rate for Payer: Multiplan Commercial |
$796.80
|
| Rate for Payer: NAPHCARE Commercial |
$597.60
|
| Rate for Payer: Preferred Network Access Commercial |
$916.32
|
| Rate for Payer: Quartz Beloit One Network |
$488.04
|
| Rate for Payer: Quartz Commercial |
$597.60
|
| Rate for Payer: WEA Trust Commercial |
$547.80
|
| Rate for Payer: WPS Commercial |
$737.74
|
|
|
RELOAD #0 POLYSORB ENDO STITCH 48 VIOLET 170052"
|
Facility
|
OP
|
$996.00
|
|
| Hospital Charge Code |
5382987
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$278.88 |
| Max. Negotiated Rate |
$3,984.00 |
| Rate for Payer: Aetna Commercial |
$896.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$856.56
|
| Rate for Payer: Aetna Managed Medicare |
$278.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$647.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$498.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$478.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$527.88
|
| Rate for Payer: Cash Price |
$298.80
|
| Rate for Payer: Cigna Commercial |
$916.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$557.36
|
| Rate for Payer: Health EOS Commercial |
$886.44
|
| Rate for Payer: HFN Commercial |
$916.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$747.00
|
| Rate for Payer: Multiplan Commercial |
$796.80
|
| Rate for Payer: NAPHCARE Commercial |
$597.60
|
| Rate for Payer: Preferred Network Access Commercial |
$916.32
|
| Rate for Payer: Quartz Beloit One Network |
$488.04
|
| Rate for Payer: Quartz Commercial |
$647.40
|
| Rate for Payer: Quartz Medicare Advantage |
$597.60
|
| Rate for Payer: The Alliance Commercial |
$3,984.00
|
| Rate for Payer: WEA Trust Commercial |
$547.80
|
| Rate for Payer: WPS Commercial |
$737.74
|
|
|
RELOAD #0 SUSRGIDAC ENDO STITCH 48 GRN 173024"
|
Facility
|
IP
|
$1,259.00
|
|
| Hospital Charge Code |
2965508
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$616.91 |
| Max. Negotiated Rate |
$1,158.28 |
| Rate for Payer: Aetna Commercial |
$1,133.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,082.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$667.27
|
| Rate for Payer: Cash Price |
$377.70
|
| Rate for Payer: Cigna Commercial |
$1,158.28
|
| Rate for Payer: Health EOS Commercial |
$1,120.51
|
| Rate for Payer: HFN Commercial |
$1,158.28
|
| Rate for Payer: Multiplan Commercial |
$1,007.20
|
| Rate for Payer: NAPHCARE Commercial |
$755.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,158.28
|
| Rate for Payer: Quartz Beloit One Network |
$616.91
|
| Rate for Payer: Quartz Commercial |
$755.40
|
| Rate for Payer: WEA Trust Commercial |
$692.45
|
| Rate for Payer: WPS Commercial |
$932.54
|
|
|
RELOAD #0 SUSRGIDAC ENDO STITCH 48 GRN 173024"
|
Facility
|
OP
|
$1,259.00
|
|
| Hospital Charge Code |
2965508
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$352.52 |
| Max. Negotiated Rate |
$5,036.00 |
| Rate for Payer: Aetna Commercial |
$1,133.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,082.74
|
| Rate for Payer: Aetna Managed Medicare |
$352.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$818.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$629.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$604.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$667.27
|
| Rate for Payer: Cash Price |
$377.70
|
| Rate for Payer: Cigna Commercial |
$1,158.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$704.54
|
| Rate for Payer: Health EOS Commercial |
$1,120.51
|
| Rate for Payer: HFN Commercial |
$1,158.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$944.25
|
| Rate for Payer: Multiplan Commercial |
$1,007.20
|
| Rate for Payer: NAPHCARE Commercial |
$755.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,158.28
|
| Rate for Payer: Quartz Beloit One Network |
$616.91
|
| Rate for Payer: Quartz Commercial |
$818.35
|
| Rate for Payer: Quartz Medicare Advantage |
$755.40
|
| Rate for Payer: The Alliance Commercial |
$5,036.00
|
| Rate for Payer: WEA Trust Commercial |
$692.45
|
| Rate for Payer: WPS Commercial |
$932.54
|
|
|
RELOAD 2-0 POLYSORB ENDO STITCH 48 VIOLET 170053"
|
Facility
|
IP
|
$996.00
|
|
| Hospital Charge Code |
5382988
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$488.04 |
| Max. Negotiated Rate |
$916.32 |
| Rate for Payer: Aetna Commercial |
$896.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$856.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$527.88
|
| Rate for Payer: Cash Price |
$298.80
|
| Rate for Payer: Cigna Commercial |
$916.32
|
| Rate for Payer: Health EOS Commercial |
$886.44
|
| Rate for Payer: HFN Commercial |
$916.32
|
| Rate for Payer: Multiplan Commercial |
$796.80
|
| Rate for Payer: NAPHCARE Commercial |
$597.60
|
| Rate for Payer: Preferred Network Access Commercial |
$916.32
|
| Rate for Payer: Quartz Beloit One Network |
$488.04
|
| Rate for Payer: Quartz Commercial |
$597.60
|
| Rate for Payer: WEA Trust Commercial |
$547.80
|
| Rate for Payer: WPS Commercial |
$737.74
|
|
|
RELOAD 2-0 POLYSORB ENDO STITCH 48 VIOLET 170053"
|
Facility
|
OP
|
$996.00
|
|
| Hospital Charge Code |
5382988
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$278.88 |
| Max. Negotiated Rate |
$3,984.00 |
| Rate for Payer: Aetna Commercial |
$896.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$856.56
|
| Rate for Payer: Aetna Managed Medicare |
$278.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$647.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$498.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$478.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$527.88
|
| Rate for Payer: Cash Price |
$298.80
|
| Rate for Payer: Cigna Commercial |
$916.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$557.36
|
| Rate for Payer: Health EOS Commercial |
$886.44
|
| Rate for Payer: HFN Commercial |
$916.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$747.00
|
| Rate for Payer: Multiplan Commercial |
$796.80
|
| Rate for Payer: NAPHCARE Commercial |
$597.60
|
| Rate for Payer: Preferred Network Access Commercial |
$916.32
|
| Rate for Payer: Quartz Beloit One Network |
$488.04
|
| Rate for Payer: Quartz Commercial |
$647.40
|
| Rate for Payer: Quartz Medicare Advantage |
$597.60
|
| Rate for Payer: The Alliance Commercial |
$3,984.00
|
| Rate for Payer: WEA Trust Commercial |
$547.80
|
| Rate for Payer: WPS Commercial |
$737.74
|
|
|
RELOAD 2-0 SURGIDAC ENDO STITCH 48 GRN 173023"
|
Facility
|
OP
|
$1,259.00
|
|
| Hospital Charge Code |
2965509
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$352.52 |
| Max. Negotiated Rate |
$5,036.00 |
| Rate for Payer: Aetna Commercial |
$1,133.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,082.74
|
| Rate for Payer: Aetna Managed Medicare |
$352.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$818.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$629.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$604.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$667.27
|
| Rate for Payer: Cash Price |
$377.70
|
| Rate for Payer: Cigna Commercial |
$1,158.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$704.54
|
| Rate for Payer: Health EOS Commercial |
$1,120.51
|
| Rate for Payer: HFN Commercial |
$1,158.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$944.25
|
| Rate for Payer: Multiplan Commercial |
$1,007.20
|
| Rate for Payer: NAPHCARE Commercial |
$755.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,158.28
|
| Rate for Payer: Quartz Beloit One Network |
$616.91
|
| Rate for Payer: Quartz Commercial |
$818.35
|
| Rate for Payer: Quartz Medicare Advantage |
$755.40
|
| Rate for Payer: The Alliance Commercial |
$5,036.00
|
| Rate for Payer: WEA Trust Commercial |
$692.45
|
| Rate for Payer: WPS Commercial |
$932.54
|
|
|
RELOAD 2-0 SURGIDAC ENDO STITCH 48 GRN 173023"
|
Facility
|
IP
|
$1,259.00
|
|
| Hospital Charge Code |
2965509
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$616.91 |
| Max. Negotiated Rate |
$1,158.28 |
| Rate for Payer: Aetna Commercial |
$1,133.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,082.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$667.27
|
| Rate for Payer: Cash Price |
$377.70
|
| Rate for Payer: Cigna Commercial |
$1,158.28
|
| Rate for Payer: Health EOS Commercial |
$1,120.51
|
| Rate for Payer: HFN Commercial |
$1,158.28
|
| Rate for Payer: Multiplan Commercial |
$1,007.20
|
| Rate for Payer: NAPHCARE Commercial |
$755.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,158.28
|
| Rate for Payer: Quartz Beloit One Network |
$616.91
|
| Rate for Payer: Quartz Commercial |
$755.40
|
| Rate for Payer: WEA Trust Commercial |
$692.45
|
| Rate for Payer: WPS Commercial |
$932.54
|
|
|
RELOAD RELIATACK 5 DEEP RELTACK5RDPTSW
|
Facility
|
OP
|
$1,756.00
|
|
| Hospital Charge Code |
4640928
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$491.68 |
| Max. Negotiated Rate |
$7,024.00 |
| Rate for Payer: Aetna Commercial |
$1,580.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,510.16
|
| Rate for Payer: Aetna Managed Medicare |
$491.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,141.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$878.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$842.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$930.68
|
| Rate for Payer: Cash Price |
$526.80
|
| Rate for Payer: Cigna Commercial |
$1,615.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$982.66
|
| Rate for Payer: Health EOS Commercial |
$1,562.84
|
| Rate for Payer: HFN Commercial |
$1,615.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,317.00
|
| Rate for Payer: Multiplan Commercial |
$1,404.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,053.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,615.52
|
| Rate for Payer: Quartz Beloit One Network |
$860.44
|
| Rate for Payer: Quartz Commercial |
$1,141.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,053.60
|
| Rate for Payer: The Alliance Commercial |
$7,024.00
|
| Rate for Payer: WEA Trust Commercial |
$965.80
|
| Rate for Payer: WPS Commercial |
$1,300.67
|
|
|
RELOAD RELIATACK 5 DEEP RELTACK5RDPTSW
|
Facility
|
IP
|
$1,756.00
|
|
| Hospital Charge Code |
4640928
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$860.44 |
| Max. Negotiated Rate |
$1,615.52 |
| Rate for Payer: Aetna Commercial |
$1,580.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,510.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$930.68
|
| Rate for Payer: Cash Price |
$526.80
|
| Rate for Payer: Cigna Commercial |
$1,615.52
|
| Rate for Payer: Health EOS Commercial |
$1,562.84
|
| Rate for Payer: HFN Commercial |
$1,615.52
|
| Rate for Payer: Multiplan Commercial |
$1,404.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,053.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,615.52
|
| Rate for Payer: Quartz Beloit One Network |
$860.44
|
| Rate for Payer: Quartz Commercial |
$1,053.60
|
| Rate for Payer: WEA Trust Commercial |
$965.80
|
| Rate for Payer: WPS Commercial |
$1,300.67
|
|
|
RELOAD RELIATACK 8 DEEP RELTACK8RDPTSW
|
Facility
|
IP
|
$2,392.00
|
|
| Hospital Charge Code |
4640733
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,172.08 |
| Max. Negotiated Rate |
$2,200.64 |
| Rate for Payer: Aetna Commercial |
$2,152.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,057.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,267.76
|
| Rate for Payer: Cash Price |
$717.60
|
| Rate for Payer: Cigna Commercial |
$2,200.64
|
| Rate for Payer: Health EOS Commercial |
$2,128.88
|
| Rate for Payer: HFN Commercial |
$2,200.64
|
| Rate for Payer: Multiplan Commercial |
$1,913.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,435.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,200.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,172.08
|
| Rate for Payer: Quartz Commercial |
$1,435.20
|
| Rate for Payer: WEA Trust Commercial |
$1,315.60
|
| Rate for Payer: WPS Commercial |
$1,771.75
|
|
|
RELOAD RELIATACK 8 DEEP RELTACK8RDPTSW
|
Facility
|
OP
|
$2,392.00
|
|
| Hospital Charge Code |
4640733
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$669.76 |
| Max. Negotiated Rate |
$9,568.00 |
| Rate for Payer: Aetna Commercial |
$2,152.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,057.12
|
| Rate for Payer: Aetna Managed Medicare |
$669.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,554.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,196.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,148.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,267.76
|
| Rate for Payer: Cash Price |
$717.60
|
| Rate for Payer: Cigna Commercial |
$2,200.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,338.56
|
| Rate for Payer: Health EOS Commercial |
$2,128.88
|
| Rate for Payer: HFN Commercial |
$2,200.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,794.00
|
| Rate for Payer: Multiplan Commercial |
$1,913.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,435.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,200.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,172.08
|
| Rate for Payer: Quartz Commercial |
$1,554.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,435.20
|
| Rate for Payer: The Alliance Commercial |
$9,568.00
|
| Rate for Payer: WEA Trust Commercial |
$1,315.60
|
| Rate for Payer: WPS Commercial |
$1,771.75
|
|
|
Rem endovas vena cava filter 37193
|
Professional
|
Both
|
$7,139.00
|
|
|
Service Code
|
CPT 37193
|
| Hospital Charge Code |
3014545
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,142.73 |
| Max. Negotiated Rate |
$6,782.05 |
| Rate for Payer: Aetna Commercial |
$6,782.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,139.54
|
| Rate for Payer: Cash Price |
$2,141.70
|
| Rate for Payer: Cash Price |
$2,141.70
|
| Rate for Payer: Cash Price |
$2,141.70
|
| Rate for Payer: Cigna Commercial |
$6,782.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,304.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,283.40
|
| Rate for Payer: Health EOS Commercial |
$6,496.49
|
| Rate for Payer: HFN Commercial |
$6,782.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,142.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,142.73
|
| Rate for Payer: Multiplan Commercial |
$5,711.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,782.05
|
| Rate for Payer: Quartz Beloit One Network |
$3,141.16
|
| Rate for Payer: Quartz Commercial |
$4,069.23
|
| Rate for Payer: The Alliance Commercial |
$3,569.50
|
| Rate for Payer: United Healthcare Medicaid |
$1,304.75
|
| Rate for Payer: WEA Trust Commercial |
$3,926.45
|
| Rate for Payer: WPS Commercial |
$5,287.86
|
|
|
Remicade 10 mg Charge
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
2958931
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.67 |
| Max. Negotiated Rate |
$300.84 |
| Rate for Payer: Aetna Commercial |
$294.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$281.22
|
| Rate for Payer: Aetna Managed Medicare |
$32.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.67
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.67
|
| Rate for Payer: Anthem Medicare Advantage |
$32.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$173.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$32.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$32.16
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$300.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$32.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$32.16
|
| Rate for Payer: Health EOS Commercial |
$291.03
|
| Rate for Payer: HFN Commercial |
$300.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$32.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$32.16
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$32.16
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$32.16
|
| Rate for Payer: Multiplan Commercial |
$261.60
|
| Rate for Payer: NAPHCARE Commercial |
$48.24
|
| Rate for Payer: Preferred Network Access Commercial |
$300.84
|
| Rate for Payer: Quartz Beloit One Network |
$160.23
|
| Rate for Payer: Quartz Commercial |
$212.55
|
| Rate for Payer: Quartz Medicare Advantage |
$32.16
|
| Rate for Payer: The Alliance Commercial |
$128.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.16
|
| Rate for Payer: WEA Trust Commercial |
$179.85
|
| Rate for Payer: Wellcare Medicare |
$32.16
|
| Rate for Payer: WPS Commercial |
$79.18
|
|
|
Remicade 10 mg Charge
|
Professional
|
Both
|
$327.00
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
2958931
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.67 |
| Max. Negotiated Rate |
$310.65 |
| Rate for Payer: Aetna Commercial |
$310.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$281.22
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$310.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.67
|
| Rate for Payer: Health EOS Commercial |
$297.57
|
| Rate for Payer: HFN Commercial |
$310.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$61.25
|
| Rate for Payer: Multiplan Commercial |
$261.60
|
| Rate for Payer: Preferred Network Access Commercial |
$310.65
|
| Rate for Payer: Quartz Beloit One Network |
$143.88
|
| Rate for Payer: Quartz Commercial |
$186.39
|
| Rate for Payer: The Alliance Commercial |
$163.50
|
| Rate for Payer: United Healthcare Medicaid |
$31.67
|
| Rate for Payer: WEA Trust Commercial |
$179.85
|
| Rate for Payer: WPS Commercial |
$79.18
|
|
|
Remicade 10 mg Charge
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
2958931
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.23 |
| Max. Negotiated Rate |
$300.84 |
| Rate for Payer: Aetna Commercial |
$294.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$281.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$173.31
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$300.84
|
| Rate for Payer: Health EOS Commercial |
$291.03
|
| Rate for Payer: HFN Commercial |
$300.84
|
| Rate for Payer: Multiplan Commercial |
$261.60
|
| Rate for Payer: NAPHCARE Commercial |
$196.20
|
| Rate for Payer: Preferred Network Access Commercial |
$300.84
|
| Rate for Payer: Quartz Beloit One Network |
$160.23
|
| Rate for Payer: Quartz Commercial |
$196.20
|
| Rate for Payer: WEA Trust Commercial |
$179.85
|
| Rate for Payer: WPS Commercial |
$242.21
|
|
