|
SA Nasal Complete PCR
|
Facility
|
OP
|
$136.00
|
|
|
Service Code
|
CPT 87640
|
| Hospital Charge Code |
4254037
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$140.36 |
| Rate for Payer: Aetna Commercial |
$122.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$116.96
|
| Rate for Payer: Aetna Managed Medicare |
$35.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.25
|
| Rate for Payer: Anthem Medicaid |
$36.26
|
| Rate for Payer: Anthem Medicare Advantage |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$72.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.09
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cigna Commercial |
$125.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$35.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$76.11
|
| Rate for Payer: Dean Health Medicaid |
$36.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$35.09
|
| Rate for Payer: Health EOS Commercial |
$121.04
|
| Rate for Payer: HFN Commercial |
$125.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$35.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$36.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.09
|
| Rate for Payer: Managed Health Services Medicaid |
$37.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$35.09
|
| Rate for Payer: Multiplan Commercial |
$108.80
|
| Rate for Payer: NAPHCARE Commercial |
$52.64
|
| Rate for Payer: Preferred Network Access Commercial |
$125.12
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$36.26
|
| Rate for Payer: Quartz Beloit One Network |
$66.64
|
| Rate for Payer: Quartz Commercial |
$88.40
|
| Rate for Payer: Quartz Medicare Advantage |
$35.09
|
| Rate for Payer: The Alliance Commercial |
$140.36
|
| Rate for Payer: United Healthcare Medicaid |
$36.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare PPO |
$102.00
|
| Rate for Payer: WEA Trust Commercial |
$74.80
|
| Rate for Payer: Wellcare Medicare |
$35.09
|
| Rate for Payer: WMAP Medicaid |
$36.26
|
| Rate for Payer: WPS Commercial |
$100.74
|
|
|
Sandostatin LAR 1 mg Charge
|
Professional
|
Both
|
$459.00
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
2958936
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$201.96 |
| Max. Negotiated Rate |
$526.40 |
| Rate for Payer: Aetna Commercial |
$436.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$394.74
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cigna Commercial |
$436.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$210.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$210.56
|
| Rate for Payer: Health EOS Commercial |
$417.69
|
| Rate for Payer: HFN Commercial |
$436.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$299.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$299.36
|
| Rate for Payer: Multiplan Commercial |
$367.20
|
| Rate for Payer: Preferred Network Access Commercial |
$436.05
|
| Rate for Payer: Quartz Beloit One Network |
$201.96
|
| Rate for Payer: Quartz Commercial |
$261.63
|
| Rate for Payer: The Alliance Commercial |
$229.50
|
| Rate for Payer: United Healthcare Medicaid |
$210.56
|
| Rate for Payer: WEA Trust Commercial |
$252.45
|
| Rate for Payer: WPS Commercial |
$526.40
|
|
|
Sandostatin LAR 1 mg Charge
|
Facility
|
IP
|
$459.00
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
2958936
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$224.91 |
| Max. Negotiated Rate |
$422.28 |
| Rate for Payer: Aetna Commercial |
$413.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$394.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$243.27
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cigna Commercial |
$422.28
|
| Rate for Payer: Health EOS Commercial |
$408.51
|
| Rate for Payer: HFN Commercial |
$422.28
|
| Rate for Payer: Multiplan Commercial |
$367.20
|
| Rate for Payer: NAPHCARE Commercial |
$275.40
|
| Rate for Payer: Preferred Network Access Commercial |
$422.28
|
| Rate for Payer: Quartz Beloit One Network |
$224.91
|
| Rate for Payer: Quartz Commercial |
$275.40
|
| Rate for Payer: WEA Trust Commercial |
$252.45
|
| Rate for Payer: WPS Commercial |
$339.98
|
|
|
Sandostatin LAR 1 mg Charge
|
Facility
|
OP
|
$459.00
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
2958936
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.56 |
| Max. Negotiated Rate |
$843.32 |
| Rate for Payer: Aetna Commercial |
$413.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$394.74
|
| Rate for Payer: Aetna Managed Medicare |
$210.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$210.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$210.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$210.56
|
| Rate for Payer: Anthem Medicare Advantage |
$210.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$243.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$210.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$210.83
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cigna Commercial |
$422.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$210.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$278.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$210.83
|
| Rate for Payer: Health EOS Commercial |
$408.51
|
| Rate for Payer: HFN Commercial |
$422.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$210.83
|
| Rate for Payer: Independent Care Health Plan Medicare |
$210.83
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$210.83
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$210.83
|
| Rate for Payer: Multiplan Commercial |
$367.20
|
| Rate for Payer: NAPHCARE Commercial |
$316.24
|
| Rate for Payer: Preferred Network Access Commercial |
$422.28
|
| Rate for Payer: Quartz Beloit One Network |
$224.91
|
| Rate for Payer: Quartz Commercial |
$298.35
|
| Rate for Payer: Quartz Medicare Advantage |
$210.83
|
| Rate for Payer: The Alliance Commercial |
$843.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$210.83
|
| Rate for Payer: WEA Trust Commercial |
$252.45
|
| Rate for Payer: Wellcare Medicare |
$210.83
|
| Rate for Payer: WPS Commercial |
$526.40
|
|
|
Sandostatin Lar 1mg J2353
|
Facility
|
OP
|
$468.00
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
5516859
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.56 |
| Max. Negotiated Rate |
$843.32 |
| Rate for Payer: Aetna Commercial |
$421.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$402.48
|
| Rate for Payer: Aetna Managed Medicare |
$210.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$210.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$210.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$210.56
|
| Rate for Payer: Anthem Medicare Advantage |
$210.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$248.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$210.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$210.83
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$430.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$210.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$278.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$210.83
|
| Rate for Payer: Health EOS Commercial |
$416.52
|
| Rate for Payer: HFN Commercial |
$430.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$210.83
|
| Rate for Payer: Independent Care Health Plan Medicare |
$210.83
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$210.83
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$210.83
|
| Rate for Payer: Multiplan Commercial |
$374.40
|
| Rate for Payer: NAPHCARE Commercial |
$316.24
|
| Rate for Payer: Preferred Network Access Commercial |
$430.56
|
| Rate for Payer: Quartz Beloit One Network |
$229.32
|
| Rate for Payer: Quartz Commercial |
$304.20
|
| Rate for Payer: Quartz Medicare Advantage |
$210.83
|
| Rate for Payer: The Alliance Commercial |
$843.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$210.83
|
| Rate for Payer: WEA Trust Commercial |
$257.40
|
| Rate for Payer: Wellcare Medicare |
$210.83
|
| Rate for Payer: WPS Commercial |
$526.40
|
|
|
Sandostatin Lar 1mg J2353
|
Professional
|
Both
|
$468.00
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
5516859
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$205.92 |
| Max. Negotiated Rate |
$526.40 |
| Rate for Payer: Aetna Commercial |
$444.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$402.48
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$444.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$210.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$210.56
|
| Rate for Payer: Health EOS Commercial |
$425.88
|
| Rate for Payer: HFN Commercial |
$444.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$299.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$299.36
|
| Rate for Payer: Multiplan Commercial |
$374.40
|
| Rate for Payer: Preferred Network Access Commercial |
$444.60
|
| Rate for Payer: Quartz Beloit One Network |
$205.92
|
| Rate for Payer: Quartz Commercial |
$266.76
|
| Rate for Payer: The Alliance Commercial |
$234.00
|
| Rate for Payer: United Healthcare Medicaid |
$210.56
|
| Rate for Payer: WEA Trust Commercial |
$257.40
|
| Rate for Payer: WPS Commercial |
$526.40
|
|
|
Sandostatin Lar 1mg J2353
|
Facility
|
IP
|
$468.00
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
5516859
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$229.32 |
| Max. Negotiated Rate |
$430.56 |
| Rate for Payer: Aetna Commercial |
$421.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$402.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$248.04
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$430.56
|
| Rate for Payer: Health EOS Commercial |
$416.52
|
| Rate for Payer: HFN Commercial |
$430.56
|
| Rate for Payer: Multiplan Commercial |
$374.40
|
| Rate for Payer: NAPHCARE Commercial |
$280.80
|
| Rate for Payer: Preferred Network Access Commercial |
$430.56
|
| Rate for Payer: Quartz Beloit One Network |
$229.32
|
| Rate for Payer: Quartz Commercial |
$280.80
|
| Rate for Payer: WEA Trust Commercial |
$257.40
|
| Rate for Payer: WPS Commercial |
$346.65
|
|
|
SA,PCR-SSTI
|
Professional
|
Both
|
$168.00
|
|
|
Service Code
|
CPT 87640
|
| Hospital Charge Code |
4125437
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$73.92 |
| Max. Negotiated Rate |
$159.60 |
| Rate for Payer: Aetna Commercial |
$159.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$144.48
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$159.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$84.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$100.80
|
| Rate for Payer: Health EOS Commercial |
$152.88
|
| Rate for Payer: HFN Commercial |
$159.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$123.87
|
| Rate for Payer: Multiplan Commercial |
$134.40
|
| Rate for Payer: Preferred Network Access Commercial |
$159.60
|
| Rate for Payer: Quartz Beloit One Network |
$73.92
|
| Rate for Payer: Quartz Commercial |
$95.76
|
| Rate for Payer: The Alliance Commercial |
$84.00
|
| Rate for Payer: WEA Trust Commercial |
$92.40
|
| Rate for Payer: WPS Commercial |
$124.44
|
|
|
SA,PCR-SSTI
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT 87640
|
| Hospital Charge Code |
4125437
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$154.56 |
| Rate for Payer: Aetna Commercial |
$151.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$144.48
|
| Rate for Payer: Aetna Managed Medicare |
$35.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.25
|
| Rate for Payer: Anthem Medicaid |
$36.26
|
| Rate for Payer: Anthem Medicare Advantage |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.09
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$154.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$35.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.01
|
| Rate for Payer: Dean Health Medicaid |
$36.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$35.09
|
| Rate for Payer: Health EOS Commercial |
$149.52
|
| Rate for Payer: HFN Commercial |
$154.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$35.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$36.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.09
|
| Rate for Payer: Managed Health Services Medicaid |
$37.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$35.09
|
| Rate for Payer: Multiplan Commercial |
$134.40
|
| Rate for Payer: NAPHCARE Commercial |
$52.64
|
| Rate for Payer: Preferred Network Access Commercial |
$154.56
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$36.26
|
| Rate for Payer: Quartz Beloit One Network |
$82.32
|
| Rate for Payer: Quartz Commercial |
$109.20
|
| Rate for Payer: Quartz Medicare Advantage |
$35.09
|
| Rate for Payer: The Alliance Commercial |
$140.36
|
| Rate for Payer: United Healthcare Medicaid |
$36.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare PPO |
$126.00
|
| Rate for Payer: WEA Trust Commercial |
$92.40
|
| Rate for Payer: Wellcare Medicare |
$35.09
|
| Rate for Payer: WMAP Medicaid |
$36.26
|
| Rate for Payer: WPS Commercial |
$124.44
|
|
|
SA,PCR-SSTI
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT 87640
|
| Hospital Charge Code |
4125437
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.32 |
| Max. Negotiated Rate |
$154.56 |
| Rate for Payer: Aetna Commercial |
$151.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$144.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.04
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$154.56
|
| Rate for Payer: Health EOS Commercial |
$149.52
|
| Rate for Payer: HFN Commercial |
$154.56
|
| Rate for Payer: Multiplan Commercial |
$134.40
|
| Rate for Payer: NAPHCARE Commercial |
$100.80
|
| Rate for Payer: Preferred Network Access Commercial |
$154.56
|
| Rate for Payer: Quartz Beloit One Network |
$82.32
|
| Rate for Payer: Quartz Commercial |
$100.80
|
| Rate for Payer: WEA Trust Commercial |
$92.40
|
| Rate for Payer: WPS Commercial |
$124.44
|
|
|
SASSI 3
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2971918
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
SASSI 3
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2971918
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
SASSI A-2
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2971917
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
SASSI A-2
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2971917
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
SAUVE KAPANEDJI PROCEDURE
|
Facility
|
OP
|
$4,170.00
|
|
| Hospital Charge Code |
2960362
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,167.60 |
| Max. Negotiated Rate |
$16,680.00 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,167.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,710.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,085.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,001.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,333.53
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,127.50
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,710.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,502.00
|
| Rate for Payer: The Alliance Commercial |
$16,680.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
SAUVE KAPANEDJI PROCEDURE
|
Facility
|
IP
|
$4,170.00
|
|
| Hospital Charge Code |
2960362
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,043.30 |
| Max. Negotiated Rate |
$3,836.40 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,502.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
SAW BLADE 0.315 X 0.05 IN NARROW SS 200138107S
|
Facility
|
OP
|
$2,384.00
|
|
| Hospital Charge Code |
5831721
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$667.52 |
| Max. Negotiated Rate |
$9,536.00 |
| Rate for Payer: Aetna Commercial |
$2,145.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,050.24
|
| Rate for Payer: Aetna Managed Medicare |
$667.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,549.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,192.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,144.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,263.52
|
| Rate for Payer: Cash Price |
$715.20
|
| Rate for Payer: Cigna Commercial |
$2,193.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,334.09
|
| Rate for Payer: Health EOS Commercial |
$2,121.76
|
| Rate for Payer: HFN Commercial |
$2,193.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,788.00
|
| Rate for Payer: Multiplan Commercial |
$1,907.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,430.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,193.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,168.16
|
| Rate for Payer: Quartz Commercial |
$1,549.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,430.40
|
| Rate for Payer: The Alliance Commercial |
$9,536.00
|
| Rate for Payer: WEA Trust Commercial |
$1,311.20
|
| Rate for Payer: WPS Commercial |
$1,765.83
|
|
|
SAW BLADE 0.315 X 0.05 IN NARROW SS 200138107S
|
Facility
|
IP
|
$2,384.00
|
|
| Hospital Charge Code |
5831721
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,168.16 |
| Max. Negotiated Rate |
$2,193.28 |
| Rate for Payer: Aetna Commercial |
$2,145.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,050.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,263.52
|
| Rate for Payer: Cash Price |
$715.20
|
| Rate for Payer: Cigna Commercial |
$2,193.28
|
| Rate for Payer: Health EOS Commercial |
$2,121.76
|
| Rate for Payer: HFN Commercial |
$2,193.28
|
| Rate for Payer: Multiplan Commercial |
$1,907.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,430.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,193.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,168.16
|
| Rate for Payer: Quartz Commercial |
$1,430.40
|
| Rate for Payer: WEA Trust Commercial |
$1,311.20
|
| Rate for Payer: WPS Commercial |
$1,765.83
|
|
|
SAW BLADE 40MM X 11MM LAPIPLASTY FOR STRYKER SM-4011
|
Facility
|
OP
|
$2,671.00
|
|
| Hospital Charge Code |
5599638
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$747.88 |
| Max. Negotiated Rate |
$10,684.00 |
| Rate for Payer: Aetna Commercial |
$2,403.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,297.06
|
| Rate for Payer: Aetna Managed Medicare |
$747.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,736.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,335.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,282.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,415.63
|
| Rate for Payer: Cash Price |
$801.30
|
| Rate for Payer: Cigna Commercial |
$2,457.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,494.69
|
| Rate for Payer: Health EOS Commercial |
$2,377.19
|
| Rate for Payer: HFN Commercial |
$2,457.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,003.25
|
| Rate for Payer: Multiplan Commercial |
$2,136.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,602.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,457.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,308.79
|
| Rate for Payer: Quartz Commercial |
$1,736.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,602.60
|
| Rate for Payer: The Alliance Commercial |
$10,684.00
|
| Rate for Payer: WEA Trust Commercial |
$1,469.05
|
| Rate for Payer: WPS Commercial |
$1,978.41
|
|
|
SAW BLADE 40MM X 11MM LAPIPLASTY FOR STRYKER SM-4011
|
Facility
|
IP
|
$2,671.00
|
|
| Hospital Charge Code |
5599638
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,308.79 |
| Max. Negotiated Rate |
$2,457.32 |
| Rate for Payer: Aetna Commercial |
$2,403.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,297.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,415.63
|
| Rate for Payer: Cash Price |
$801.30
|
| Rate for Payer: Cigna Commercial |
$2,457.32
|
| Rate for Payer: Health EOS Commercial |
$2,377.19
|
| Rate for Payer: HFN Commercial |
$2,457.32
|
| Rate for Payer: Multiplan Commercial |
$2,136.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,602.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,457.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,308.79
|
| Rate for Payer: Quartz Commercial |
$1,602.60
|
| Rate for Payer: WEA Trust Commercial |
$1,469.05
|
| Rate for Payer: WPS Commercial |
$1,978.41
|
|
|
SAW BLADE MICRO CHOICE WITH STOP C8904
|
Facility
|
OP
|
$1,539.00
|
|
| Hospital Charge Code |
2964873
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$430.92 |
| Max. Negotiated Rate |
$6,156.00 |
| Rate for Payer: Aetna Commercial |
$1,385.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,323.54
|
| Rate for Payer: Aetna Managed Medicare |
$430.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,000.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$769.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$738.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$815.67
|
| Rate for Payer: Cash Price |
$461.70
|
| Rate for Payer: Cigna Commercial |
$1,415.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$861.22
|
| Rate for Payer: Health EOS Commercial |
$1,369.71
|
| Rate for Payer: HFN Commercial |
$1,415.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,154.25
|
| Rate for Payer: Multiplan Commercial |
$1,231.20
|
| Rate for Payer: NAPHCARE Commercial |
$923.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,415.88
|
| Rate for Payer: Quartz Beloit One Network |
$754.11
|
| Rate for Payer: Quartz Commercial |
$1,000.35
|
| Rate for Payer: Quartz Medicare Advantage |
$923.40
|
| Rate for Payer: The Alliance Commercial |
$6,156.00
|
| Rate for Payer: WEA Trust Commercial |
$846.45
|
| Rate for Payer: WPS Commercial |
$1,139.94
|
|
|
SAW BLADE MICRO CHOICE WITH STOP C8904
|
Facility
|
IP
|
$1,539.00
|
|
| Hospital Charge Code |
2964873
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$754.11 |
| Max. Negotiated Rate |
$1,415.88 |
| Rate for Payer: Aetna Commercial |
$1,385.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,323.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$815.67
|
| Rate for Payer: Cash Price |
$461.70
|
| Rate for Payer: Cigna Commercial |
$1,415.88
|
| Rate for Payer: Health EOS Commercial |
$1,369.71
|
| Rate for Payer: HFN Commercial |
$1,415.88
|
| Rate for Payer: Multiplan Commercial |
$1,231.20
|
| Rate for Payer: NAPHCARE Commercial |
$923.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,415.88
|
| Rate for Payer: Quartz Beloit One Network |
$754.11
|
| Rate for Payer: Quartz Commercial |
$923.40
|
| Rate for Payer: WEA Trust Commercial |
$846.45
|
| Rate for Payer: WPS Commercial |
$1,139.94
|
|
|
SAW BLADE OXFORD KNEE RESECTION OSCILLATING 90 X 13 X .89 13-0900-89Y-F1
|
Facility
|
IP
|
$2,012.00
|
|
| Hospital Charge Code |
6181518
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$985.88 |
| Max. Negotiated Rate |
$1,851.04 |
| Rate for Payer: Aetna Commercial |
$1,810.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,730.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,066.36
|
| Rate for Payer: Cash Price |
$603.60
|
| Rate for Payer: Cigna Commercial |
$1,851.04
|
| Rate for Payer: Health EOS Commercial |
$1,790.68
|
| Rate for Payer: HFN Commercial |
$1,851.04
|
| Rate for Payer: Multiplan Commercial |
$1,609.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,207.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,851.04
|
| Rate for Payer: Quartz Beloit One Network |
$985.88
|
| Rate for Payer: Quartz Commercial |
$1,207.20
|
| Rate for Payer: WEA Trust Commercial |
$1,106.60
|
| Rate for Payer: WPS Commercial |
$1,490.29
|
|
|
SAW BLADE OXFORD KNEE RESECTION OSCILLATING 90 X 13 X .89 13-0900-89Y-F1
|
Facility
|
OP
|
$2,012.00
|
|
| Hospital Charge Code |
6181518
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$563.36 |
| Max. Negotiated Rate |
$8,048.00 |
| Rate for Payer: Aetna Commercial |
$1,810.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,730.32
|
| Rate for Payer: Aetna Managed Medicare |
$563.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,307.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,006.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$965.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,066.36
|
| Rate for Payer: Cash Price |
$603.60
|
| Rate for Payer: Cigna Commercial |
$1,851.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,125.92
|
| Rate for Payer: Health EOS Commercial |
$1,790.68
|
| Rate for Payer: HFN Commercial |
$1,851.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,509.00
|
| Rate for Payer: Multiplan Commercial |
$1,609.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,207.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,851.04
|
| Rate for Payer: Quartz Beloit One Network |
$985.88
|
| Rate for Payer: Quartz Commercial |
$1,307.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,207.20
|
| Rate for Payer: The Alliance Commercial |
$8,048.00
|
| Rate for Payer: WEA Trust Commercial |
$1,106.60
|
| Rate for Payer: WPS Commercial |
$1,490.29
|
|
|
SAW BLADE OXFORD KNEE RESECTION PROCEDURE 3 PACK 506298
|
Facility
|
IP
|
$7,181.00
|
|
| Hospital Charge Code |
4595635
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
