|
Purkinje Type 1, 2 & TR
|
Facility
|
OP
|
$266.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
2942954
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$244.72 |
| Rate for Payer: Aetna Commercial |
$239.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$228.76
|
| Rate for Payer: Aetna Managed Medicare |
$12.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.00
|
| Rate for Payer: Anthem Medicaid |
$12.45
|
| Rate for Payer: Anthem Medicare Advantage |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.05
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna Commercial |
$244.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$148.85
|
| Rate for Payer: Dean Health Medicaid |
$12.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.05
|
| Rate for Payer: Health EOS Commercial |
$236.74
|
| Rate for Payer: HFN Commercial |
$244.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.05
|
| Rate for Payer: Managed Health Services Medicaid |
$12.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.05
|
| Rate for Payer: Multiplan Commercial |
$212.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.08
|
| Rate for Payer: Preferred Network Access Commercial |
$244.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.45
|
| Rate for Payer: Quartz Beloit One Network |
$130.34
|
| Rate for Payer: Quartz Commercial |
$172.90
|
| Rate for Payer: Quartz Medicare Advantage |
$12.05
|
| Rate for Payer: The Alliance Commercial |
$48.20
|
| Rate for Payer: United Healthcare Medicaid |
$12.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.05
|
| Rate for Payer: United Healthcare PPO |
$199.50
|
| Rate for Payer: WEA Trust Commercial |
$146.30
|
| Rate for Payer: Wellcare Medicare |
$12.05
|
| Rate for Payer: WMAP Medicaid |
$12.45
|
| Rate for Payer: WPS Commercial |
$197.03
|
|
|
Purkinje Type 1, 2 & TR
|
Professional
|
Both
|
$266.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
2942954
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$252.70 |
| Rate for Payer: Aetna Commercial |
$252.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$228.76
|
| Rate for Payer: Anthem Commercial |
$16.61
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna Commercial |
$252.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$133.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.60
|
| Rate for Payer: Health EOS Commercial |
$242.06
|
| Rate for Payer: HFN Commercial |
$252.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.54
|
| Rate for Payer: Multiplan Commercial |
$212.80
|
| Rate for Payer: Preferred Network Access Commercial |
$252.70
|
| Rate for Payer: Quartz Beloit One Network |
$117.04
|
| Rate for Payer: Quartz Commercial |
$151.62
|
| Rate for Payer: The Alliance Commercial |
$133.00
|
| Rate for Payer: WEA Trust Commercial |
$146.30
|
| Rate for Payer: WPS Commercial |
$197.03
|
|
|
Purkinje Type 1, 2 & TR
|
Facility
|
IP
|
$266.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
2942954
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$130.34 |
| Max. Negotiated Rate |
$244.72 |
| Rate for Payer: Aetna Commercial |
$239.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$228.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.98
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna Commercial |
$244.72
|
| Rate for Payer: Health EOS Commercial |
$236.74
|
| Rate for Payer: HFN Commercial |
$244.72
|
| Rate for Payer: Multiplan Commercial |
$212.80
|
| Rate for Payer: NAPHCARE Commercial |
$159.60
|
| Rate for Payer: Preferred Network Access Commercial |
$244.72
|
| Rate for Payer: Quartz Beloit One Network |
$130.34
|
| Rate for Payer: Quartz Commercial |
$159.60
|
| Rate for Payer: WEA Trust Commercial |
$146.30
|
| Rate for Payer: WPS Commercial |
$197.03
|
|
|
Purkinje Type 2
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
2942955
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$48.60
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Purkinje Type 2
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
2942955
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Aetna Managed Medicare |
$12.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.00
|
| Rate for Payer: Anthem Medicaid |
$12.45
|
| Rate for Payer: Anthem Medicare Advantage |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.05
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.33
|
| Rate for Payer: Dean Health Medicaid |
$12.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.05
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.05
|
| Rate for Payer: Managed Health Services Medicaid |
$12.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.05
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.08
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.45
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$52.65
|
| Rate for Payer: Quartz Medicare Advantage |
$12.05
|
| Rate for Payer: The Alliance Commercial |
$48.20
|
| Rate for Payer: United Healthcare Medicaid |
$12.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.05
|
| Rate for Payer: United Healthcare PPO |
$60.75
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: Wellcare Medicare |
$12.05
|
| Rate for Payer: WMAP Medicaid |
$12.45
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Purkinje Type 2
|
Professional
|
Both
|
$81.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
2942955
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$76.95 |
| Rate for Payer: Aetna Commercial |
$76.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Anthem Commercial |
$16.61
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$76.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$40.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.60
|
| Rate for Payer: Health EOS Commercial |
$73.71
|
| Rate for Payer: HFN Commercial |
$76.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.54
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: Preferred Network Access Commercial |
$76.95
|
| Rate for Payer: Quartz Beloit One Network |
$35.64
|
| Rate for Payer: Quartz Commercial |
$46.17
|
| Rate for Payer: The Alliance Commercial |
$40.50
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Purkinje Type TR
|
Professional
|
Both
|
$81.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
2942956
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$76.95 |
| Rate for Payer: Aetna Commercial |
$76.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Anthem Commercial |
$16.61
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$76.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$40.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.60
|
| Rate for Payer: Health EOS Commercial |
$73.71
|
| Rate for Payer: HFN Commercial |
$76.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.54
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: Preferred Network Access Commercial |
$76.95
|
| Rate for Payer: Quartz Beloit One Network |
$35.64
|
| Rate for Payer: Quartz Commercial |
$46.17
|
| Rate for Payer: The Alliance Commercial |
$40.50
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Purkinje Type TR
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
2942956
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$48.60
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Purkinje Type TR
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
2942956
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Aetna Managed Medicare |
$12.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.00
|
| Rate for Payer: Anthem Medicaid |
$12.45
|
| Rate for Payer: Anthem Medicare Advantage |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.05
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.33
|
| Rate for Payer: Dean Health Medicaid |
$12.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.05
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.05
|
| Rate for Payer: Managed Health Services Medicaid |
$12.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.05
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.08
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.45
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$52.65
|
| Rate for Payer: Quartz Medicare Advantage |
$12.05
|
| Rate for Payer: The Alliance Commercial |
$48.20
|
| Rate for Payer: United Healthcare Medicaid |
$12.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.05
|
| Rate for Payer: United Healthcare PPO |
$60.75
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: Wellcare Medicare |
$12.05
|
| Rate for Payer: WMAP Medicaid |
$12.45
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Put on patient* - Defibrillator Pads
|
Facility
|
OP
|
$753.00
|
|
| Hospital Charge Code |
4075873
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$210.84 |
| Max. Negotiated Rate |
$3,012.00 |
| Rate for Payer: Aetna Commercial |
$677.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$647.58
|
| Rate for Payer: Aetna Managed Medicare |
$210.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$489.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$376.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$361.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$399.09
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cigna Commercial |
$692.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$421.38
|
| Rate for Payer: Health EOS Commercial |
$670.17
|
| Rate for Payer: HFN Commercial |
$692.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$564.75
|
| Rate for Payer: Multiplan Commercial |
$602.40
|
| Rate for Payer: NAPHCARE Commercial |
$451.80
|
| Rate for Payer: Preferred Network Access Commercial |
$692.76
|
| Rate for Payer: Quartz Beloit One Network |
$368.97
|
| Rate for Payer: Quartz Commercial |
$489.45
|
| Rate for Payer: Quartz Medicare Advantage |
$451.80
|
| Rate for Payer: The Alliance Commercial |
$3,012.00
|
| Rate for Payer: WEA Trust Commercial |
$414.15
|
| Rate for Payer: WPS Commercial |
$557.75
|
|
|
Put on patient* - Defibrillator Pads
|
Facility
|
IP
|
$753.00
|
|
| Hospital Charge Code |
4075873
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$368.97 |
| Max. Negotiated Rate |
$692.76 |
| Rate for Payer: Aetna Commercial |
$677.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$647.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$399.09
|
| Rate for Payer: Cash Price |
$225.90
|
| Rate for Payer: Cigna Commercial |
$692.76
|
| Rate for Payer: Health EOS Commercial |
$670.17
|
| Rate for Payer: HFN Commercial |
$692.76
|
| Rate for Payer: Multiplan Commercial |
$602.40
|
| Rate for Payer: NAPHCARE Commercial |
$451.80
|
| Rate for Payer: Preferred Network Access Commercial |
$692.76
|
| Rate for Payer: Quartz Beloit One Network |
$368.97
|
| Rate for Payer: Quartz Commercial |
$451.80
|
| Rate for Payer: WEA Trust Commercial |
$414.15
|
| Rate for Payer: WPS Commercial |
$557.75
|
|
|
PUTTY FIBERGRAFT BONE GRAFT SUBSTITUTE 4CC (BIOACTIVE GLASS MATRIX) 78000040
|
Facility
|
IP
|
$4,729.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226144
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,317.21 |
| Max. Negotiated Rate |
$4,350.68 |
| Rate for Payer: Aetna Commercial |
$4,256.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,066.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,506.37
|
| Rate for Payer: Cash Price |
$1,418.70
|
| Rate for Payer: Cigna Commercial |
$4,350.68
|
| Rate for Payer: Health EOS Commercial |
$4,208.81
|
| Rate for Payer: HFN Commercial |
$4,350.68
|
| Rate for Payer: Multiplan Commercial |
$3,783.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,837.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,350.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,317.21
|
| Rate for Payer: Quartz Commercial |
$2,837.40
|
| Rate for Payer: WEA Trust Commercial |
$2,600.95
|
| Rate for Payer: WPS Commercial |
$3,502.77
|
|
|
PUTTY FIBERGRAFT BONE GRAFT SUBSTITUTE 4CC (BIOACTIVE GLASS MATRIX) 78000040
|
Facility
|
OP
|
$4,729.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226144
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,324.12 |
| Max. Negotiated Rate |
$18,916.00 |
| Rate for Payer: Aetna Commercial |
$4,256.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,066.94
|
| Rate for Payer: Aetna Managed Medicare |
$1,324.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,073.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,364.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,269.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,506.37
|
| Rate for Payer: Cash Price |
$1,418.70
|
| Rate for Payer: Cigna Commercial |
$4,350.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,646.35
|
| Rate for Payer: Health EOS Commercial |
$4,208.81
|
| Rate for Payer: HFN Commercial |
$4,350.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,546.75
|
| Rate for Payer: Multiplan Commercial |
$3,783.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,837.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,350.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,317.21
|
| Rate for Payer: Quartz Commercial |
$3,073.85
|
| Rate for Payer: Quartz Medicare Advantage |
$2,837.40
|
| Rate for Payer: The Alliance Commercial |
$18,916.00
|
| Rate for Payer: WEA Trust Commercial |
$2,600.95
|
| Rate for Payer: WPS Commercial |
$3,502.77
|
|
|
PUTTY THERA MED-SOFT RED 5# #50719905
|
Facility
|
OP
|
$988.00
|
|
| Hospital Charge Code |
2969541
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$276.64 |
| Max. Negotiated Rate |
$3,952.00 |
| Rate for Payer: Aetna Commercial |
$889.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$849.68
|
| Rate for Payer: Aetna Managed Medicare |
$276.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$642.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$494.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$474.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$523.64
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cigna Commercial |
$908.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$552.88
|
| Rate for Payer: Health EOS Commercial |
$879.32
|
| Rate for Payer: HFN Commercial |
$908.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$741.00
|
| Rate for Payer: Multiplan Commercial |
$790.40
|
| Rate for Payer: NAPHCARE Commercial |
$592.80
|
| Rate for Payer: Preferred Network Access Commercial |
$908.96
|
| Rate for Payer: Quartz Beloit One Network |
$484.12
|
| Rate for Payer: Quartz Commercial |
$642.20
|
| Rate for Payer: Quartz Medicare Advantage |
$592.80
|
| Rate for Payer: The Alliance Commercial |
$3,952.00
|
| Rate for Payer: WEA Trust Commercial |
$543.40
|
| Rate for Payer: WPS Commercial |
$731.81
|
|
|
PUTTY THERA MED-SOFT RED 5# #50719905
|
Facility
|
IP
|
$988.00
|
|
| Hospital Charge Code |
2969541
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$484.12 |
| Max. Negotiated Rate |
$908.96 |
| Rate for Payer: Aetna Commercial |
$889.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$849.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$523.64
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cigna Commercial |
$908.96
|
| Rate for Payer: Health EOS Commercial |
$879.32
|
| Rate for Payer: HFN Commercial |
$908.96
|
| Rate for Payer: Multiplan Commercial |
$790.40
|
| Rate for Payer: NAPHCARE Commercial |
$592.80
|
| Rate for Payer: Preferred Network Access Commercial |
$908.96
|
| Rate for Payer: Quartz Beloit One Network |
$484.12
|
| Rate for Payer: Quartz Commercial |
$592.80
|
| Rate for Payer: WEA Trust Commercial |
$543.40
|
| Rate for Payer: WPS Commercial |
$731.81
|
|
|
PUTTY THERAPY 5# YELLOW #5071-05
|
Facility
|
OP
|
$809.00
|
|
| Hospital Charge Code |
2969615
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$226.52 |
| Max. Negotiated Rate |
$3,236.00 |
| Rate for Payer: Aetna Commercial |
$728.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$695.74
|
| Rate for Payer: Aetna Managed Medicare |
$226.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$525.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$404.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$388.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$428.77
|
| Rate for Payer: Cash Price |
$242.70
|
| Rate for Payer: Cigna Commercial |
$744.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$452.72
|
| Rate for Payer: Health EOS Commercial |
$720.01
|
| Rate for Payer: HFN Commercial |
$744.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$606.75
|
| Rate for Payer: Multiplan Commercial |
$647.20
|
| Rate for Payer: NAPHCARE Commercial |
$485.40
|
| Rate for Payer: Preferred Network Access Commercial |
$744.28
|
| Rate for Payer: Quartz Beloit One Network |
$396.41
|
| Rate for Payer: Quartz Commercial |
$525.85
|
| Rate for Payer: Quartz Medicare Advantage |
$485.40
|
| Rate for Payer: The Alliance Commercial |
$3,236.00
|
| Rate for Payer: WEA Trust Commercial |
$444.95
|
| Rate for Payer: WPS Commercial |
$599.23
|
|
|
PUTTY THERAPY 5# YELLOW #5071-05
|
Facility
|
IP
|
$809.00
|
|
| Hospital Charge Code |
2969615
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$396.41 |
| Max. Negotiated Rate |
$744.28 |
| Rate for Payer: Aetna Commercial |
$728.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$695.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$428.77
|
| Rate for Payer: Cash Price |
$242.70
|
| Rate for Payer: Cigna Commercial |
$744.28
|
| Rate for Payer: Health EOS Commercial |
$720.01
|
| Rate for Payer: HFN Commercial |
$744.28
|
| Rate for Payer: Multiplan Commercial |
$647.20
|
| Rate for Payer: NAPHCARE Commercial |
$485.40
|
| Rate for Payer: Preferred Network Access Commercial |
$744.28
|
| Rate for Payer: Quartz Beloit One Network |
$396.41
|
| Rate for Payer: Quartz Commercial |
$485.40
|
| Rate for Payer: WEA Trust Commercial |
$444.95
|
| Rate for Payer: WPS Commercial |
$599.23
|
|
|
PYELOPLASTY
|
Facility
|
OP
|
$4,460.00
|
|
| Hospital Charge Code |
2960328
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,248.80 |
| Max. Negotiated Rate |
$17,840.00 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,248.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,899.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,230.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,140.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,495.82
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,345.00
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,899.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,676.00
|
| Rate for Payer: The Alliance Commercial |
$17,840.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
PYELOPLASTY
|
Facility
|
IP
|
$4,460.00
|
|
| Hospital Charge Code |
2960328
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,185.40 |
| Max. Negotiated Rate |
$4,103.20 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,676.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
PYELOSTOMY
|
Facility
|
OP
|
$4,460.00
|
|
| Hospital Charge Code |
2960329
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,248.80 |
| Max. Negotiated Rate |
$17,840.00 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,248.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,899.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,230.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,140.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,495.82
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,345.00
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,899.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,676.00
|
| Rate for Payer: The Alliance Commercial |
$17,840.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
PYELOSTOMY
|
Facility
|
IP
|
$4,460.00
|
|
| Hospital Charge Code |
2960329
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,185.40 |
| Max. Negotiated Rate |
$4,103.20 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,676.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
PYELOTOMY
|
Facility
|
OP
|
$4,460.00
|
|
| Hospital Charge Code |
2960330
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,248.80 |
| Max. Negotiated Rate |
$17,840.00 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,248.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,899.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,230.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,140.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,495.82
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,345.00
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,899.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,676.00
|
| Rate for Payer: The Alliance Commercial |
$17,840.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
PYELOTOMY
|
Facility
|
IP
|
$4,460.00
|
|
| Hospital Charge Code |
2960330
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,185.40 |
| Max. Negotiated Rate |
$4,103.20 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,676.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
PYLOROMYOTOMY, PEDIATRIC/RAMSTEDT PROCEDURE
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960331
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,928.15 |
| Max. Negotiated Rate |
$3,620.20 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,361.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
PYLOROMYOTOMY, PEDIATRIC/RAMSTEDT PROCEDURE
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960331
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
