|
Saccharomyces cerevisiae Antibodies (ASCA)
|
Professional
|
Both
|
$76.00
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
5438795
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$75.09 |
| Rate for Payer: Aetna Commercial |
$75.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.97
|
| Rate for Payer: Aetna Managed Medicare |
$12.74
|
| Rate for Payer: Anthem Medicare Advantage |
$12.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.74
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$75.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.74
|
| Rate for Payer: Health EOS Commercial |
$71.93
|
| Rate for Payer: HFN Commercial |
$75.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.74
|
| Rate for Payer: Multiplan Commercial |
$63.23
|
| Rate for Payer: NAPHCARE Commercial |
$19.11
|
| Rate for Payer: Preferred Network Access Commercial |
$75.09
|
| Rate for Payer: Quartz Beloit One Network |
$34.78
|
| Rate for Payer: Quartz Commercial |
$45.05
|
| Rate for Payer: Quartz Medicare Advantage |
$12.74
|
| Rate for Payer: The Alliance Commercial |
$50.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.74
|
| Rate for Payer: WEA Trust Commercial |
$43.47
|
| Rate for Payer: WPS Commercial |
$56.06
|
|
|
SACRAL ILIAC INJECTION
|
Facility
|
OP
|
$294.00
|
|
| Hospital Charge Code |
2960565
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$85.61 |
| Max. Negotiated Rate |
$281.30 |
| Rate for Payer: Aetna Commercial |
$275.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.95
|
| Rate for Payer: Aetna Managed Medicare |
$85.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$198.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$152.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$146.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$162.05
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cigna Commercial |
$281.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$171.11
|
| Rate for Payer: Health EOS Commercial |
$272.13
|
| Rate for Payer: HFN Commercial |
$281.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$229.32
|
| Rate for Payer: Multiplan Commercial |
$244.61
|
| Rate for Payer: NAPHCARE Commercial |
$183.46
|
| Rate for Payer: Preferred Network Access Commercial |
$281.30
|
| Rate for Payer: Quartz Beloit One Network |
$149.82
|
| Rate for Payer: Quartz Commercial |
$198.74
|
| Rate for Payer: Quartz Medicare Advantage |
$183.46
|
| Rate for Payer: The Alliance Commercial |
$152.88
|
| Rate for Payer: WEA Trust Commercial |
$168.17
|
| Rate for Payer: WPS Commercial |
$226.47
|
|
|
SACRAL ILIAC INJECTION
|
Facility
|
IP
|
$294.00
|
|
| Hospital Charge Code |
2960565
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$149.82 |
| Max. Negotiated Rate |
$281.30 |
| Rate for Payer: Aetna Commercial |
$275.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$262.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$162.05
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cigna Commercial |
$281.30
|
| Rate for Payer: Health EOS Commercial |
$272.13
|
| Rate for Payer: HFN Commercial |
$281.30
|
| Rate for Payer: Multiplan Commercial |
$244.61
|
| Rate for Payer: Preferred Network Access Commercial |
$281.30
|
| Rate for Payer: Quartz Beloit One Network |
$149.82
|
| Rate for Payer: Quartz Commercial |
$183.46
|
| Rate for Payer: WEA Trust Commercial |
$168.17
|
| Rate for Payer: WPS Commercial |
$226.47
|
|
|
SACRAL SPINAL STIMULATION
|
Facility
|
OP
|
$4,500.00
|
|
| Hospital Charge Code |
5280644
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,310.40 |
| Max. Negotiated Rate |
$4,305.60 |
| Rate for Payer: Aetna Commercial |
$4,212.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,024.80
|
| Rate for Payer: Aetna Managed Medicare |
$1,310.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,042.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,340.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,246.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,480.40
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cigna Commercial |
$4,305.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,619.00
|
| Rate for Payer: Health EOS Commercial |
$4,165.20
|
| Rate for Payer: HFN Commercial |
$4,305.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,510.00
|
| Rate for Payer: Multiplan Commercial |
$3,744.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,808.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,305.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,293.20
|
| Rate for Payer: Quartz Commercial |
$3,042.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,808.00
|
| Rate for Payer: The Alliance Commercial |
$2,340.00
|
| Rate for Payer: WEA Trust Commercial |
$2,574.00
|
| Rate for Payer: WPS Commercial |
$3,466.35
|
|
|
SACRAL SPINAL STIMULATION
|
Facility
|
IP
|
$4,500.00
|
|
| Hospital Charge Code |
5280644
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,293.20 |
| Max. Negotiated Rate |
$4,305.60 |
| Rate for Payer: Aetna Commercial |
$4,212.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,024.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,480.40
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cigna Commercial |
$4,305.60
|
| Rate for Payer: Health EOS Commercial |
$4,165.20
|
| Rate for Payer: HFN Commercial |
$4,305.60
|
| Rate for Payer: Multiplan Commercial |
$3,744.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,305.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,293.20
|
| Rate for Payer: Quartz Commercial |
$2,808.00
|
| Rate for Payer: WEA Trust Commercial |
$2,574.00
|
| Rate for Payer: WPS Commercial |
$3,466.35
|
|
|
SACROPLASTY BILATERAL
|
Facility
|
OP
|
$2,321.00
|
|
| Hospital Charge Code |
6180094
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$675.88 |
| Max. Negotiated Rate |
$2,220.73 |
| Rate for Payer: Aetna Commercial |
$2,172.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,075.90
|
| Rate for Payer: Aetna Managed Medicare |
$675.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,569.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,206.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,158.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,279.34
|
| Rate for Payer: Cash Price |
$696.30
|
| Rate for Payer: Cigna Commercial |
$2,220.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,350.82
|
| Rate for Payer: Health EOS Commercial |
$2,148.32
|
| Rate for Payer: HFN Commercial |
$2,220.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,810.38
|
| Rate for Payer: Multiplan Commercial |
$1,931.07
|
| Rate for Payer: NAPHCARE Commercial |
$1,448.30
|
| Rate for Payer: Preferred Network Access Commercial |
$2,220.73
|
| Rate for Payer: Quartz Beloit One Network |
$1,182.78
|
| Rate for Payer: Quartz Commercial |
$1,569.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,448.30
|
| Rate for Payer: The Alliance Commercial |
$1,206.92
|
| Rate for Payer: WEA Trust Commercial |
$1,327.61
|
| Rate for Payer: WPS Commercial |
$1,787.87
|
|
|
SACROPLASTY BILATERAL
|
Facility
|
IP
|
$2,321.00
|
|
| Hospital Charge Code |
6180094
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,182.78 |
| Max. Negotiated Rate |
$2,220.73 |
| Rate for Payer: Aetna Commercial |
$2,172.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,075.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,279.34
|
| Rate for Payer: Cash Price |
$696.30
|
| Rate for Payer: Cigna Commercial |
$2,220.73
|
| Rate for Payer: Health EOS Commercial |
$2,148.32
|
| Rate for Payer: HFN Commercial |
$2,220.73
|
| Rate for Payer: Multiplan Commercial |
$1,931.07
|
| Rate for Payer: Preferred Network Access Commercial |
$2,220.73
|
| Rate for Payer: Quartz Beloit One Network |
$1,182.78
|
| Rate for Payer: Quartz Commercial |
$1,448.30
|
| Rate for Payer: WEA Trust Commercial |
$1,327.61
|
| Rate for Payer: WPS Commercial |
$1,787.87
|
|
|
SACROPLASTY UNILATERAL
|
Facility
|
OP
|
$1,853.00
|
|
| Hospital Charge Code |
6180095
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$539.59 |
| Max. Negotiated Rate |
$1,772.95 |
| Rate for Payer: Aetna Commercial |
$1,734.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,657.32
|
| Rate for Payer: Aetna Managed Medicare |
$539.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,252.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$963.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$925.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,021.37
|
| Rate for Payer: Cash Price |
$555.90
|
| Rate for Payer: Cigna Commercial |
$1,772.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,078.45
|
| Rate for Payer: Health EOS Commercial |
$1,715.14
|
| Rate for Payer: HFN Commercial |
$1,772.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,445.34
|
| Rate for Payer: Multiplan Commercial |
$1,541.70
|
| Rate for Payer: NAPHCARE Commercial |
$1,156.27
|
| Rate for Payer: Preferred Network Access Commercial |
$1,772.95
|
| Rate for Payer: Quartz Beloit One Network |
$944.29
|
| Rate for Payer: Quartz Commercial |
$1,252.63
|
| Rate for Payer: Quartz Medicare Advantage |
$1,156.27
|
| Rate for Payer: The Alliance Commercial |
$963.56
|
| Rate for Payer: WEA Trust Commercial |
$1,059.92
|
| Rate for Payer: WPS Commercial |
$1,427.37
|
|
|
SACROPLASTY UNILATERAL
|
Facility
|
IP
|
$1,853.00
|
|
| Hospital Charge Code |
6180095
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$944.29 |
| Max. Negotiated Rate |
$1,772.95 |
| Rate for Payer: Aetna Commercial |
$1,734.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,657.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,021.37
|
| Rate for Payer: Cash Price |
$555.90
|
| Rate for Payer: Cigna Commercial |
$1,772.95
|
| Rate for Payer: Health EOS Commercial |
$1,715.14
|
| Rate for Payer: HFN Commercial |
$1,772.95
|
| Rate for Payer: Multiplan Commercial |
$1,541.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,772.95
|
| Rate for Payer: Quartz Beloit One Network |
$944.29
|
| Rate for Payer: Quartz Commercial |
$1,156.27
|
| Rate for Payer: WEA Trust Commercial |
$1,059.92
|
| Rate for Payer: WPS Commercial |
$1,427.37
|
|
|
SafeSheath 6Fr
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550954
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$163.58 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$200.30
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
SafeSheath 6Fr
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550954
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.89 |
| Max. Negotiated Rate |
$317.15 |
| Rate for Payer: Aetna Commercial |
$317.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$317.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$166.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.30
|
| Rate for Payer: Health EOS Commercial |
$303.79
|
| Rate for Payer: HFN Commercial |
$317.15
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$317.15
|
| Rate for Payer: Quartz Beloit One Network |
$146.89
|
| Rate for Payer: Quartz Commercial |
$190.29
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
SafeSheath 6Fr
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550954
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$93.48 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Aetna Managed Medicare |
$93.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$166.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.82
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.38
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: NAPHCARE Commercial |
$200.30
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$217.00
|
| Rate for Payer: Quartz Medicare Advantage |
$200.30
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
SafeSheath 7Fr
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550956
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.89 |
| Max. Negotiated Rate |
$317.15 |
| Rate for Payer: Aetna Commercial |
$317.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$317.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$166.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.30
|
| Rate for Payer: Health EOS Commercial |
$303.79
|
| Rate for Payer: HFN Commercial |
$317.15
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$317.15
|
| Rate for Payer: Quartz Beloit One Network |
$146.89
|
| Rate for Payer: Quartz Commercial |
$190.29
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
SafeSheath 7Fr
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550956
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$163.58 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$200.30
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
SafeSheath 7Fr
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550956
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$93.48 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Aetna Managed Medicare |
$93.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$166.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.82
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.38
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: NAPHCARE Commercial |
$200.30
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$217.00
|
| Rate for Payer: Quartz Medicare Advantage |
$200.30
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
SafeSheath 8Fr
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550958
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$163.58 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$200.30
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
SafeSheath 8Fr
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550958
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$93.48 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Aetna Managed Medicare |
$93.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$166.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.82
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.38
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: NAPHCARE Commercial |
$200.30
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$217.00
|
| Rate for Payer: Quartz Medicare Advantage |
$200.30
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
SafeSheath 8Fr
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550958
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.89 |
| Max. Negotiated Rate |
$317.15 |
| Rate for Payer: Aetna Commercial |
$317.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$317.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$166.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.30
|
| Rate for Payer: Health EOS Commercial |
$303.79
|
| Rate for Payer: HFN Commercial |
$317.15
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$317.15
|
| Rate for Payer: Quartz Beloit One Network |
$146.89
|
| Rate for Payer: Quartz Commercial |
$190.29
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
SafeSheath 9Fr
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550960
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$93.48 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Aetna Managed Medicare |
$93.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$166.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.82
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.38
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: NAPHCARE Commercial |
$200.30
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$217.00
|
| Rate for Payer: Quartz Medicare Advantage |
$200.30
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
SafeSheath 9Fr
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550960
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.89 |
| Max. Negotiated Rate |
$317.15 |
| Rate for Payer: Aetna Commercial |
$317.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$317.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$166.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.30
|
| Rate for Payer: Health EOS Commercial |
$303.79
|
| Rate for Payer: HFN Commercial |
$317.15
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$317.15
|
| Rate for Payer: Quartz Beloit One Network |
$146.89
|
| Rate for Payer: Quartz Commercial |
$190.29
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
SafeSheath 9Fr
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550960
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$163.58 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$200.30
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
SAFETY BLADE #10 BARD-PARKER 373910
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
5384676
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.42 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$27.46
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
|
SAFETY BLADE #10 BARD-PARKER 373910
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
5384676
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.81 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Aetna Managed Medicare |
$12.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.61
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.32
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: NAPHCARE Commercial |
$27.46
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$29.74
|
| Rate for Payer: Quartz Medicare Advantage |
$27.46
|
| Rate for Payer: The Alliance Commercial |
$22.88
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
|
SAFETY BLADE #11 BARD-PARKER 373911
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
5384678
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.42 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$27.46
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
|
SAFETY BLADE #11 BARD-PARKER 373911
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
5384678
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.81 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Aetna Managed Medicare |
$12.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.61
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.32
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: NAPHCARE Commercial |
$27.46
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$29.74
|
| Rate for Payer: Quartz Medicare Advantage |
$27.46
|
| Rate for Payer: The Alliance Commercial |
$22.88
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
