|
SA Nasal Complete PCR
|
Facility
|
IP
|
$136.00
|
|
|
Service Code
|
CPT 87640
|
| Hospital Charge Code |
4254037
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$69.31 |
| Max. Negotiated Rate |
$130.12 |
| Rate for Payer: Aetna Commercial |
$127.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$121.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.96
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cigna Commercial |
$130.12
|
| Rate for Payer: Health EOS Commercial |
$125.88
|
| Rate for Payer: HFN Commercial |
$130.12
|
| Rate for Payer: Multiplan Commercial |
$113.15
|
| Rate for Payer: Preferred Network Access Commercial |
$130.12
|
| Rate for Payer: Quartz Beloit One Network |
$69.31
|
| Rate for Payer: Quartz Commercial |
$84.86
|
| Rate for Payer: WEA Trust Commercial |
$77.79
|
| Rate for Payer: WPS Commercial |
$104.76
|
|
|
SA Nasal Complete PCR
|
Facility
|
OP
|
$136.00
|
|
|
Service Code
|
CPT 87640
|
| Hospital Charge Code |
4254037
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.49 |
| Max. Negotiated Rate |
$145.97 |
| Rate for Payer: Aetna Commercial |
$127.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$121.64
|
| Rate for Payer: Aetna Managed Medicare |
$36.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$136.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$63.86
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.58
|
| Rate for Payer: Anthem Medicare Advantage |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$36.49
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cigna Commercial |
$130.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$36.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$79.15
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$36.49
|
| Rate for Payer: Health EOS Commercial |
$125.88
|
| Rate for Payer: HFN Commercial |
$130.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$135.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$36.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$36.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$36.49
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$36.49
|
| Rate for Payer: Multiplan Commercial |
$113.15
|
| Rate for Payer: NAPHCARE Commercial |
$54.74
|
| Rate for Payer: Preferred Network Access Commercial |
$130.12
|
| Rate for Payer: Quartz Beloit One Network |
$69.31
|
| Rate for Payer: Quartz Commercial |
$91.94
|
| Rate for Payer: Quartz Medicare Advantage |
$36.49
|
| Rate for Payer: The Alliance Commercial |
$145.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.49
|
| Rate for Payer: United Healthcare PPO |
$106.08
|
| Rate for Payer: WEA Trust Commercial |
$77.79
|
| Rate for Payer: Wellcare Medicare |
$36.49
|
| Rate for Payer: WPS Commercial |
$104.76
|
|
|
Sandostatin LAR 1 mg Charge
|
Professional
|
Both
|
$459.00
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
2958936
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$207.14 |
| Max. Negotiated Rate |
$569.63 |
| Rate for Payer: Aetna Commercial |
$453.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$410.53
|
| Rate for Payer: Aetna Managed Medicare |
$207.14
|
| Rate for Payer: Anthem Medicare Advantage |
$207.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$207.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$207.14
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cigna Commercial |
$453.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$207.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$218.98
|
| Rate for Payer: Health EOS Commercial |
$434.40
|
| Rate for Payer: HFN Commercial |
$453.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$311.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$311.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$207.14
|
| Rate for Payer: Multiplan Commercial |
$381.89
|
| Rate for Payer: NAPHCARE Commercial |
$310.71
|
| Rate for Payer: Preferred Network Access Commercial |
$453.49
|
| Rate for Payer: Quartz Beloit One Network |
$210.04
|
| Rate for Payer: Quartz Commercial |
$272.10
|
| Rate for Payer: Quartz Medicare Advantage |
$207.14
|
| Rate for Payer: The Alliance Commercial |
$569.63
|
| Rate for Payer: United Healthcare Medicaid |
$207.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$207.14
|
| Rate for Payer: WEA Trust Commercial |
$262.55
|
| Rate for Payer: WPS Commercial |
$547.46
|
|
|
Sandostatin LAR 1 mg Charge
|
Facility
|
OP
|
$459.00
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
2958936
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$207.14 |
| Max. Negotiated Rate |
$828.55 |
| Rate for Payer: Aetna Commercial |
$429.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$410.53
|
| Rate for Payer: Aetna Managed Medicare |
$207.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$218.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$218.98
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$218.98
|
| Rate for Payer: Anthem Medicare Advantage |
$207.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$207.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$207.14
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cigna Commercial |
$439.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$207.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$289.71
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$207.14
|
| Rate for Payer: Health EOS Commercial |
$424.85
|
| Rate for Payer: HFN Commercial |
$439.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$770.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$207.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$207.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$207.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$207.14
|
| Rate for Payer: Multiplan Commercial |
$381.89
|
| Rate for Payer: NAPHCARE Commercial |
$310.71
|
| Rate for Payer: Preferred Network Access Commercial |
$439.17
|
| Rate for Payer: Quartz Beloit One Network |
$233.91
|
| Rate for Payer: Quartz Commercial |
$310.28
|
| Rate for Payer: Quartz Medicare Advantage |
$207.14
|
| Rate for Payer: The Alliance Commercial |
$828.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$207.14
|
| Rate for Payer: WEA Trust Commercial |
$262.55
|
| Rate for Payer: Wellcare Medicare |
$207.14
|
| Rate for Payer: WPS Commercial |
$547.46
|
|
|
Sandostatin LAR 1 mg Charge
|
Facility
|
IP
|
$459.00
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
2958936
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$233.91 |
| Max. Negotiated Rate |
$439.17 |
| Rate for Payer: Aetna Commercial |
$429.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$410.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.00
|
| Rate for Payer: Cash Price |
$137.70
|
| Rate for Payer: Cigna Commercial |
$439.17
|
| Rate for Payer: Health EOS Commercial |
$424.85
|
| Rate for Payer: HFN Commercial |
$439.17
|
| Rate for Payer: Multiplan Commercial |
$381.89
|
| Rate for Payer: Preferred Network Access Commercial |
$439.17
|
| Rate for Payer: Quartz Beloit One Network |
$233.91
|
| Rate for Payer: Quartz Commercial |
$286.42
|
| Rate for Payer: WEA Trust Commercial |
$262.55
|
| Rate for Payer: WPS Commercial |
$353.57
|
|
|
Sandostatin Lar 1mg J2353
|
Facility
|
IP
|
$468.00
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
5516859
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$238.49 |
| Max. Negotiated Rate |
$447.78 |
| Rate for Payer: Aetna Commercial |
$438.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$418.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$257.96
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$447.78
|
| Rate for Payer: Health EOS Commercial |
$433.18
|
| Rate for Payer: HFN Commercial |
$447.78
|
| Rate for Payer: Multiplan Commercial |
$389.38
|
| Rate for Payer: Preferred Network Access Commercial |
$447.78
|
| Rate for Payer: Quartz Beloit One Network |
$238.49
|
| Rate for Payer: Quartz Commercial |
$292.03
|
| Rate for Payer: WEA Trust Commercial |
$267.70
|
| Rate for Payer: WPS Commercial |
$360.50
|
|
|
Sandostatin Lar 1mg J2353
|
Facility
|
OP
|
$468.00
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
5516859
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$207.14 |
| Max. Negotiated Rate |
$828.55 |
| Rate for Payer: Aetna Commercial |
$438.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$418.58
|
| Rate for Payer: Aetna Managed Medicare |
$207.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$218.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$218.98
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$218.98
|
| Rate for Payer: Anthem Medicare Advantage |
$207.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$257.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$207.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$207.14
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$447.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$207.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$289.71
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$207.14
|
| Rate for Payer: Health EOS Commercial |
$433.18
|
| Rate for Payer: HFN Commercial |
$447.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$770.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$207.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$207.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$207.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$207.14
|
| Rate for Payer: Multiplan Commercial |
$389.38
|
| Rate for Payer: NAPHCARE Commercial |
$310.71
|
| Rate for Payer: Preferred Network Access Commercial |
$447.78
|
| Rate for Payer: Quartz Beloit One Network |
$238.49
|
| Rate for Payer: Quartz Commercial |
$316.37
|
| Rate for Payer: Quartz Medicare Advantage |
$207.14
|
| Rate for Payer: The Alliance Commercial |
$828.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$207.14
|
| Rate for Payer: WEA Trust Commercial |
$267.70
|
| Rate for Payer: Wellcare Medicare |
$207.14
|
| Rate for Payer: WPS Commercial |
$547.46
|
|
|
Sandostatin Lar 1mg J2353
|
Professional
|
Both
|
$468.00
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
5516859
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$207.14 |
| Max. Negotiated Rate |
$569.63 |
| Rate for Payer: Aetna Commercial |
$462.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$418.58
|
| Rate for Payer: Aetna Managed Medicare |
$207.14
|
| Rate for Payer: Anthem Medicare Advantage |
$207.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$207.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$207.14
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$462.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$207.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$218.98
|
| Rate for Payer: Health EOS Commercial |
$442.92
|
| Rate for Payer: HFN Commercial |
$462.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$311.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$311.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$207.14
|
| Rate for Payer: Multiplan Commercial |
$389.38
|
| Rate for Payer: NAPHCARE Commercial |
$310.71
|
| Rate for Payer: Preferred Network Access Commercial |
$462.38
|
| Rate for Payer: Quartz Beloit One Network |
$214.16
|
| Rate for Payer: Quartz Commercial |
$277.43
|
| Rate for Payer: Quartz Medicare Advantage |
$207.14
|
| Rate for Payer: The Alliance Commercial |
$569.63
|
| Rate for Payer: United Healthcare Medicaid |
$207.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$207.14
|
| Rate for Payer: WEA Trust Commercial |
$267.70
|
| Rate for Payer: WPS Commercial |
$547.46
|
|
|
SA,PCR-SSTI
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT 87640
|
| Hospital Charge Code |
4125437
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.49 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna Commercial |
$157.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.26
|
| Rate for Payer: Aetna Managed Medicare |
$36.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$136.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$63.86
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.58
|
| Rate for Payer: Anthem Medicare Advantage |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$36.49
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$160.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$36.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$36.49
|
| Rate for Payer: Health EOS Commercial |
$155.50
|
| Rate for Payer: HFN Commercial |
$160.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$135.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$36.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$36.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$36.49
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$36.49
|
| Rate for Payer: Multiplan Commercial |
$139.78
|
| Rate for Payer: NAPHCARE Commercial |
$54.74
|
| Rate for Payer: Preferred Network Access Commercial |
$160.74
|
| Rate for Payer: Quartz Beloit One Network |
$85.61
|
| Rate for Payer: Quartz Commercial |
$113.57
|
| Rate for Payer: Quartz Medicare Advantage |
$36.49
|
| Rate for Payer: The Alliance Commercial |
$145.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.49
|
| Rate for Payer: United Healthcare PPO |
$131.04
|
| Rate for Payer: WEA Trust Commercial |
$96.10
|
| Rate for Payer: Wellcare Medicare |
$36.49
|
| Rate for Payer: WPS Commercial |
$129.41
|
|
|
SA,PCR-SSTI
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT 87640
|
| Hospital Charge Code |
4125437
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$85.61 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna Commercial |
$157.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.60
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$160.74
|
| Rate for Payer: Health EOS Commercial |
$155.50
|
| Rate for Payer: HFN Commercial |
$160.74
|
| Rate for Payer: Multiplan Commercial |
$139.78
|
| Rate for Payer: Preferred Network Access Commercial |
$160.74
|
| Rate for Payer: Quartz Beloit One Network |
$85.61
|
| Rate for Payer: Quartz Commercial |
$104.83
|
| Rate for Payer: WEA Trust Commercial |
$96.10
|
| Rate for Payer: WPS Commercial |
$129.41
|
|
|
SA,PCR-SSTI
|
Professional
|
Both
|
$168.00
|
|
|
Service Code
|
CPT 87640
|
| Hospital Charge Code |
4125437
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.49 |
| Max. Negotiated Rate |
$165.98 |
| Rate for Payer: Aetna Commercial |
$165.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.26
|
| Rate for Payer: Aetna Managed Medicare |
$36.49
|
| Rate for Payer: Anthem Medicare Advantage |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$36.49
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna Commercial |
$165.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$87.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.49
|
| Rate for Payer: Health EOS Commercial |
$159.00
|
| Rate for Payer: HFN Commercial |
$165.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$128.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$128.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$36.49
|
| Rate for Payer: Multiplan Commercial |
$139.78
|
| Rate for Payer: NAPHCARE Commercial |
$54.74
|
| Rate for Payer: Preferred Network Access Commercial |
$165.98
|
| Rate for Payer: Quartz Beloit One Network |
$76.88
|
| Rate for Payer: Quartz Commercial |
$99.59
|
| Rate for Payer: Quartz Medicare Advantage |
$36.49
|
| Rate for Payer: The Alliance Commercial |
$144.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.49
|
| Rate for Payer: WEA Trust Commercial |
$96.10
|
| Rate for Payer: WPS Commercial |
$160.57
|
|
|
SASSI 3
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2971918
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
SASSI 3
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2971918
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
SASSI A-2
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2971917
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
SASSI A-2
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2971917
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
SAUVE KAPANEDJI PROCEDURE
|
Facility
|
IP
|
$4,170.00
|
|
| Hospital Charge Code |
2960362
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,125.03 |
| Max. Negotiated Rate |
$3,989.86 |
| Rate for Payer: Aetna Commercial |
$3,903.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,729.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,298.50
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,989.86
|
| Rate for Payer: Health EOS Commercial |
$3,859.75
|
| Rate for Payer: HFN Commercial |
$3,989.86
|
| Rate for Payer: Multiplan Commercial |
$3,469.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,989.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,125.03
|
| Rate for Payer: Quartz Commercial |
$2,602.08
|
| Rate for Payer: WEA Trust Commercial |
$2,385.24
|
| Rate for Payer: WPS Commercial |
$3,212.15
|
|
|
SAUVE KAPANEDJI PROCEDURE
|
Facility
|
OP
|
$4,170.00
|
|
| Hospital Charge Code |
2960362
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,214.30 |
| Max. Negotiated Rate |
$3,989.86 |
| Rate for Payer: Aetna Commercial |
$3,903.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,729.65
|
| Rate for Payer: Aetna Managed Medicare |
$1,214.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,818.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,168.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,081.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,298.50
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,989.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,426.94
|
| Rate for Payer: Health EOS Commercial |
$3,859.75
|
| Rate for Payer: HFN Commercial |
$3,989.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,252.60
|
| Rate for Payer: Multiplan Commercial |
$3,469.44
|
| Rate for Payer: NAPHCARE Commercial |
$2,602.08
|
| Rate for Payer: Preferred Network Access Commercial |
$3,989.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,125.03
|
| Rate for Payer: Quartz Commercial |
$2,818.92
|
| Rate for Payer: Quartz Medicare Advantage |
$2,602.08
|
| Rate for Payer: The Alliance Commercial |
$2,168.40
|
| Rate for Payer: WEA Trust Commercial |
$2,385.24
|
| Rate for Payer: WPS Commercial |
$3,212.15
|
|
|
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 |
$694.22 |
| Max. Negotiated Rate |
$2,281.01 |
| Rate for Payer: Aetna Commercial |
$2,231.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,132.25
|
| Rate for Payer: Aetna Managed Medicare |
$694.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,611.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,239.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,190.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,314.06
|
| Rate for Payer: Cash Price |
$715.20
|
| Rate for Payer: Cigna Commercial |
$2,281.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,387.49
|
| Rate for Payer: Health EOS Commercial |
$2,206.63
|
| Rate for Payer: HFN Commercial |
$2,281.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,859.52
|
| Rate for Payer: Multiplan Commercial |
$1,983.49
|
| Rate for Payer: NAPHCARE Commercial |
$1,487.62
|
| Rate for Payer: Preferred Network Access Commercial |
$2,281.01
|
| Rate for Payer: Quartz Beloit One Network |
$1,214.89
|
| Rate for Payer: Quartz Commercial |
$1,611.58
|
| Rate for Payer: Quartz Medicare Advantage |
$1,487.62
|
| Rate for Payer: The Alliance Commercial |
$1,239.68
|
| Rate for Payer: WEA Trust Commercial |
$1,363.65
|
| Rate for Payer: WPS Commercial |
$1,836.40
|
|
|
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 |
$1,214.89 |
| Max. Negotiated Rate |
$2,281.01 |
| Rate for Payer: Aetna Commercial |
$2,231.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,132.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,314.06
|
| Rate for Payer: Cash Price |
$715.20
|
| Rate for Payer: Cigna Commercial |
$2,281.01
|
| Rate for Payer: Health EOS Commercial |
$2,206.63
|
| Rate for Payer: HFN Commercial |
$2,281.01
|
| Rate for Payer: Multiplan Commercial |
$1,983.49
|
| Rate for Payer: Preferred Network Access Commercial |
$2,281.01
|
| Rate for Payer: Quartz Beloit One Network |
$1,214.89
|
| Rate for Payer: Quartz Commercial |
$1,487.62
|
| Rate for Payer: WEA Trust Commercial |
$1,363.65
|
| Rate for Payer: WPS Commercial |
$1,836.40
|
|
|
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 |
$777.80 |
| Max. Negotiated Rate |
$2,555.61 |
| Rate for Payer: Aetna Commercial |
$2,500.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,388.94
|
| Rate for Payer: Aetna Managed Medicare |
$777.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,805.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,388.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,333.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,472.26
|
| Rate for Payer: Cash Price |
$801.30
|
| Rate for Payer: Cigna Commercial |
$2,555.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,554.52
|
| Rate for Payer: Health EOS Commercial |
$2,472.28
|
| Rate for Payer: HFN Commercial |
$2,555.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,083.38
|
| Rate for Payer: Multiplan Commercial |
$2,222.27
|
| Rate for Payer: NAPHCARE Commercial |
$1,666.70
|
| Rate for Payer: Preferred Network Access Commercial |
$2,555.61
|
| Rate for Payer: Quartz Beloit One Network |
$1,361.14
|
| Rate for Payer: Quartz Commercial |
$1,805.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,666.70
|
| Rate for Payer: The Alliance Commercial |
$1,388.92
|
| Rate for Payer: WEA Trust Commercial |
$1,527.81
|
| Rate for Payer: WPS Commercial |
$2,057.47
|
|
|
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 |
$1,361.14 |
| Max. Negotiated Rate |
$2,555.61 |
| Rate for Payer: Aetna Commercial |
$2,500.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,388.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,472.26
|
| Rate for Payer: Cash Price |
$801.30
|
| Rate for Payer: Cigna Commercial |
$2,555.61
|
| Rate for Payer: Health EOS Commercial |
$2,472.28
|
| Rate for Payer: HFN Commercial |
$2,555.61
|
| Rate for Payer: Multiplan Commercial |
$2,222.27
|
| Rate for Payer: Preferred Network Access Commercial |
$2,555.61
|
| Rate for Payer: Quartz Beloit One Network |
$1,361.14
|
| Rate for Payer: Quartz Commercial |
$1,666.70
|
| Rate for Payer: WEA Trust Commercial |
$1,527.81
|
| Rate for Payer: WPS Commercial |
$2,057.47
|
|
|
SAW BLADE MICRO CHOICE WITH STOP C8904
|
Facility
|
OP
|
$1,539.00
|
|
| Hospital Charge Code |
2964873
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$448.16 |
| Max. Negotiated Rate |
$1,472.52 |
| Rate for Payer: Aetna Commercial |
$1,440.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,376.48
|
| Rate for Payer: Aetna Managed Medicare |
$448.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,040.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$800.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$768.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$848.30
|
| Rate for Payer: Cash Price |
$461.70
|
| Rate for Payer: Cigna Commercial |
$1,472.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$895.70
|
| Rate for Payer: Health EOS Commercial |
$1,424.50
|
| Rate for Payer: HFN Commercial |
$1,472.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,200.42
|
| Rate for Payer: Multiplan Commercial |
$1,280.45
|
| Rate for Payer: NAPHCARE Commercial |
$960.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,472.52
|
| Rate for Payer: Quartz Beloit One Network |
$784.27
|
| Rate for Payer: Quartz Commercial |
$1,040.36
|
| Rate for Payer: Quartz Medicare Advantage |
$960.34
|
| Rate for Payer: The Alliance Commercial |
$800.28
|
| Rate for Payer: WEA Trust Commercial |
$880.31
|
| Rate for Payer: WPS Commercial |
$1,185.49
|
|
|
SAW BLADE MICRO CHOICE WITH STOP C8904
|
Facility
|
IP
|
$1,539.00
|
|
| Hospital Charge Code |
2964873
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$784.27 |
| Max. Negotiated Rate |
$1,472.52 |
| Rate for Payer: Aetna Commercial |
$1,440.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,376.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$848.30
|
| Rate for Payer: Cash Price |
$461.70
|
| Rate for Payer: Cigna Commercial |
$1,472.52
|
| Rate for Payer: Health EOS Commercial |
$1,424.50
|
| Rate for Payer: HFN Commercial |
$1,472.52
|
| Rate for Payer: Multiplan Commercial |
$1,280.45
|
| Rate for Payer: Preferred Network Access Commercial |
$1,472.52
|
| Rate for Payer: Quartz Beloit One Network |
$784.27
|
| Rate for Payer: Quartz Commercial |
$960.34
|
| Rate for Payer: WEA Trust Commercial |
$880.31
|
| Rate for Payer: WPS Commercial |
$1,185.49
|
|
|
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 |
$585.89 |
| Max. Negotiated Rate |
$1,925.08 |
| Rate for Payer: Aetna Commercial |
$1,883.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,799.53
|
| Rate for Payer: Aetna Managed Medicare |
$585.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,360.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,046.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,004.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,109.01
|
| Rate for Payer: Cash Price |
$603.60
|
| Rate for Payer: Cigna Commercial |
$1,925.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,170.98
|
| Rate for Payer: Health EOS Commercial |
$1,862.31
|
| Rate for Payer: HFN Commercial |
$1,925.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,569.36
|
| Rate for Payer: Multiplan Commercial |
$1,673.98
|
| Rate for Payer: NAPHCARE Commercial |
$1,255.49
|
| Rate for Payer: Preferred Network Access Commercial |
$1,925.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,025.32
|
| Rate for Payer: Quartz Commercial |
$1,360.11
|
| Rate for Payer: Quartz Medicare Advantage |
$1,255.49
|
| Rate for Payer: The Alliance Commercial |
$1,046.24
|
| Rate for Payer: WEA Trust Commercial |
$1,150.86
|
| Rate for Payer: WPS Commercial |
$1,549.84
|
|
|
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 |
$1,025.32 |
| Max. Negotiated Rate |
$1,925.08 |
| Rate for Payer: Aetna Commercial |
$1,883.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,799.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,109.01
|
| Rate for Payer: Cash Price |
$603.60
|
| Rate for Payer: Cigna Commercial |
$1,925.08
|
| Rate for Payer: Health EOS Commercial |
$1,862.31
|
| Rate for Payer: HFN Commercial |
$1,925.08
|
| Rate for Payer: Multiplan Commercial |
$1,673.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,925.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,025.32
|
| Rate for Payer: Quartz Commercial |
$1,255.49
|
| Rate for Payer: WEA Trust Commercial |
$1,150.86
|
| Rate for Payer: WPS Commercial |
$1,549.84
|
|
