|
RV1 VACCINE 2 DOSE SCHEDULE LIVE FOR ORAL USE 90681 - VFC
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90681
|
| Hospital Charge Code |
5949631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$83.32 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Aetna Managed Medicare |
$5.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.66
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.62
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$13.54
|
| Rate for Payer: Quartz Medicare Advantage |
$12.50
|
| Rate for Payer: The Alliance Commercial |
$83.32
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
RV1 VACCINE 2 DOSE SCHEDULE LIVE FOR ORAL USE 90681 - VFC
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90681
|
| Hospital Charge Code |
5949631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$12.50
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
RV/RA Angiogram
|
Facility
|
OP
|
$788.00
|
|
|
Service Code
|
CPT 93566
|
| Hospital Charge Code |
5218698
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$220.64 |
| Max. Negotiated Rate |
$3,152.00 |
| Rate for Payer: Aetna Commercial |
$709.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$677.68
|
| Rate for Payer: Aetna Managed Medicare |
$220.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$512.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$394.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$378.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$417.64
|
| Rate for Payer: Cash Price |
$236.40
|
| Rate for Payer: Cigna Commercial |
$724.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$440.96
|
| Rate for Payer: Health EOS Commercial |
$701.32
|
| Rate for Payer: HFN Commercial |
$724.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$591.00
|
| Rate for Payer: Multiplan Commercial |
$630.40
|
| Rate for Payer: NAPHCARE Commercial |
$472.80
|
| Rate for Payer: Preferred Network Access Commercial |
$724.96
|
| Rate for Payer: Quartz Beloit One Network |
$386.12
|
| Rate for Payer: Quartz Commercial |
$512.20
|
| Rate for Payer: Quartz Medicare Advantage |
$472.80
|
| Rate for Payer: The Alliance Commercial |
$3,152.00
|
| Rate for Payer: WEA Trust Commercial |
$433.40
|
| Rate for Payer: WPS Commercial |
$583.67
|
|
|
RV/RA Angiogram
|
Facility
|
IP
|
$788.00
|
|
|
Service Code
|
CPT 93566
|
| Hospital Charge Code |
5218698
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$386.12 |
| Max. Negotiated Rate |
$724.96 |
| Rate for Payer: Aetna Commercial |
$709.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$677.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$417.64
|
| Rate for Payer: Cash Price |
$236.40
|
| Rate for Payer: Cigna Commercial |
$724.96
|
| Rate for Payer: Health EOS Commercial |
$701.32
|
| Rate for Payer: HFN Commercial |
$724.96
|
| Rate for Payer: Multiplan Commercial |
$630.40
|
| Rate for Payer: NAPHCARE Commercial |
$472.80
|
| Rate for Payer: Preferred Network Access Commercial |
$724.96
|
| Rate for Payer: Quartz Beloit One Network |
$386.12
|
| Rate for Payer: Quartz Commercial |
$472.80
|
| Rate for Payer: WEA Trust Commercial |
$433.40
|
| Rate for Payer: WPS Commercial |
$583.67
|
|
|
Saccharomyces cerevisiae Antibodies (ASCA)
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
5438795
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$37.24 |
| Max. Negotiated Rate |
$69.92 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.28
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$69.92
|
| Rate for Payer: Health EOS Commercial |
$67.64
|
| Rate for Payer: HFN Commercial |
$69.92
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: NAPHCARE Commercial |
$45.60
|
| Rate for Payer: Preferred Network Access Commercial |
$69.92
|
| Rate for Payer: Quartz Beloit One Network |
$37.24
|
| Rate for Payer: Quartz Commercial |
$45.60
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
|
Saccharomyces cerevisiae Antibodies (ASCA)
|
Professional
|
Both
|
$76.00
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
5438795
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.44 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Aetna Commercial |
$72.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$72.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$38.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.60
|
| Rate for Payer: Health EOS Commercial |
$69.16
|
| Rate for Payer: HFN Commercial |
$72.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.24
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: Preferred Network Access Commercial |
$72.20
|
| Rate for Payer: Quartz Beloit One Network |
$33.44
|
| Rate for Payer: Quartz Commercial |
$43.32
|
| Rate for Payer: The Alliance Commercial |
$38.00
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
|
Saccharomyces cerevisiae Antibodies (ASCA)
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
5438795
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$69.92 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Aetna Managed Medicare |
$12.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.34
|
| Rate for Payer: Anthem Medicaid |
$7.15
|
| Rate for Payer: Anthem Medicare Advantage |
$12.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.25
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$69.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.53
|
| Rate for Payer: Dean Health Medicaid |
$7.15
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.25
|
| Rate for Payer: Health EOS Commercial |
$67.64
|
| Rate for Payer: HFN Commercial |
$69.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.25
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.25
|
| Rate for Payer: Managed Health Services Medicaid |
$7.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.25
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.25
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.38
|
| Rate for Payer: Preferred Network Access Commercial |
$69.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7.15
|
| Rate for Payer: Quartz Beloit One Network |
$37.24
|
| Rate for Payer: Quartz Commercial |
$49.40
|
| Rate for Payer: Quartz Medicare Advantage |
$12.25
|
| Rate for Payer: The Alliance Commercial |
$49.00
|
| Rate for Payer: United Healthcare Medicaid |
$7.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.25
|
| Rate for Payer: United Healthcare PPO |
$57.00
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: Wellcare Medicare |
$12.25
|
| Rate for Payer: WMAP Medicaid |
$7.15
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
|
SACRAL ILIAC INJECTION
|
Facility
|
OP
|
$294.00
|
|
| Hospital Charge Code |
2960565
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$82.32 |
| Max. Negotiated Rate |
$1,176.00 |
| Rate for Payer: Aetna Commercial |
$264.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$252.84
|
| Rate for Payer: Aetna Managed Medicare |
$82.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$191.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$147.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$141.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$155.82
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cigna Commercial |
$270.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$164.52
|
| Rate for Payer: Health EOS Commercial |
$261.66
|
| Rate for Payer: HFN Commercial |
$270.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$220.50
|
| Rate for Payer: Multiplan Commercial |
$235.20
|
| Rate for Payer: NAPHCARE Commercial |
$176.40
|
| Rate for Payer: Preferred Network Access Commercial |
$270.48
|
| Rate for Payer: Quartz Beloit One Network |
$144.06
|
| Rate for Payer: Quartz Commercial |
$191.10
|
| Rate for Payer: Quartz Medicare Advantage |
$176.40
|
| Rate for Payer: The Alliance Commercial |
$1,176.00
|
| Rate for Payer: WEA Trust Commercial |
$161.70
|
| Rate for Payer: WPS Commercial |
$217.77
|
|
|
SACRAL ILIAC INJECTION
|
Facility
|
IP
|
$294.00
|
|
| Hospital Charge Code |
2960565
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$144.06 |
| Max. Negotiated Rate |
$270.48 |
| Rate for Payer: Aetna Commercial |
$264.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$252.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$155.82
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cigna Commercial |
$270.48
|
| Rate for Payer: Health EOS Commercial |
$261.66
|
| Rate for Payer: HFN Commercial |
$270.48
|
| Rate for Payer: Multiplan Commercial |
$235.20
|
| Rate for Payer: NAPHCARE Commercial |
$176.40
|
| Rate for Payer: Preferred Network Access Commercial |
$270.48
|
| Rate for Payer: Quartz Beloit One Network |
$144.06
|
| Rate for Payer: Quartz Commercial |
$176.40
|
| Rate for Payer: WEA Trust Commercial |
$161.70
|
| Rate for Payer: WPS Commercial |
$217.77
|
|
|
SACRAL SPINAL STIMULATION
|
Facility
|
IP
|
$4,500.00
|
|
| Hospital Charge Code |
5280644
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,205.00 |
| Max. Negotiated Rate |
$4,140.00 |
| Rate for Payer: Aetna Commercial |
$4,050.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,870.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,385.00
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cigna Commercial |
$4,140.00
|
| Rate for Payer: Health EOS Commercial |
$4,005.00
|
| Rate for Payer: HFN Commercial |
$4,140.00
|
| Rate for Payer: Multiplan Commercial |
$3,600.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,700.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,140.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,205.00
|
| Rate for Payer: Quartz Commercial |
$2,700.00
|
| Rate for Payer: WEA Trust Commercial |
$2,475.00
|
| Rate for Payer: WPS Commercial |
$3,333.15
|
|
|
SACRAL SPINAL STIMULATION
|
Facility
|
OP
|
$4,500.00
|
|
| Hospital Charge Code |
5280644
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,260.00 |
| Max. Negotiated Rate |
$18,000.00 |
| Rate for Payer: Aetna Commercial |
$4,050.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,870.00
|
| Rate for Payer: Aetna Managed Medicare |
$1,260.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,925.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,250.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,160.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,385.00
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cigna Commercial |
$4,140.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,518.20
|
| Rate for Payer: Health EOS Commercial |
$4,005.00
|
| Rate for Payer: HFN Commercial |
$4,140.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,375.00
|
| Rate for Payer: Multiplan Commercial |
$3,600.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,700.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,140.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,205.00
|
| Rate for Payer: Quartz Commercial |
$2,925.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,700.00
|
| Rate for Payer: The Alliance Commercial |
$18,000.00
|
| Rate for Payer: WEA Trust Commercial |
$2,475.00
|
| Rate for Payer: WPS Commercial |
$3,333.15
|
|
|
SACROPLASTY BILATERAL
|
Facility
|
OP
|
$2,321.00
|
|
| Hospital Charge Code |
6180094
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$649.88 |
| Max. Negotiated Rate |
$9,284.00 |
| Rate for Payer: Aetna Commercial |
$2,088.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,996.06
|
| Rate for Payer: Aetna Managed Medicare |
$649.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,508.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,160.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,114.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,230.13
|
| Rate for Payer: Cash Price |
$696.30
|
| Rate for Payer: Cigna Commercial |
$2,135.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,298.83
|
| Rate for Payer: Health EOS Commercial |
$2,065.69
|
| Rate for Payer: HFN Commercial |
$2,135.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,740.75
|
| Rate for Payer: Multiplan Commercial |
$1,856.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,392.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,135.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,137.29
|
| Rate for Payer: Quartz Commercial |
$1,508.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,392.60
|
| Rate for Payer: The Alliance Commercial |
$9,284.00
|
| Rate for Payer: WEA Trust Commercial |
$1,276.55
|
| Rate for Payer: WPS Commercial |
$1,719.16
|
|
|
SACROPLASTY BILATERAL
|
Facility
|
IP
|
$2,321.00
|
|
| Hospital Charge Code |
6180094
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,137.29 |
| Max. Negotiated Rate |
$2,135.32 |
| Rate for Payer: Aetna Commercial |
$2,088.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,996.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,230.13
|
| Rate for Payer: Cash Price |
$696.30
|
| Rate for Payer: Cigna Commercial |
$2,135.32
|
| Rate for Payer: Health EOS Commercial |
$2,065.69
|
| Rate for Payer: HFN Commercial |
$2,135.32
|
| Rate for Payer: Multiplan Commercial |
$1,856.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,392.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,135.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,137.29
|
| Rate for Payer: Quartz Commercial |
$1,392.60
|
| Rate for Payer: WEA Trust Commercial |
$1,276.55
|
| Rate for Payer: WPS Commercial |
$1,719.16
|
|
|
SACROPLASTY UNILATERAL
|
Facility
|
IP
|
$1,853.00
|
|
| Hospital Charge Code |
6180095
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$907.97 |
| Max. Negotiated Rate |
$1,704.76 |
| Rate for Payer: Aetna Commercial |
$1,667.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,593.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$982.09
|
| Rate for Payer: Cash Price |
$555.90
|
| Rate for Payer: Cigna Commercial |
$1,704.76
|
| Rate for Payer: Health EOS Commercial |
$1,649.17
|
| Rate for Payer: HFN Commercial |
$1,704.76
|
| Rate for Payer: Multiplan Commercial |
$1,482.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,111.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,704.76
|
| Rate for Payer: Quartz Beloit One Network |
$907.97
|
| Rate for Payer: Quartz Commercial |
$1,111.80
|
| Rate for Payer: WEA Trust Commercial |
$1,019.15
|
| Rate for Payer: WPS Commercial |
$1,372.52
|
|
|
SACROPLASTY UNILATERAL
|
Facility
|
OP
|
$1,853.00
|
|
| Hospital Charge Code |
6180095
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$518.84 |
| Max. Negotiated Rate |
$7,412.00 |
| Rate for Payer: Aetna Commercial |
$1,667.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,593.58
|
| Rate for Payer: Aetna Managed Medicare |
$518.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,204.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$926.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$889.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$982.09
|
| Rate for Payer: Cash Price |
$555.90
|
| Rate for Payer: Cigna Commercial |
$1,704.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,036.94
|
| Rate for Payer: Health EOS Commercial |
$1,649.17
|
| Rate for Payer: HFN Commercial |
$1,704.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,389.75
|
| Rate for Payer: Multiplan Commercial |
$1,482.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,111.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,704.76
|
| Rate for Payer: Quartz Beloit One Network |
$907.97
|
| Rate for Payer: Quartz Commercial |
$1,204.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,111.80
|
| Rate for Payer: The Alliance Commercial |
$7,412.00
|
| Rate for Payer: WEA Trust Commercial |
$1,019.15
|
| Rate for Payer: WPS Commercial |
$1,372.52
|
|
|
SafeSheath 6Fr
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550954
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$89.88 |
| Max. Negotiated Rate |
$1,284.00 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Aetna Managed Medicare |
$89.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$208.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$160.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$154.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$179.63
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$240.75
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$192.60
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$208.65
|
| Rate for Payer: Quartz Medicare Advantage |
$192.60
|
| Rate for Payer: The Alliance Commercial |
$1,284.00
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
SafeSheath 6Fr
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550954
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$157.29 |
| Max. Negotiated Rate |
$295.32 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$192.60
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$192.60
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
SafeSheath 6Fr
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550954
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.24 |
| Max. Negotiated Rate |
$304.95 |
| Rate for Payer: Aetna Commercial |
$304.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$304.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$160.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.60
|
| Rate for Payer: Health EOS Commercial |
$292.11
|
| Rate for Payer: HFN Commercial |
$304.95
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: Preferred Network Access Commercial |
$304.95
|
| Rate for Payer: Quartz Beloit One Network |
$141.24
|
| Rate for Payer: Quartz Commercial |
$182.97
|
| Rate for Payer: The Alliance Commercial |
$160.50
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
SafeSheath 7Fr
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550956
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.24 |
| Max. Negotiated Rate |
$304.95 |
| Rate for Payer: Aetna Commercial |
$304.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$304.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$160.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.60
|
| Rate for Payer: Health EOS Commercial |
$292.11
|
| Rate for Payer: HFN Commercial |
$304.95
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: Preferred Network Access Commercial |
$304.95
|
| Rate for Payer: Quartz Beloit One Network |
$141.24
|
| Rate for Payer: Quartz Commercial |
$182.97
|
| Rate for Payer: The Alliance Commercial |
$160.50
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
SafeSheath 7Fr
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550956
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$157.29 |
| Max. Negotiated Rate |
$295.32 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$192.60
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$192.60
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
SafeSheath 7Fr
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550956
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$89.88 |
| Max. Negotiated Rate |
$1,284.00 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Aetna Managed Medicare |
$89.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$208.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$160.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$154.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$179.63
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$240.75
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$192.60
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$208.65
|
| Rate for Payer: Quartz Medicare Advantage |
$192.60
|
| Rate for Payer: The Alliance Commercial |
$1,284.00
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
SafeSheath 8Fr
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550958
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$89.88 |
| Max. Negotiated Rate |
$1,284.00 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Aetna Managed Medicare |
$89.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$208.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$160.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$154.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$179.63
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$240.75
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$192.60
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$208.65
|
| Rate for Payer: Quartz Medicare Advantage |
$192.60
|
| Rate for Payer: The Alliance Commercial |
$1,284.00
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
SafeSheath 8Fr
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550958
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$157.29 |
| Max. Negotiated Rate |
$295.32 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$192.60
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$192.60
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
SafeSheath 8Fr
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550958
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.24 |
| Max. Negotiated Rate |
$304.95 |
| Rate for Payer: Aetna Commercial |
$304.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$304.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$160.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.60
|
| Rate for Payer: Health EOS Commercial |
$292.11
|
| Rate for Payer: HFN Commercial |
$304.95
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: Preferred Network Access Commercial |
$304.95
|
| Rate for Payer: Quartz Beloit One Network |
$141.24
|
| Rate for Payer: Quartz Commercial |
$182.97
|
| Rate for Payer: The Alliance Commercial |
$160.50
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
SafeSheath 9Fr
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS C1892
|
| Hospital Charge Code |
2550960
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$89.88 |
| Max. Negotiated Rate |
$1,284.00 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Aetna Managed Medicare |
$89.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$208.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$160.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$154.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$179.63
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$240.75
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$192.60
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$208.65
|
| Rate for Payer: Quartz Medicare Advantage |
$192.60
|
| Rate for Payer: The Alliance Commercial |
$1,284.00
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
