|
ATRICLIP 45MM LAA EXCLUSION FLEX HANDLE ACH245
|
Facility
IP
|
$11,482.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2964750
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,626.18 |
| Max. Negotiated Rate |
$10,563.44 |
| Rate for Payer: Aetna Commercial |
$10,333.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,085.46
|
| Rate for Payer: Cash Price |
$3,444.60
|
| Rate for Payer: Cigna Commercial |
$10,563.44
|
| Rate for Payer: Health EOS Commercial |
$10,218.98
|
| Rate for Payer: HFN Commercial |
$10,563.44
|
| Rate for Payer: Multiplan Commercial |
$9,185.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,889.20
|
| Rate for Payer: Preferred Network Access Commercial |
$10,563.44
|
| Rate for Payer: Quartz Beloit One Network |
$5,626.18
|
| Rate for Payer: Quartz Commercial |
$6,889.20
|
| Rate for Payer: WEA Trust Commercial |
$6,315.10
|
| Rate for Payer: WPS Commercial |
$8,504.72
|
|
|
ATRICLIP 45MM LAA EXCLUSION FLEX HANDLE ACH245
|
Facility
OP
|
$11,482.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2964750
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,214.96 |
| Max. Negotiated Rate |
$10,563.44 |
| Rate for Payer: Aetna Commercial |
$10,333.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,874.52
|
| Rate for Payer: Aetna Managed Medicare |
$3,214.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,463.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,741.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,511.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,085.46
|
| Rate for Payer: Cash Price |
$3,444.60
|
| Rate for Payer: Cigna Commercial |
$10,563.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,425.33
|
| Rate for Payer: Health EOS Commercial |
$10,218.98
|
| Rate for Payer: HFN Commercial |
$10,563.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,611.50
|
| Rate for Payer: Multiplan Commercial |
$9,185.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,889.20
|
| Rate for Payer: Preferred Network Access Commercial |
$10,563.44
|
| Rate for Payer: Quartz Beloit One Network |
$5,626.18
|
| Rate for Payer: Quartz Commercial |
$7,463.30
|
| Rate for Payer: Quartz Medicare Advantage |
$6,889.20
|
| Rate for Payer: WEA Trust Commercial |
$6,315.10
|
| Rate for Payer: WPS Commercial |
$8,504.72
|
|
|
ATRICLIP 45MM LAA FLEX V ACHV45
|
Facility
IP
|
$9,717.00
|
|
| Hospital Charge Code |
5685805
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,761.33 |
| Max. Negotiated Rate |
$8,939.64 |
| Rate for Payer: Aetna Commercial |
$8,745.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,150.01
|
| Rate for Payer: Cash Price |
$2,915.10
|
| Rate for Payer: Cigna Commercial |
$8,939.64
|
| Rate for Payer: Health EOS Commercial |
$8,648.13
|
| Rate for Payer: HFN Commercial |
$8,939.64
|
| Rate for Payer: Multiplan Commercial |
$7,773.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,830.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,939.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,761.33
|
| Rate for Payer: Quartz Commercial |
$5,830.20
|
| Rate for Payer: WEA Trust Commercial |
$5,344.35
|
| Rate for Payer: WPS Commercial |
$7,197.38
|
|
|
ATRICLIP 45MM LAA FLEX V ACHV45
|
Facility
OP
|
$9,717.00
|
|
| Hospital Charge Code |
5685805
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,720.76 |
| Max. Negotiated Rate |
$38,868.00 |
| Rate for Payer: Aetna Commercial |
$8,745.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,356.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,720.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,316.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,858.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,664.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,150.01
|
| Rate for Payer: Cash Price |
$2,915.10
|
| Rate for Payer: Cigna Commercial |
$8,939.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,437.63
|
| Rate for Payer: Health EOS Commercial |
$8,648.13
|
| Rate for Payer: HFN Commercial |
$8,939.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,287.75
|
| Rate for Payer: Multiplan Commercial |
$7,773.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,830.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,939.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,761.33
|
| Rate for Payer: Quartz Commercial |
$6,316.05
|
| Rate for Payer: Quartz Medicare Advantage |
$5,830.20
|
| Rate for Payer: The Alliance Commercial |
$38,868.00
|
| Rate for Payer: WEA Trust Commercial |
$5,344.35
|
| Rate for Payer: WPS Commercial |
$7,197.38
|
|
|
ATRICLIP 50MM LAA EXCLUSION FLEX HANDLE ACH250
|
Facility
IP
|
$11,482.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2964751
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,626.18 |
| Max. Negotiated Rate |
$10,563.44 |
| Rate for Payer: Aetna Commercial |
$10,333.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,085.46
|
| Rate for Payer: Cash Price |
$3,444.60
|
| Rate for Payer: Cigna Commercial |
$10,563.44
|
| Rate for Payer: Health EOS Commercial |
$10,218.98
|
| Rate for Payer: HFN Commercial |
$10,563.44
|
| Rate for Payer: Multiplan Commercial |
$9,185.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,889.20
|
| Rate for Payer: Preferred Network Access Commercial |
$10,563.44
|
| Rate for Payer: Quartz Beloit One Network |
$5,626.18
|
| Rate for Payer: Quartz Commercial |
$6,889.20
|
| Rate for Payer: WEA Trust Commercial |
$6,315.10
|
| Rate for Payer: WPS Commercial |
$8,504.72
|
|
|
ATRICLIP 50MM LAA EXCLUSION FLEX HANDLE ACH250
|
Facility
OP
|
$11,482.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2964751
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,214.96 |
| Max. Negotiated Rate |
$10,563.44 |
| Rate for Payer: Aetna Commercial |
$10,333.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,874.52
|
| Rate for Payer: Aetna Managed Medicare |
$3,214.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,463.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,741.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,511.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,085.46
|
| Rate for Payer: Cash Price |
$3,444.60
|
| Rate for Payer: Cigna Commercial |
$10,563.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,425.33
|
| Rate for Payer: Health EOS Commercial |
$10,218.98
|
| Rate for Payer: HFN Commercial |
$10,563.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,611.50
|
| Rate for Payer: Multiplan Commercial |
$9,185.60
|
| Rate for Payer: NAPHCARE Commercial |
$6,889.20
|
| Rate for Payer: Preferred Network Access Commercial |
$10,563.44
|
| Rate for Payer: Quartz Beloit One Network |
$5,626.18
|
| Rate for Payer: Quartz Commercial |
$7,463.30
|
| Rate for Payer: Quartz Medicare Advantage |
$6,889.20
|
| Rate for Payer: WEA Trust Commercial |
$6,315.10
|
| Rate for Payer: WPS Commercial |
$8,504.72
|
|
|
ATRICLIP 50MM LAA FLEX V ACHV50
|
Facility
IP
|
$9,717.00
|
|
| Hospital Charge Code |
5685806
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,761.33 |
| Max. Negotiated Rate |
$8,939.64 |
| Rate for Payer: Aetna Commercial |
$8,745.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,150.01
|
| Rate for Payer: Cash Price |
$2,915.10
|
| Rate for Payer: Cigna Commercial |
$8,939.64
|
| Rate for Payer: Health EOS Commercial |
$8,648.13
|
| Rate for Payer: HFN Commercial |
$8,939.64
|
| Rate for Payer: Multiplan Commercial |
$7,773.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,830.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,939.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,761.33
|
| Rate for Payer: Quartz Commercial |
$5,830.20
|
| Rate for Payer: WEA Trust Commercial |
$5,344.35
|
| Rate for Payer: WPS Commercial |
$7,197.38
|
|
|
ATRICLIP 50MM LAA FLEX V ACHV50
|
Facility
OP
|
$9,717.00
|
|
| Hospital Charge Code |
5685806
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,720.76 |
| Max. Negotiated Rate |
$38,868.00 |
| Rate for Payer: Aetna Commercial |
$8,745.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,356.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,720.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,316.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,858.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,664.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,150.01
|
| Rate for Payer: Cash Price |
$2,915.10
|
| Rate for Payer: Cigna Commercial |
$8,939.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,437.63
|
| Rate for Payer: Health EOS Commercial |
$8,648.13
|
| Rate for Payer: HFN Commercial |
$8,939.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,287.75
|
| Rate for Payer: Multiplan Commercial |
$7,773.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,830.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,939.64
|
| Rate for Payer: Quartz Beloit One Network |
$4,761.33
|
| Rate for Payer: Quartz Commercial |
$6,316.05
|
| Rate for Payer: Quartz Medicare Advantage |
$5,830.20
|
| Rate for Payer: The Alliance Commercial |
$38,868.00
|
| Rate for Payer: WEA Trust Commercial |
$5,344.35
|
| Rate for Payer: WPS Commercial |
$7,197.38
|
|
|
ATRICLIP SELECTION GUIDE CGG100
|
Facility
IP
|
$2,829.00
|
|
| Hospital Charge Code |
2969515
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,386.21 |
| Max. Negotiated Rate |
$2,602.68 |
| Rate for Payer: Aetna Commercial |
$2,546.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,499.37
|
| Rate for Payer: Cash Price |
$848.70
|
| Rate for Payer: Cigna Commercial |
$2,602.68
|
| Rate for Payer: Health EOS Commercial |
$2,517.81
|
| Rate for Payer: HFN Commercial |
$2,602.68
|
| Rate for Payer: Multiplan Commercial |
$2,263.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,697.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,602.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,386.21
|
| Rate for Payer: Quartz Commercial |
$1,697.40
|
| Rate for Payer: WEA Trust Commercial |
$1,555.95
|
| Rate for Payer: WPS Commercial |
$2,095.44
|
|
|
ATRICLIP SELECTION GUIDE CGG100
|
Facility
OP
|
$2,829.00
|
|
| Hospital Charge Code |
2969515
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$792.12 |
| Max. Negotiated Rate |
$11,316.00 |
| Rate for Payer: Aetna Commercial |
$2,546.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,432.94
|
| Rate for Payer: Aetna Managed Medicare |
$792.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,838.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,414.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,357.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,499.37
|
| Rate for Payer: Cash Price |
$848.70
|
| Rate for Payer: Cigna Commercial |
$2,602.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,583.11
|
| Rate for Payer: Health EOS Commercial |
$2,517.81
|
| Rate for Payer: HFN Commercial |
$2,602.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,121.75
|
| Rate for Payer: Multiplan Commercial |
$2,263.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,697.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,602.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,386.21
|
| Rate for Payer: Quartz Commercial |
$1,838.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,697.40
|
| Rate for Payer: The Alliance Commercial |
$11,316.00
|
| Rate for Payer: WEA Trust Commercial |
$1,555.95
|
| Rate for Payer: WPS Commercial |
$2,095.44
|
|
|
ATRICULAR SURFACE PERSONA VE 6-9 CD 10MM 42-5224-005-10
|
Facility
IP
|
$8,771.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3333502
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,297.79 |
| Max. Negotiated Rate |
$8,069.32 |
| Rate for Payer: Aetna Commercial |
$7,893.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,648.63
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,069.32
|
| Rate for Payer: Health EOS Commercial |
$7,806.19
|
| Rate for Payer: HFN Commercial |
$8,069.32
|
| Rate for Payer: Multiplan Commercial |
$7,016.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,262.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,069.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,297.79
|
| Rate for Payer: Quartz Commercial |
$5,262.60
|
| Rate for Payer: WEA Trust Commercial |
$4,824.05
|
| Rate for Payer: WPS Commercial |
$6,496.68
|
|
|
ATRICULAR SURFACE PERSONA VE 6-9 CD 10MM 42-5224-005-10
|
Facility
OP
|
$8,771.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3333502
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,455.88 |
| Max. Negotiated Rate |
$8,069.32 |
| Rate for Payer: Aetna Commercial |
$7,893.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,543.06
|
| Rate for Payer: Aetna Managed Medicare |
$2,455.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,701.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,385.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,210.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,648.63
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,069.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,908.25
|
| Rate for Payer: Health EOS Commercial |
$7,806.19
|
| Rate for Payer: HFN Commercial |
$8,069.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,578.25
|
| Rate for Payer: Multiplan Commercial |
$7,016.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,262.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,069.32
|
| Rate for Payer: Quartz Beloit One Network |
$4,297.79
|
| Rate for Payer: Quartz Commercial |
$5,701.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,262.60
|
| Rate for Payer: WEA Trust Commercial |
$4,824.05
|
| Rate for Payer: WPS Commercial |
$6,496.68
|
|
|
ATRIUM MINI-EXPRESS 500ML 16400
|
Facility
OP
|
$1,160.00
|
|
|
Service Code
|
HCPCS A7048
|
| Hospital Charge Code |
4508741
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$324.80 |
| Max. Negotiated Rate |
$1,067.20 |
| Rate for Payer: Aetna Commercial |
$1,044.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$997.60
|
| Rate for Payer: Aetna Managed Medicare |
$324.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$754.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$580.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$556.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$614.80
|
| Rate for Payer: Cash Price |
$348.00
|
| Rate for Payer: Cigna Commercial |
$1,067.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$649.14
|
| Rate for Payer: Health EOS Commercial |
$1,032.40
|
| Rate for Payer: HFN Commercial |
$1,067.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$870.00
|
| Rate for Payer: Multiplan Commercial |
$928.00
|
| Rate for Payer: NAPHCARE Commercial |
$696.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,067.20
|
| Rate for Payer: Quartz Beloit One Network |
$568.40
|
| Rate for Payer: Quartz Commercial |
$754.00
|
| Rate for Payer: Quartz Medicare Advantage |
$696.00
|
| Rate for Payer: WEA Trust Commercial |
$638.00
|
| Rate for Payer: WPS Commercial |
$859.21
|
|
|
ATRIUM MINI-EXPRESS 500ML 16400
|
Facility
IP
|
$1,160.00
|
|
|
Service Code
|
HCPCS A7048
|
| Hospital Charge Code |
4508741
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$568.40 |
| Max. Negotiated Rate |
$1,067.20 |
| Rate for Payer: Aetna Commercial |
$1,044.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$614.80
|
| Rate for Payer: Cash Price |
$348.00
|
| Rate for Payer: Cigna Commercial |
$1,067.20
|
| Rate for Payer: Health EOS Commercial |
$1,032.40
|
| Rate for Payer: HFN Commercial |
$1,067.20
|
| Rate for Payer: Multiplan Commercial |
$928.00
|
| Rate for Payer: NAPHCARE Commercial |
$696.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,067.20
|
| Rate for Payer: Quartz Beloit One Network |
$568.40
|
| Rate for Payer: Quartz Commercial |
$696.00
|
| Rate for Payer: WEA Trust Commercial |
$638.00
|
| Rate for Payer: WPS Commercial |
$859.21
|
|
|
atrixtra 0.5 mg Charge
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
2958956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
atrixtra 0.5 mg Charge
|
Professional
|
$22.00
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
2958956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$20.90 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$1.07
|
| Rate for Payer: Anthem Medicare Advantage |
$1.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1.07
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.03
|
| Rate for Payer: Health EOS Commercial |
$20.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1.07
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: Preferred Network Access Commercial |
$20.90
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.54
|
| Rate for Payer: Quartz Medicare Advantage |
$1.07
|
| Rate for Payer: The Alliance Commercial |
$2.95
|
| Rate for Payer: United Healthcare Medicaid |
$1.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.07
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$2.58
|
|
|
atrixtra 0.5 mg Charge
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
2958956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$232.36 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.36
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$13.20
|
| Rate for Payer: The Alliance Commercial |
$232.36
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$2.58
|
|
|
Atropine 0.01 mg Charge
|
Professional
|
$7.00
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
2958881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$0.09
|
| Rate for Payer: Anthem Medicare Advantage |
$0.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.09
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.07
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: Quartz Medicare Advantage |
$0.09
|
| Rate for Payer: The Alliance Commercial |
$0.24
|
| Rate for Payer: United Healthcare Medicaid |
$0.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.09
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$0.17
|
|
|
Atropine 0.01 mg Charge
|
Facility
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
2958881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$346.32 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.09
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$346.32
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$0.17
|
|
|
Atropine 0.01 mg Charge
|
Facility
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
2958881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
atropine 1 mg/mL Inj 1ml vial [Med]
|
Facility
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
2983106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
atropine 1 mg/mL Inj 1ml vial [Med]
|
Facility
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
2983106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$346.32 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.09
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$346.32
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$0.17
|
|
|
Atropine 1% Ophth Solution 5ml [Med]
|
Facility
OP
|
$189.00
|
|
| Hospital Charge Code |
2974908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.92 |
| Max. Negotiated Rate |
$756.00 |
| Rate for Payer: Aetna Commercial |
$170.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.54
|
| Rate for Payer: Aetna Managed Medicare |
$52.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$122.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$94.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$90.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.17
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$173.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$105.76
|
| Rate for Payer: Health EOS Commercial |
$168.21
|
| Rate for Payer: HFN Commercial |
$173.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$141.75
|
| Rate for Payer: Multiplan Commercial |
$151.20
|
| Rate for Payer: NAPHCARE Commercial |
$113.40
|
| Rate for Payer: Preferred Network Access Commercial |
$173.88
|
| Rate for Payer: Quartz Beloit One Network |
$92.61
|
| Rate for Payer: Quartz Commercial |
$122.85
|
| Rate for Payer: Quartz Medicare Advantage |
$113.40
|
| Rate for Payer: The Alliance Commercial |
$756.00
|
| Rate for Payer: WEA Trust Commercial |
$103.95
|
| Rate for Payer: WPS Commercial |
$139.99
|
|
|
Atropine 1% Ophth Solution 5ml [Med]
|
Facility
IP
|
$189.00
|
|
| Hospital Charge Code |
2974908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$92.61 |
| Max. Negotiated Rate |
$173.88 |
| Rate for Payer: Aetna Commercial |
$170.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.17
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$173.88
|
| Rate for Payer: Health EOS Commercial |
$168.21
|
| Rate for Payer: HFN Commercial |
$173.88
|
| Rate for Payer: Multiplan Commercial |
$151.20
|
| Rate for Payer: NAPHCARE Commercial |
$113.40
|
| Rate for Payer: Preferred Network Access Commercial |
$173.88
|
| Rate for Payer: Quartz Beloit One Network |
$92.61
|
| Rate for Payer: Quartz Commercial |
$113.40
|
| Rate for Payer: WEA Trust Commercial |
$103.95
|
| Rate for Payer: WPS Commercial |
$139.99
|
|
|
ATTACHMENT C2C DISPOSABLE 4607-300-032
|
Facility
IP
|
$3,805.00
|
|
| Hospital Charge Code |
6228125
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,864.45 |
| Max. Negotiated Rate |
$3,500.60 |
| Rate for Payer: Aetna Commercial |
$3,424.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,016.65
|
| Rate for Payer: Cash Price |
$1,141.50
|
| Rate for Payer: Cigna Commercial |
$3,500.60
|
| Rate for Payer: Health EOS Commercial |
$3,386.45
|
| Rate for Payer: HFN Commercial |
$3,500.60
|
| Rate for Payer: Multiplan Commercial |
$3,044.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,283.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,500.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,864.45
|
| Rate for Payer: Quartz Commercial |
$2,283.00
|
| Rate for Payer: WEA Trust Commercial |
$2,092.75
|
| Rate for Payer: WPS Commercial |
$2,818.36
|
|
