|
SCREW VARIAX 2 MINI 2.7MM X 36MM 656436
|
Facility
|
IP
|
$1,321.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685717
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.29 |
| Max. Negotiated Rate |
$1,215.32 |
| Rate for Payer: Aetna Commercial |
$1,188.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.13
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,215.32
|
| Rate for Payer: Health EOS Commercial |
$1,175.69
|
| Rate for Payer: HFN Commercial |
$1,215.32
|
| Rate for Payer: Multiplan Commercial |
$1,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$792.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,215.32
|
| Rate for Payer: Quartz Beloit One Network |
$647.29
|
| Rate for Payer: Quartz Commercial |
$792.60
|
| Rate for Payer: WEA Trust Commercial |
$726.55
|
| Rate for Payer: WPS Commercial |
$978.46
|
|
|
SCREW VARIAX 2 MINI 2.7MM X 38MM 656438
|
Facility
|
OP
|
$1,321.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$369.88 |
| Max. Negotiated Rate |
$5,284.00 |
| Rate for Payer: Aetna Commercial |
$1,188.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.06
|
| Rate for Payer: Aetna Managed Medicare |
$369.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$858.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$660.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$634.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.13
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,215.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$739.23
|
| Rate for Payer: Health EOS Commercial |
$1,175.69
|
| Rate for Payer: HFN Commercial |
$1,215.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$990.75
|
| Rate for Payer: Multiplan Commercial |
$1,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$792.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,215.32
|
| Rate for Payer: Quartz Beloit One Network |
$647.29
|
| Rate for Payer: Quartz Commercial |
$858.65
|
| Rate for Payer: Quartz Medicare Advantage |
$792.60
|
| Rate for Payer: The Alliance Commercial |
$5,284.00
|
| Rate for Payer: WEA Trust Commercial |
$726.55
|
| Rate for Payer: WPS Commercial |
$978.46
|
|
|
SCREW VARIAX 2 MINI 2.7MM X 38MM 656438
|
Facility
|
IP
|
$1,321.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.29 |
| Max. Negotiated Rate |
$1,215.32 |
| Rate for Payer: Aetna Commercial |
$1,188.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.13
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,215.32
|
| Rate for Payer: Health EOS Commercial |
$1,175.69
|
| Rate for Payer: HFN Commercial |
$1,215.32
|
| Rate for Payer: Multiplan Commercial |
$1,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$792.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,215.32
|
| Rate for Payer: Quartz Beloit One Network |
$647.29
|
| Rate for Payer: Quartz Commercial |
$792.60
|
| Rate for Payer: WEA Trust Commercial |
$726.55
|
| Rate for Payer: WPS Commercial |
$978.46
|
|
|
SCREW VARIAX 2 MINI 2.7MM X 40MM 656440
|
Facility
|
IP
|
$1,321.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685719
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.29 |
| Max. Negotiated Rate |
$1,215.32 |
| Rate for Payer: Aetna Commercial |
$1,188.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.13
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,215.32
|
| Rate for Payer: Health EOS Commercial |
$1,175.69
|
| Rate for Payer: HFN Commercial |
$1,215.32
|
| Rate for Payer: Multiplan Commercial |
$1,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$792.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,215.32
|
| Rate for Payer: Quartz Beloit One Network |
$647.29
|
| Rate for Payer: Quartz Commercial |
$792.60
|
| Rate for Payer: WEA Trust Commercial |
$726.55
|
| Rate for Payer: WPS Commercial |
$978.46
|
|
|
SCREW VARIAX 2 MINI 2.7MM X 40MM 656440
|
Facility
|
OP
|
$1,321.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685719
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$369.88 |
| Max. Negotiated Rate |
$5,284.00 |
| Rate for Payer: Aetna Commercial |
$1,188.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.06
|
| Rate for Payer: Aetna Managed Medicare |
$369.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$858.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$660.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$634.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.13
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,215.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$739.23
|
| Rate for Payer: Health EOS Commercial |
$1,175.69
|
| Rate for Payer: HFN Commercial |
$1,215.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$990.75
|
| Rate for Payer: Multiplan Commercial |
$1,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$792.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,215.32
|
| Rate for Payer: Quartz Beloit One Network |
$647.29
|
| Rate for Payer: Quartz Commercial |
$858.65
|
| Rate for Payer: Quartz Medicare Advantage |
$792.60
|
| Rate for Payer: The Alliance Commercial |
$5,284.00
|
| Rate for Payer: WEA Trust Commercial |
$726.55
|
| Rate for Payer: WPS Commercial |
$978.46
|
|
|
SCREW VARIAX 2 MINI 2.7MM X 42MM 656442
|
Facility
|
OP
|
$1,321.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685720
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$369.88 |
| Max. Negotiated Rate |
$5,284.00 |
| Rate for Payer: Aetna Commercial |
$1,188.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.06
|
| Rate for Payer: Aetna Managed Medicare |
$369.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$858.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$660.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$634.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.13
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,215.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$739.23
|
| Rate for Payer: Health EOS Commercial |
$1,175.69
|
| Rate for Payer: HFN Commercial |
$1,215.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$990.75
|
| Rate for Payer: Multiplan Commercial |
$1,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$792.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,215.32
|
| Rate for Payer: Quartz Beloit One Network |
$647.29
|
| Rate for Payer: Quartz Commercial |
$858.65
|
| Rate for Payer: Quartz Medicare Advantage |
$792.60
|
| Rate for Payer: The Alliance Commercial |
$5,284.00
|
| Rate for Payer: WEA Trust Commercial |
$726.55
|
| Rate for Payer: WPS Commercial |
$978.46
|
|
|
SCREW VARIAX 2 MINI 2.7MM X 42MM 656442
|
Facility
|
IP
|
$1,321.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685720
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.29 |
| Max. Negotiated Rate |
$1,215.32 |
| Rate for Payer: Aetna Commercial |
$1,188.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.13
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,215.32
|
| Rate for Payer: Health EOS Commercial |
$1,175.69
|
| Rate for Payer: HFN Commercial |
$1,215.32
|
| Rate for Payer: Multiplan Commercial |
$1,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$792.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,215.32
|
| Rate for Payer: Quartz Beloit One Network |
$647.29
|
| Rate for Payer: Quartz Commercial |
$792.60
|
| Rate for Payer: WEA Trust Commercial |
$726.55
|
| Rate for Payer: WPS Commercial |
$978.46
|
|
|
SCREW VARIAX 2 MINI 2.7MM X 46MM 656446
|
Facility
|
OP
|
$1,321.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685721
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$369.88 |
| Max. Negotiated Rate |
$5,284.00 |
| Rate for Payer: Aetna Commercial |
$1,188.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.06
|
| Rate for Payer: Aetna Managed Medicare |
$369.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$858.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$660.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$634.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.13
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,215.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$739.23
|
| Rate for Payer: Health EOS Commercial |
$1,175.69
|
| Rate for Payer: HFN Commercial |
$1,215.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$990.75
|
| Rate for Payer: Multiplan Commercial |
$1,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$792.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,215.32
|
| Rate for Payer: Quartz Beloit One Network |
$647.29
|
| Rate for Payer: Quartz Commercial |
$858.65
|
| Rate for Payer: Quartz Medicare Advantage |
$792.60
|
| Rate for Payer: The Alliance Commercial |
$5,284.00
|
| Rate for Payer: WEA Trust Commercial |
$726.55
|
| Rate for Payer: WPS Commercial |
$978.46
|
|
|
SCREW VARIAX 2 MINI 2.7MM X 46MM 656446
|
Facility
|
IP
|
$1,321.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685721
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.29 |
| Max. Negotiated Rate |
$1,215.32 |
| Rate for Payer: Aetna Commercial |
$1,188.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.13
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,215.32
|
| Rate for Payer: Health EOS Commercial |
$1,175.69
|
| Rate for Payer: HFN Commercial |
$1,215.32
|
| Rate for Payer: Multiplan Commercial |
$1,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$792.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,215.32
|
| Rate for Payer: Quartz Beloit One Network |
$647.29
|
| Rate for Payer: Quartz Commercial |
$792.60
|
| Rate for Payer: WEA Trust Commercial |
$726.55
|
| Rate for Payer: WPS Commercial |
$978.46
|
|
|
SCREW VARIAX 2 MINI 2.7MM X 48MM 656448
|
Facility
|
IP
|
$1,321.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685722
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.29 |
| Max. Negotiated Rate |
$1,215.32 |
| Rate for Payer: Aetna Commercial |
$1,188.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.13
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,215.32
|
| Rate for Payer: Health EOS Commercial |
$1,175.69
|
| Rate for Payer: HFN Commercial |
$1,215.32
|
| Rate for Payer: Multiplan Commercial |
$1,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$792.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,215.32
|
| Rate for Payer: Quartz Beloit One Network |
$647.29
|
| Rate for Payer: Quartz Commercial |
$792.60
|
| Rate for Payer: WEA Trust Commercial |
$726.55
|
| Rate for Payer: WPS Commercial |
$978.46
|
|
|
SCREW VARIAX 2 MINI 2.7MM X 48MM 656448
|
Facility
|
OP
|
$1,321.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685722
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$369.88 |
| Max. Negotiated Rate |
$5,284.00 |
| Rate for Payer: Aetna Commercial |
$1,188.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,136.06
|
| Rate for Payer: Aetna Managed Medicare |
$369.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$858.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$660.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$634.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$700.13
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,215.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$739.23
|
| Rate for Payer: Health EOS Commercial |
$1,175.69
|
| Rate for Payer: HFN Commercial |
$1,215.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$990.75
|
| Rate for Payer: Multiplan Commercial |
$1,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$792.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,215.32
|
| Rate for Payer: Quartz Beloit One Network |
$647.29
|
| Rate for Payer: Quartz Commercial |
$858.65
|
| Rate for Payer: Quartz Medicare Advantage |
$792.60
|
| Rate for Payer: The Alliance Commercial |
$5,284.00
|
| Rate for Payer: WEA Trust Commercial |
$726.55
|
| Rate for Payer: WPS Commercial |
$978.46
|
|
|
SCREW/WASHER 2.7MM DIA X 10MM L TI STERILE 285210SND
|
Facility
|
OP
|
$4,266.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5617661
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.48 |
| Max. Negotiated Rate |
$17,064.00 |
| Rate for Payer: Aetna Commercial |
$3,839.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,668.76
|
| Rate for Payer: Aetna Managed Medicare |
$1,194.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,772.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,133.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,047.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,260.98
|
| Rate for Payer: Cash Price |
$1,279.80
|
| Rate for Payer: Cigna Commercial |
$3,924.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,387.25
|
| Rate for Payer: Health EOS Commercial |
$3,796.74
|
| Rate for Payer: HFN Commercial |
$3,924.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,199.50
|
| Rate for Payer: Multiplan Commercial |
$3,412.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,559.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,924.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,090.34
|
| Rate for Payer: Quartz Commercial |
$2,772.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,559.60
|
| Rate for Payer: The Alliance Commercial |
$17,064.00
|
| Rate for Payer: WEA Trust Commercial |
$2,346.30
|
| Rate for Payer: WPS Commercial |
$3,159.83
|
|
|
SCREW/WASHER 2.7MM DIA X 10MM L TI STERILE 285210SND
|
Facility
|
IP
|
$4,266.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5617661
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,090.34 |
| Max. Negotiated Rate |
$3,924.72 |
| Rate for Payer: Aetna Commercial |
$3,839.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,668.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,260.98
|
| Rate for Payer: Cash Price |
$1,279.80
|
| Rate for Payer: Cigna Commercial |
$3,924.72
|
| Rate for Payer: Health EOS Commercial |
$3,796.74
|
| Rate for Payer: HFN Commercial |
$3,924.72
|
| Rate for Payer: Multiplan Commercial |
$3,412.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,559.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,924.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,090.34
|
| Rate for Payer: Quartz Commercial |
$2,559.60
|
| Rate for Payer: WEA Trust Commercial |
$2,346.30
|
| Rate for Payer: WPS Commercial |
$3,159.83
|
|
|
SCREW/WASHER 2.7MM DIA X 14MM L TI STERILE 285214SND
|
Facility
|
OP
|
$4,266.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5617663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.48 |
| Max. Negotiated Rate |
$17,064.00 |
| Rate for Payer: Aetna Commercial |
$3,839.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,668.76
|
| Rate for Payer: Aetna Managed Medicare |
$1,194.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,772.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,133.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,047.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,260.98
|
| Rate for Payer: Cash Price |
$1,279.80
|
| Rate for Payer: Cigna Commercial |
$3,924.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,387.25
|
| Rate for Payer: Health EOS Commercial |
$3,796.74
|
| Rate for Payer: HFN Commercial |
$3,924.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,199.50
|
| Rate for Payer: Multiplan Commercial |
$3,412.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,559.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,924.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,090.34
|
| Rate for Payer: Quartz Commercial |
$2,772.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,559.60
|
| Rate for Payer: The Alliance Commercial |
$17,064.00
|
| Rate for Payer: WEA Trust Commercial |
$2,346.30
|
| Rate for Payer: WPS Commercial |
$3,159.83
|
|
|
SCREW/WASHER 2.7MM DIA X 14MM L TI STERILE 285214SND
|
Facility
|
IP
|
$4,266.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5617663
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,090.34 |
| Max. Negotiated Rate |
$3,924.72 |
| Rate for Payer: Aetna Commercial |
$3,839.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,668.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,260.98
|
| Rate for Payer: Cash Price |
$1,279.80
|
| Rate for Payer: Cigna Commercial |
$3,924.72
|
| Rate for Payer: Health EOS Commercial |
$3,796.74
|
| Rate for Payer: HFN Commercial |
$3,924.72
|
| Rate for Payer: Multiplan Commercial |
$3,412.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,559.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,924.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,090.34
|
| Rate for Payer: Quartz Commercial |
$2,559.60
|
| Rate for Payer: WEA Trust Commercial |
$2,346.30
|
| Rate for Payer: WPS Commercial |
$3,159.83
|
|
|
SCROTAL EXPLORATION
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960366
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
SCROTAL EXPLORATION
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960366
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
SCROTOPLASTY, SIMPLE
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2950486
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
SCROTOPLASTY, SIMPLE
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2950486
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,928.15 |
| Max. Negotiated Rate |
$3,620.20 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,361.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
SCROTOPLASTY; SIMPLE
|
Facility
|
OP
|
$13,782.96
|
|
|
Service Code
|
CPT 55175
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,445.74 |
| Max. Negotiated Rate |
$13,782.96 |
| Rate for Payer: Aetna Managed Medicare |
$3,445.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,445.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,445.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,445.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,445.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,445.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,818.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,445.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,445.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,445.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,445.74
|
| Rate for Payer: NAPHCARE Commercial |
$5,168.61
|
| Rate for Payer: Quartz Medicare Advantage |
$3,445.74
|
| Rate for Payer: The Alliance Commercial |
$13,782.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,445.74
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: Wellcare Medicare |
$3,445.74
|
|
|
SCRUB CHLORAPREP 10.5ML ORANGE 930715
|
Facility
|
OP
|
$123.00
|
|
| Hospital Charge Code |
2962949
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.44 |
| Max. Negotiated Rate |
$492.00 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Aetna Managed Medicare |
$34.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$79.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$59.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.83
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.25
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$79.95
|
| Rate for Payer: Quartz Medicare Advantage |
$73.80
|
| Rate for Payer: The Alliance Commercial |
$492.00
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
SCRUB CHLORAPREP 10.5ML ORANGE 930715
|
Facility
|
IP
|
$123.00
|
|
| Hospital Charge Code |
2962949
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$60.27 |
| Max. Negotiated Rate |
$113.16 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$73.80
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
SCRUB SURGICAL CHLORAPREP 26ML 930815
|
Facility
|
IP
|
$200.00
|
|
| Hospital Charge Code |
2963097
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.00 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: Aetna Commercial |
$180.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$184.00
|
| Rate for Payer: Health EOS Commercial |
$178.00
|
| Rate for Payer: HFN Commercial |
$184.00
|
| Rate for Payer: Multiplan Commercial |
$160.00
|
| Rate for Payer: NAPHCARE Commercial |
$120.00
|
| Rate for Payer: Preferred Network Access Commercial |
$184.00
|
| Rate for Payer: Quartz Beloit One Network |
$98.00
|
| Rate for Payer: Quartz Commercial |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$110.00
|
| Rate for Payer: WPS Commercial |
$148.14
|
|
|
SCRUB SURGICAL CHLORAPREP 26ML 930815
|
Facility
|
OP
|
$200.00
|
|
| Hospital Charge Code |
2963097
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$800.00 |
| Rate for Payer: Aetna Commercial |
$180.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.00
|
| Rate for Payer: Aetna Managed Medicare |
$56.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$130.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$100.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$96.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$184.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.92
|
| Rate for Payer: Health EOS Commercial |
$178.00
|
| Rate for Payer: HFN Commercial |
$184.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$150.00
|
| Rate for Payer: Multiplan Commercial |
$160.00
|
| Rate for Payer: NAPHCARE Commercial |
$120.00
|
| Rate for Payer: Preferred Network Access Commercial |
$184.00
|
| Rate for Payer: Quartz Beloit One Network |
$98.00
|
| Rate for Payer: Quartz Commercial |
$130.00
|
| Rate for Payer: Quartz Medicare Advantage |
$120.00
|
| Rate for Payer: The Alliance Commercial |
$800.00
|
| Rate for Payer: WEA Trust Commercial |
$110.00
|
| Rate for Payer: WPS Commercial |
$148.14
|
|
|
SCRUB SURGICAL DURA-PREP 8630
|
Facility
|
OP
|
$151.00
|
|
| Hospital Charge Code |
2963341
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.28 |
| Max. Negotiated Rate |
$604.00 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Aetna Managed Medicare |
$42.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.50
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.25
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$98.15
|
| Rate for Payer: Quartz Medicare Advantage |
$90.60
|
| Rate for Payer: The Alliance Commercial |
$604.00
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
