|
SET HEATED INSUFFLATION TUBING/CONNECTOR ARTHREX DISPOSABLE AR-3290-1007
|
Facility
|
OP
|
$1,425.00
|
|
| Hospital Charge Code |
5074897
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$399.00 |
| Max. Negotiated Rate |
$5,700.00 |
| Rate for Payer: Aetna Commercial |
$1,282.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,225.50
|
| Rate for Payer: Aetna Managed Medicare |
$399.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$926.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$712.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$684.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$755.25
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cigna Commercial |
$1,311.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$797.43
|
| Rate for Payer: Health EOS Commercial |
$1,268.25
|
| Rate for Payer: HFN Commercial |
$1,311.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,068.75
|
| Rate for Payer: Multiplan Commercial |
$1,140.00
|
| Rate for Payer: NAPHCARE Commercial |
$855.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,311.00
|
| Rate for Payer: Quartz Beloit One Network |
$698.25
|
| Rate for Payer: Quartz Commercial |
$926.25
|
| Rate for Payer: Quartz Medicare Advantage |
$855.00
|
| Rate for Payer: The Alliance Commercial |
$5,700.00
|
| Rate for Payer: WEA Trust Commercial |
$783.75
|
| Rate for Payer: WPS Commercial |
$1,055.50
|
|
|
SET HEATED INSUFFLATION TUBING/CONNECTOR ARTHREX DISPOSABLE AR-3290-1007
|
Facility
|
IP
|
$1,425.00
|
|
| Hospital Charge Code |
5074897
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$698.25 |
| Max. Negotiated Rate |
$1,311.00 |
| Rate for Payer: Aetna Commercial |
$1,282.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,225.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$755.25
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cigna Commercial |
$1,311.00
|
| Rate for Payer: Health EOS Commercial |
$1,268.25
|
| Rate for Payer: HFN Commercial |
$1,311.00
|
| Rate for Payer: Multiplan Commercial |
$1,140.00
|
| Rate for Payer: NAPHCARE Commercial |
$855.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,311.00
|
| Rate for Payer: Quartz Beloit One Network |
$698.25
|
| Rate for Payer: Quartz Commercial |
$855.00
|
| Rate for Payer: WEA Trust Commercial |
$783.75
|
| Rate for Payer: WPS Commercial |
$1,055.50
|
|
|
SET NON-HEATED INSUFFLATION TUBING/CONNECTOR ARTHREX DISPOSABLE AR-3290-1001
|
Facility
|
IP
|
$684.00
|
|
| Hospital Charge Code |
5496911
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$335.16 |
| Max. Negotiated Rate |
$629.28 |
| Rate for Payer: Aetna Commercial |
$615.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$588.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$362.52
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$629.28
|
| Rate for Payer: Health EOS Commercial |
$608.76
|
| Rate for Payer: HFN Commercial |
$629.28
|
| Rate for Payer: Multiplan Commercial |
$547.20
|
| Rate for Payer: NAPHCARE Commercial |
$410.40
|
| Rate for Payer: Preferred Network Access Commercial |
$629.28
|
| Rate for Payer: Quartz Beloit One Network |
$335.16
|
| Rate for Payer: Quartz Commercial |
$410.40
|
| Rate for Payer: WEA Trust Commercial |
$376.20
|
| Rate for Payer: WPS Commercial |
$506.64
|
|
|
SET NON-HEATED INSUFFLATION TUBING/CONNECTOR ARTHREX DISPOSABLE AR-3290-1001
|
Facility
|
OP
|
$684.00
|
|
| Hospital Charge Code |
5496911
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$191.52 |
| Max. Negotiated Rate |
$2,736.00 |
| Rate for Payer: Aetna Commercial |
$615.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$588.24
|
| Rate for Payer: Aetna Managed Medicare |
$191.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$444.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$342.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$328.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$362.52
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$629.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$382.77
|
| Rate for Payer: Health EOS Commercial |
$608.76
|
| Rate for Payer: HFN Commercial |
$629.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$513.00
|
| Rate for Payer: Multiplan Commercial |
$547.20
|
| Rate for Payer: NAPHCARE Commercial |
$410.40
|
| Rate for Payer: Preferred Network Access Commercial |
$629.28
|
| Rate for Payer: Quartz Beloit One Network |
$335.16
|
| Rate for Payer: Quartz Commercial |
$444.60
|
| Rate for Payer: Quartz Medicare Advantage |
$410.40
|
| Rate for Payer: The Alliance Commercial |
$2,736.00
|
| Rate for Payer: WEA Trust Commercial |
$376.20
|
| Rate for Payer: WPS Commercial |
$506.64
|
|
|
SET OUTFLOW CASSETTE/TUBING ARTHROSCOPY ARTHREX AR-6430
|
Facility
|
IP
|
$888.00
|
|
| Hospital Charge Code |
5074887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$435.12 |
| Max. Negotiated Rate |
$816.96 |
| Rate for Payer: Aetna Commercial |
$799.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$763.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.64
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna Commercial |
$816.96
|
| Rate for Payer: Health EOS Commercial |
$790.32
|
| Rate for Payer: HFN Commercial |
$816.96
|
| Rate for Payer: Multiplan Commercial |
$710.40
|
| Rate for Payer: NAPHCARE Commercial |
$532.80
|
| Rate for Payer: Preferred Network Access Commercial |
$816.96
|
| Rate for Payer: Quartz Beloit One Network |
$435.12
|
| Rate for Payer: Quartz Commercial |
$532.80
|
| Rate for Payer: WEA Trust Commercial |
$488.40
|
| Rate for Payer: WPS Commercial |
$657.74
|
|
|
SET OUTFLOW CASSETTE/TUBING ARTHROSCOPY ARTHREX AR-6430
|
Facility
|
OP
|
$888.00
|
|
| Hospital Charge Code |
5074887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$248.64 |
| Max. Negotiated Rate |
$3,552.00 |
| Rate for Payer: Aetna Commercial |
$799.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$763.68
|
| Rate for Payer: Aetna Managed Medicare |
$248.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$577.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$444.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$426.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.64
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna Commercial |
$816.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$496.92
|
| Rate for Payer: Health EOS Commercial |
$790.32
|
| Rate for Payer: HFN Commercial |
$816.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$666.00
|
| Rate for Payer: Multiplan Commercial |
$710.40
|
| Rate for Payer: NAPHCARE Commercial |
$532.80
|
| Rate for Payer: Preferred Network Access Commercial |
$816.96
|
| Rate for Payer: Quartz Beloit One Network |
$435.12
|
| Rate for Payer: Quartz Commercial |
$577.20
|
| Rate for Payer: Quartz Medicare Advantage |
$532.80
|
| Rate for Payer: The Alliance Commercial |
$3,552.00
|
| Rate for Payer: WEA Trust Commercial |
$488.40
|
| Rate for Payer: WPS Commercial |
$657.74
|
|
|
SET RE-ENTRY MALECOT NEPHROSTOMY CATHETER 24F X 35CM M0064101070
|
Facility
|
OP
|
$1,234.00
|
|
| Hospital Charge Code |
5415303
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$345.52 |
| Max. Negotiated Rate |
$4,936.00 |
| Rate for Payer: Aetna Commercial |
$1,110.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,061.24
|
| Rate for Payer: Aetna Managed Medicare |
$345.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$802.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$617.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$592.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$654.02
|
| Rate for Payer: Cash Price |
$370.20
|
| Rate for Payer: Cigna Commercial |
$1,135.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$690.55
|
| Rate for Payer: Health EOS Commercial |
$1,098.26
|
| Rate for Payer: HFN Commercial |
$1,135.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$925.50
|
| Rate for Payer: Multiplan Commercial |
$987.20
|
| Rate for Payer: NAPHCARE Commercial |
$740.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,135.28
|
| Rate for Payer: Quartz Beloit One Network |
$604.66
|
| Rate for Payer: Quartz Commercial |
$802.10
|
| Rate for Payer: Quartz Medicare Advantage |
$740.40
|
| Rate for Payer: The Alliance Commercial |
$4,936.00
|
| Rate for Payer: WEA Trust Commercial |
$678.70
|
| Rate for Payer: WPS Commercial |
$914.02
|
|
|
SET RE-ENTRY MALECOT NEPHROSTOMY CATHETER 24F X 35CM M0064101070
|
Facility
|
IP
|
$1,234.00
|
|
| Hospital Charge Code |
5415303
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$604.66 |
| Max. Negotiated Rate |
$1,135.28 |
| Rate for Payer: Aetna Commercial |
$1,110.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,061.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$654.02
|
| Rate for Payer: Cash Price |
$370.20
|
| Rate for Payer: Cigna Commercial |
$1,135.28
|
| Rate for Payer: Health EOS Commercial |
$1,098.26
|
| Rate for Payer: HFN Commercial |
$1,135.28
|
| Rate for Payer: Multiplan Commercial |
$987.20
|
| Rate for Payer: NAPHCARE Commercial |
$740.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,135.28
|
| Rate for Payer: Quartz Beloit One Network |
$604.66
|
| Rate for Payer: Quartz Commercial |
$740.40
|
| Rate for Payer: WEA Trust Commercial |
$678.70
|
| Rate for Payer: WPS Commercial |
$914.02
|
|
|
SET SCREW TI 8 X 17.5MM 3003-0822S
|
Facility
|
OP
|
$2,110.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
4120815
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$590.80 |
| Max. Negotiated Rate |
$8,440.00 |
| Rate for Payer: Aetna Commercial |
$1,899.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,814.60
|
| Rate for Payer: Aetna Managed Medicare |
$590.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,371.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,055.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,012.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,118.30
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cigna Commercial |
$1,941.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,180.76
|
| Rate for Payer: Health EOS Commercial |
$1,877.90
|
| Rate for Payer: HFN Commercial |
$1,941.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,582.50
|
| Rate for Payer: Multiplan Commercial |
$1,688.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,266.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,941.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,033.90
|
| Rate for Payer: Quartz Commercial |
$1,371.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,266.00
|
| Rate for Payer: The Alliance Commercial |
$8,440.00
|
| Rate for Payer: WEA Trust Commercial |
$1,160.50
|
| Rate for Payer: WPS Commercial |
$1,562.88
|
|
|
SET SCREW TI 8 X 17.5MM 3003-0822S
|
Facility
|
IP
|
$2,110.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
4120815
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,033.90 |
| Max. Negotiated Rate |
$1,941.20 |
| Rate for Payer: Aetna Commercial |
$1,899.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,814.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,118.30
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cigna Commercial |
$1,941.20
|
| Rate for Payer: Health EOS Commercial |
$1,877.90
|
| Rate for Payer: HFN Commercial |
$1,941.20
|
| Rate for Payer: Multiplan Commercial |
$1,688.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,266.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,941.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,033.90
|
| Rate for Payer: Quartz Commercial |
$1,266.00
|
| Rate for Payer: WEA Trust Commercial |
$1,160.50
|
| Rate for Payer: WPS Commercial |
$1,562.88
|
|
|
SET SMALL BORE EXTENTION 60 IN #MX448L60
|
Facility
|
OP
|
$48.00
|
|
| Hospital Charge Code |
2974610
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Aetna Managed Medicare |
$13.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.86
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$31.20
|
| Rate for Payer: Quartz Medicare Advantage |
$28.80
|
| Rate for Payer: The Alliance Commercial |
$192.00
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
SET SMALL BORE EXTENTION 60 IN #MX448L60
|
Facility
|
IP
|
$48.00
|
|
| Hospital Charge Code |
2974610
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$44.16 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$28.80
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
SET ULTRATHANE MCLEAN ENTERAL FEEDING TUBE 9.5 FR. #MRT-9.5-130
|
Facility
|
IP
|
$48.00
|
|
| Hospital Charge Code |
2972284
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$44.16 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$28.80
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
SET ULTRATHANE MCLEAN ENTERAL FEEDING TUBE 9.5 FR. #MRT-9.5-130
|
Facility
|
OP
|
$48.00
|
|
| Hospital Charge Code |
2972284
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Aetna Managed Medicare |
$13.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.86
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$31.20
|
| Rate for Payer: Quartz Medicare Advantage |
$28.80
|
| Rate for Payer: The Alliance Commercial |
$192.00
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
Setup - Therapeutic Gases Charge
|
Facility
|
IP
|
$725.00
|
|
| Hospital Charge Code |
3004206
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$355.25 |
| Max. Negotiated Rate |
$667.00 |
| Rate for Payer: Aetna Commercial |
$652.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$623.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$384.25
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cigna Commercial |
$667.00
|
| Rate for Payer: Health EOS Commercial |
$645.25
|
| Rate for Payer: HFN Commercial |
$667.00
|
| Rate for Payer: Multiplan Commercial |
$580.00
|
| Rate for Payer: NAPHCARE Commercial |
$435.00
|
| Rate for Payer: Preferred Network Access Commercial |
$667.00
|
| Rate for Payer: Quartz Beloit One Network |
$355.25
|
| Rate for Payer: Quartz Commercial |
$435.00
|
| Rate for Payer: WEA Trust Commercial |
$398.75
|
| Rate for Payer: WPS Commercial |
$537.01
|
|
|
Setup - Therapeutic Gases Charge
|
Facility
|
OP
|
$725.00
|
|
| Hospital Charge Code |
3004206
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$203.00 |
| Max. Negotiated Rate |
$2,900.00 |
| Rate for Payer: Aetna Commercial |
$652.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$623.50
|
| Rate for Payer: Aetna Managed Medicare |
$203.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$471.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$362.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$348.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$384.25
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cigna Commercial |
$667.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$405.71
|
| Rate for Payer: Health EOS Commercial |
$645.25
|
| Rate for Payer: HFN Commercial |
$667.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$543.75
|
| Rate for Payer: Multiplan Commercial |
$580.00
|
| Rate for Payer: NAPHCARE Commercial |
$435.00
|
| Rate for Payer: Preferred Network Access Commercial |
$667.00
|
| Rate for Payer: Quartz Beloit One Network |
$355.25
|
| Rate for Payer: Quartz Commercial |
$471.25
|
| Rate for Payer: Quartz Medicare Advantage |
$435.00
|
| Rate for Payer: The Alliance Commercial |
$2,900.00
|
| Rate for Payer: WEA Trust Commercial |
$398.75
|
| Rate for Payer: WPS Commercial |
$537.01
|
|
|
SET Y-TYPE TUR BLADDER IRRIGATION 2C4041
|
Facility
|
OP
|
$171.00
|
|
| Hospital Charge Code |
2963418
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.88 |
| Max. Negotiated Rate |
$684.00 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.06
|
| Rate for Payer: Aetna Managed Medicare |
$47.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$111.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$85.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$82.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.63
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$157.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.69
|
| Rate for Payer: Health EOS Commercial |
$152.19
|
| Rate for Payer: HFN Commercial |
$157.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$128.25
|
| Rate for Payer: Multiplan Commercial |
$136.80
|
| Rate for Payer: NAPHCARE Commercial |
$102.60
|
| Rate for Payer: Preferred Network Access Commercial |
$157.32
|
| Rate for Payer: Quartz Beloit One Network |
$83.79
|
| Rate for Payer: Quartz Commercial |
$111.15
|
| Rate for Payer: Quartz Medicare Advantage |
$102.60
|
| Rate for Payer: The Alliance Commercial |
$684.00
|
| Rate for Payer: WEA Trust Commercial |
$94.05
|
| Rate for Payer: WPS Commercial |
$126.66
|
|
|
SET Y-TYPE TUR BLADDER IRRIGATION 2C4041
|
Facility
|
IP
|
$171.00
|
|
| Hospital Charge Code |
2963418
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$83.79 |
| Max. Negotiated Rate |
$157.32 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.63
|
| Rate for Payer: Cash Price |
$51.30
|
| Rate for Payer: Cigna Commercial |
$157.32
|
| Rate for Payer: Health EOS Commercial |
$152.19
|
| Rate for Payer: HFN Commercial |
$157.32
|
| Rate for Payer: Multiplan Commercial |
$136.80
|
| Rate for Payer: NAPHCARE Commercial |
$102.60
|
| Rate for Payer: Preferred Network Access Commercial |
$157.32
|
| Rate for Payer: Quartz Beloit One Network |
$83.79
|
| Rate for Payer: Quartz Commercial |
$102.60
|
| Rate for Payer: WEA Trust Commercial |
$94.05
|
| Rate for Payer: WPS Commercial |
$126.66
|
|
|
Sex Hormone Binding Globulin
|
Professional
|
Both
|
$296.00
|
|
|
Service Code
|
CPT 84270
|
| Hospital Charge Code |
978066
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$76.71 |
| Max. Negotiated Rate |
$281.20 |
| Rate for Payer: Aetna Commercial |
$281.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.56
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$281.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$148.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$177.60
|
| Rate for Payer: Health EOS Commercial |
$269.36
|
| Rate for Payer: HFN Commercial |
$281.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$76.71
|
| Rate for Payer: Multiplan Commercial |
$236.80
|
| Rate for Payer: Preferred Network Access Commercial |
$281.20
|
| Rate for Payer: Quartz Beloit One Network |
$130.24
|
| Rate for Payer: Quartz Commercial |
$168.72
|
| Rate for Payer: The Alliance Commercial |
$148.00
|
| Rate for Payer: WEA Trust Commercial |
$162.80
|
| Rate for Payer: WPS Commercial |
$219.25
|
|
|
Sex Hormone Binding Globulin
|
Professional
|
Both
|
$199.00
|
|
|
Service Code
|
CPT 84270
|
| Hospital Charge Code |
2943014
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$76.71 |
| Max. Negotiated Rate |
$189.05 |
| Rate for Payer: Aetna Commercial |
$189.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.14
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cigna Commercial |
$189.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$99.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.40
|
| Rate for Payer: Health EOS Commercial |
$181.09
|
| Rate for Payer: HFN Commercial |
$189.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$76.71
|
| Rate for Payer: Multiplan Commercial |
$159.20
|
| Rate for Payer: Preferred Network Access Commercial |
$189.05
|
| Rate for Payer: Quartz Beloit One Network |
$87.56
|
| Rate for Payer: Quartz Commercial |
$113.43
|
| Rate for Payer: The Alliance Commercial |
$99.50
|
| Rate for Payer: WEA Trust Commercial |
$109.45
|
| Rate for Payer: WPS Commercial |
$147.40
|
|
|
Sex Hormone Binding Globulin
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
CPT 84270
|
| Hospital Charge Code |
2943014
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$97.51 |
| Max. Negotiated Rate |
$183.08 |
| Rate for Payer: Aetna Commercial |
$179.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.47
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cigna Commercial |
$183.08
|
| Rate for Payer: Health EOS Commercial |
$177.11
|
| Rate for Payer: HFN Commercial |
$183.08
|
| Rate for Payer: Multiplan Commercial |
$159.20
|
| Rate for Payer: NAPHCARE Commercial |
$119.40
|
| Rate for Payer: Preferred Network Access Commercial |
$183.08
|
| Rate for Payer: Quartz Beloit One Network |
$97.51
|
| Rate for Payer: Quartz Commercial |
$119.40
|
| Rate for Payer: WEA Trust Commercial |
$109.45
|
| Rate for Payer: WPS Commercial |
$147.40
|
|
|
Sex Hormone Binding Globulin
|
Facility
|
IP
|
$296.00
|
|
|
Service Code
|
CPT 84270
|
| Hospital Charge Code |
978066
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$145.04 |
| Max. Negotiated Rate |
$272.32 |
| Rate for Payer: Multiplan Commercial |
$236.80
|
| Rate for Payer: NAPHCARE Commercial |
$177.60
|
| Rate for Payer: Aetna Commercial |
$266.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$156.88
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$272.32
|
| Rate for Payer: Health EOS Commercial |
$263.44
|
| Rate for Payer: HFN Commercial |
$272.32
|
| Rate for Payer: Preferred Network Access Commercial |
$272.32
|
| Rate for Payer: Quartz Beloit One Network |
$145.04
|
| Rate for Payer: Quartz Commercial |
$177.60
|
| Rate for Payer: WEA Trust Commercial |
$162.80
|
| Rate for Payer: WPS Commercial |
$219.25
|
|
|
Sex Hormone Binding Globulin
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
CPT 84270
|
| Hospital Charge Code |
2943014
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.73 |
| Max. Negotiated Rate |
$183.08 |
| Rate for Payer: Aetna Commercial |
$179.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.14
|
| Rate for Payer: Aetna Managed Medicare |
$21.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$38.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.07
|
| Rate for Payer: Anthem Medicaid |
$22.45
|
| Rate for Payer: Anthem Medicare Advantage |
$21.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.73
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cigna Commercial |
$183.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$21.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.36
|
| Rate for Payer: Dean Health Medicaid |
$22.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$21.73
|
| Rate for Payer: Health EOS Commercial |
$177.11
|
| Rate for Payer: HFN Commercial |
$183.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.73
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$22.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.73
|
| Rate for Payer: Managed Health Services Medicaid |
$23.35
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$21.73
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$21.73
|
| Rate for Payer: Multiplan Commercial |
$159.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.60
|
| Rate for Payer: Preferred Network Access Commercial |
$183.08
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$22.45
|
| Rate for Payer: Quartz Beloit One Network |
$97.51
|
| Rate for Payer: Quartz Commercial |
$129.35
|
| Rate for Payer: Quartz Medicare Advantage |
$21.73
|
| Rate for Payer: The Alliance Commercial |
$86.92
|
| Rate for Payer: United Healthcare Medicaid |
$22.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.73
|
| Rate for Payer: United Healthcare PPO |
$149.25
|
| Rate for Payer: WEA Trust Commercial |
$109.45
|
| Rate for Payer: Wellcare Medicare |
$21.73
|
| Rate for Payer: WMAP Medicaid |
$22.45
|
| Rate for Payer: WPS Commercial |
$147.40
|
|
|
Sex Hormone Binding Globulin
|
Facility
|
OP
|
$296.00
|
|
|
Service Code
|
CPT 84270
|
| Hospital Charge Code |
978066
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.73 |
| Max. Negotiated Rate |
$272.32 |
| Rate for Payer: Aetna Commercial |
$266.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.56
|
| Rate for Payer: Aetna Managed Medicare |
$21.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$38.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.07
|
| Rate for Payer: Anthem Medicaid |
$22.45
|
| Rate for Payer: Anthem Medicare Advantage |
$21.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$156.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.73
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$272.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$21.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$165.64
|
| Rate for Payer: Dean Health Medicaid |
$22.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$21.73
|
| Rate for Payer: Health EOS Commercial |
$263.44
|
| Rate for Payer: HFN Commercial |
$272.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.73
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$22.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.73
|
| Rate for Payer: Managed Health Services Medicaid |
$23.35
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$21.73
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$21.73
|
| Rate for Payer: Multiplan Commercial |
$236.80
|
| Rate for Payer: NAPHCARE Commercial |
$32.60
|
| Rate for Payer: Preferred Network Access Commercial |
$272.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$22.45
|
| Rate for Payer: Quartz Beloit One Network |
$145.04
|
| Rate for Payer: Quartz Commercial |
$192.40
|
| Rate for Payer: Quartz Medicare Advantage |
$21.73
|
| Rate for Payer: The Alliance Commercial |
$86.92
|
| Rate for Payer: United Healthcare Medicaid |
$22.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.73
|
| Rate for Payer: United Healthcare PPO |
$222.00
|
| Rate for Payer: WEA Trust Commercial |
$162.80
|
| Rate for Payer: Wellcare Medicare |
$21.73
|
| Rate for Payer: WMAP Medicaid |
$22.45
|
| Rate for Payer: WPS Commercial |
$219.25
|
|
|
Sezary Diagnostic Flow Cytometry
|
Professional
|
Both
|
$240.00
|
|
|
Service Code
|
CPT 88184
|
| Hospital Charge Code |
5364855
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$105.60 |
| Max. Negotiated Rate |
$230.47 |
| Rate for Payer: Aetna Commercial |
$228.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$206.40
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$228.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$120.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.00
|
| Rate for Payer: Health EOS Commercial |
$218.40
|
| Rate for Payer: HFN Commercial |
$228.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$230.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$230.47
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: Preferred Network Access Commercial |
$228.00
|
| Rate for Payer: Quartz Beloit One Network |
$105.60
|
| Rate for Payer: Quartz Commercial |
$136.80
|
| Rate for Payer: The Alliance Commercial |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$132.00
|
| Rate for Payer: WPS Commercial |
$177.77
|
|
