|
ATRICLIP SELECTION GUIDE CGG100
|
Facility
|
OP
|
$2,829.00
|
|
| Hospital Charge Code |
2969515
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$823.80 |
| Max. Negotiated Rate |
$2,706.79 |
| Rate for Payer: Aetna Commercial |
$2,647.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,530.26
|
| Rate for Payer: Aetna Managed Medicare |
$823.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,912.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,471.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,412.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,559.34
|
| Rate for Payer: Cash Price |
$848.70
|
| Rate for Payer: Cigna Commercial |
$2,706.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,646.48
|
| Rate for Payer: Health EOS Commercial |
$2,618.52
|
| Rate for Payer: HFN Commercial |
$2,706.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,206.62
|
| Rate for Payer: Multiplan Commercial |
$2,353.73
|
| Rate for Payer: NAPHCARE Commercial |
$1,765.30
|
| Rate for Payer: Preferred Network Access Commercial |
$2,706.79
|
| Rate for Payer: Quartz Beloit One Network |
$1,441.66
|
| Rate for Payer: Quartz Commercial |
$1,912.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,765.30
|
| Rate for Payer: The Alliance Commercial |
$1,471.08
|
| Rate for Payer: WEA Trust Commercial |
$1,618.19
|
| Rate for Payer: WPS Commercial |
$2,179.18
|
|
|
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 |
$2,554.12 |
| Max. Negotiated Rate |
$8,392.09 |
| Rate for Payer: Aetna Commercial |
$8,209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,844.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,554.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,929.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,560.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,378.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,834.58
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,392.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,104.72
|
| Rate for Payer: Health EOS Commercial |
$8,118.44
|
| Rate for Payer: HFN Commercial |
$8,392.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,841.38
|
| Rate for Payer: Multiplan Commercial |
$7,297.47
|
| Rate for Payer: NAPHCARE Commercial |
$5,473.10
|
| Rate for Payer: Preferred Network Access Commercial |
$8,392.09
|
| Rate for Payer: Quartz Beloit One Network |
$4,469.70
|
| Rate for Payer: Quartz Commercial |
$5,929.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5,473.10
|
| Rate for Payer: The Alliance Commercial |
$4,560.92
|
| Rate for Payer: WEA Trust Commercial |
$5,017.01
|
| Rate for Payer: WPS Commercial |
$6,756.30
|
|
|
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 |
$4,469.70 |
| Max. Negotiated Rate |
$8,392.09 |
| Rate for Payer: Aetna Commercial |
$8,209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,844.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,834.58
|
| Rate for Payer: Cash Price |
$2,631.30
|
| Rate for Payer: Cigna Commercial |
$8,392.09
|
| Rate for Payer: Health EOS Commercial |
$8,118.44
|
| Rate for Payer: HFN Commercial |
$8,392.09
|
| Rate for Payer: Multiplan Commercial |
$7,297.47
|
| Rate for Payer: Preferred Network Access Commercial |
$8,392.09
|
| Rate for Payer: Quartz Beloit One Network |
$4,469.70
|
| Rate for Payer: Quartz Commercial |
$5,473.10
|
| Rate for Payer: WEA Trust Commercial |
$5,017.01
|
| Rate for Payer: WPS Commercial |
$6,756.30
|
|
|
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 |
$591.14 |
| Max. Negotiated Rate |
$1,109.89 |
| Rate for Payer: Aetna Commercial |
$1,085.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,037.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$639.39
|
| Rate for Payer: Cash Price |
$348.00
|
| Rate for Payer: Cigna Commercial |
$1,109.89
|
| Rate for Payer: Health EOS Commercial |
$1,073.70
|
| Rate for Payer: HFN Commercial |
$1,109.89
|
| Rate for Payer: Multiplan Commercial |
$965.12
|
| Rate for Payer: Preferred Network Access Commercial |
$1,109.89
|
| Rate for Payer: Quartz Beloit One Network |
$591.14
|
| Rate for Payer: Quartz Commercial |
$723.84
|
| Rate for Payer: WEA Trust Commercial |
$663.52
|
| Rate for Payer: WPS Commercial |
$893.55
|
|
|
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 |
$250.97 |
| Max. Negotiated Rate |
$1,109.89 |
| Rate for Payer: Aetna Commercial |
$1,085.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,037.50
|
| Rate for Payer: Aetna Managed Medicare |
$337.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$784.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$603.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$579.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$639.39
|
| Rate for Payer: Cash Price |
$348.00
|
| Rate for Payer: Cash Price |
$348.00
|
| Rate for Payer: Cigna Commercial |
$1,109.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$675.12
|
| Rate for Payer: Health EOS Commercial |
$1,073.70
|
| Rate for Payer: HFN Commercial |
$1,109.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$904.80
|
| Rate for Payer: Multiplan Commercial |
$965.12
|
| Rate for Payer: NAPHCARE Commercial |
$723.84
|
| Rate for Payer: Preferred Network Access Commercial |
$1,109.89
|
| Rate for Payer: Quartz Beloit One Network |
$591.14
|
| Rate for Payer: Quartz Commercial |
$784.16
|
| Rate for Payer: Quartz Medicare Advantage |
$723.84
|
| Rate for Payer: The Alliance Commercial |
$250.97
|
| Rate for Payer: WEA Trust Commercial |
$663.52
|
| Rate for Payer: WPS Commercial |
$893.55
|
|
|
atrixtra 0.5 mg Charge
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
2958956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$21.74 |
| Rate for Payer: Aetna Commercial |
$21.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$0.92
|
| Rate for Payer: Anthem Medicare Advantage |
$0.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.92
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.07
|
| Rate for Payer: Health EOS Commercial |
$20.82
|
| Rate for Payer: HFN Commercial |
$21.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$1.37
|
| Rate for Payer: Preferred Network Access Commercial |
$21.74
|
| Rate for Payer: Quartz Beloit One Network |
$10.07
|
| Rate for Payer: Quartz Commercial |
$13.04
|
| Rate for Payer: Quartz Medicare Advantage |
$0.92
|
| Rate for Payer: The Alliance Commercial |
$2.52
|
| Rate for Payer: United Healthcare Medicaid |
$0.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.92
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$2.68
|
|
|
atrixtra 0.5 mg Charge
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
2958956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
atrixtra 0.5 mg Charge
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
2958956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.42
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$3.66
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$2.68
|
|
|
Atropine 0.01 mg Charge
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
2958881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
Atropine 0.01 mg Charge
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
2958881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$6.92 |
| Rate for Payer: Aetna Commercial |
$6.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$0.10
|
| Rate for Payer: Anthem Medicare Advantage |
$0.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.07
|
| Rate for Payer: Health EOS Commercial |
$6.62
|
| Rate for Payer: HFN Commercial |
$6.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$0.16
|
| Rate for Payer: Preferred Network Access Commercial |
$6.92
|
| Rate for Payer: Quartz Beloit One Network |
$3.20
|
| Rate for Payer: Quartz Commercial |
$4.15
|
| Rate for Payer: Quartz Medicare Advantage |
$0.10
|
| Rate for Payer: The Alliance Commercial |
$0.29
|
| Rate for Payer: United Healthcare Medicaid |
$0.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.10
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$0.18
|
|
|
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 |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$2.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.09
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$4.37
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.73
|
| Rate for Payer: Quartz Medicare Advantage |
$4.37
|
| Rate for Payer: The Alliance Commercial |
$0.42
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$0.18
|
|
|
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 |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
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 |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$2.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.09
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$4.37
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.73
|
| Rate for Payer: Quartz Medicare Advantage |
$4.37
|
| Rate for Payer: The Alliance Commercial |
$0.42
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$0.18
|
|
|
Atropine 1% Ophth Solution 5ml [Med]
|
Facility
|
OP
|
$189.00
|
|
| Hospital Charge Code |
2974908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.04 |
| Max. Negotiated Rate |
$180.84 |
| Rate for Payer: Aetna Commercial |
$176.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.04
|
| Rate for Payer: Aetna Managed Medicare |
$55.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$127.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$98.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$94.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.18
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$180.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.00
|
| Rate for Payer: Health EOS Commercial |
$174.94
|
| Rate for Payer: HFN Commercial |
$180.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.42
|
| Rate for Payer: Multiplan Commercial |
$157.25
|
| Rate for Payer: NAPHCARE Commercial |
$117.94
|
| Rate for Payer: Preferred Network Access Commercial |
$180.84
|
| Rate for Payer: Quartz Beloit One Network |
$96.31
|
| Rate for Payer: Quartz Commercial |
$127.76
|
| Rate for Payer: Quartz Medicare Advantage |
$117.94
|
| Rate for Payer: The Alliance Commercial |
$98.28
|
| Rate for Payer: WEA Trust Commercial |
$108.11
|
| Rate for Payer: WPS Commercial |
$145.59
|
|
|
Atropine 1% Ophth Solution 5ml [Med]
|
Facility
|
IP
|
$189.00
|
|
| Hospital Charge Code |
2974908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.31 |
| Max. Negotiated Rate |
$180.84 |
| Rate for Payer: Aetna Commercial |
$176.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.18
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$180.84
|
| Rate for Payer: Health EOS Commercial |
$174.94
|
| Rate for Payer: HFN Commercial |
$180.84
|
| Rate for Payer: Multiplan Commercial |
$157.25
|
| Rate for Payer: Preferred Network Access Commercial |
$180.84
|
| Rate for Payer: Quartz Beloit One Network |
$96.31
|
| Rate for Payer: Quartz Commercial |
$117.94
|
| Rate for Payer: WEA Trust Commercial |
$108.11
|
| Rate for Payer: WPS Commercial |
$145.59
|
|
|
ATTACHMENT C2C DISPOSABLE 4607-300-032
|
Facility
|
IP
|
$3,805.00
|
|
| Hospital Charge Code |
6228125
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,939.03 |
| Max. Negotiated Rate |
$3,640.62 |
| Rate for Payer: Aetna Commercial |
$3,561.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,403.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,097.32
|
| Rate for Payer: Cash Price |
$1,141.50
|
| Rate for Payer: Cigna Commercial |
$3,640.62
|
| Rate for Payer: Health EOS Commercial |
$3,521.91
|
| Rate for Payer: HFN Commercial |
$3,640.62
|
| Rate for Payer: Multiplan Commercial |
$3,165.76
|
| Rate for Payer: Preferred Network Access Commercial |
$3,640.62
|
| Rate for Payer: Quartz Beloit One Network |
$1,939.03
|
| Rate for Payer: Quartz Commercial |
$2,374.32
|
| Rate for Payer: WEA Trust Commercial |
$2,176.46
|
| Rate for Payer: WPS Commercial |
$2,930.99
|
|
|
ATTACHMENT C2C DISPOSABLE 4607-300-032
|
Facility
|
OP
|
$3,805.00
|
|
| Hospital Charge Code |
6228125
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,108.02 |
| Max. Negotiated Rate |
$3,640.62 |
| Rate for Payer: Aetna Commercial |
$3,561.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,403.19
|
| Rate for Payer: Aetna Managed Medicare |
$1,108.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,572.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,978.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,899.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,097.32
|
| Rate for Payer: Cash Price |
$1,141.50
|
| Rate for Payer: Cigna Commercial |
$3,640.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,214.51
|
| Rate for Payer: Health EOS Commercial |
$3,521.91
|
| Rate for Payer: HFN Commercial |
$3,640.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,967.90
|
| Rate for Payer: Multiplan Commercial |
$3,165.76
|
| Rate for Payer: NAPHCARE Commercial |
$2,374.32
|
| Rate for Payer: Preferred Network Access Commercial |
$3,640.62
|
| Rate for Payer: Quartz Beloit One Network |
$1,939.03
|
| Rate for Payer: Quartz Commercial |
$2,572.18
|
| Rate for Payer: Quartz Medicare Advantage |
$2,374.32
|
| Rate for Payer: The Alliance Commercial |
$1,978.60
|
| Rate for Payer: WEA Trust Commercial |
$2,176.46
|
| Rate for Payer: WPS Commercial |
$2,930.99
|
|
|
.Atypical P ANCA Titer
|
Professional
|
Both
|
$65.00
|
|
|
Service Code
|
CPT 86037
|
| Hospital Charge Code |
6209196
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$64.22 |
| Rate for Payer: Aetna Commercial |
$64.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$58.14
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cigna Commercial |
$64.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$61.52
|
| Rate for Payer: HFN Commercial |
$64.22
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$54.08
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$64.22
|
| Rate for Payer: Quartz Beloit One Network |
$29.74
|
| Rate for Payer: Quartz Commercial |
$38.53
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$49.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: WEA Trust Commercial |
$37.18
|
| Rate for Payer: WPS Commercial |
$55.14
|
|
|
.Atypical P ANCA Titer
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
CPT 86037
|
| Hospital Charge Code |
6209196
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$62.19 |
| Rate for Payer: Aetna Commercial |
$60.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$58.14
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.93
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.80
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cigna Commercial |
$62.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.83
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$60.16
|
| Rate for Payer: HFN Commercial |
$62.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$54.08
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$62.19
|
| Rate for Payer: Quartz Beloit One Network |
$33.12
|
| Rate for Payer: Quartz Commercial |
$43.94
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$50.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: United Healthcare PPO |
$50.70
|
| Rate for Payer: WEA Trust Commercial |
$37.18
|
| Rate for Payer: Wellcare Medicare |
$12.53
|
| Rate for Payer: WPS Commercial |
$50.07
|
|
|
.Atypical P ANCA Titer
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
CPT 86037
|
| Hospital Charge Code |
6209196
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.12 |
| Max. Negotiated Rate |
$62.19 |
| Rate for Payer: Aetna Commercial |
$60.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$58.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.83
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cigna Commercial |
$62.19
|
| Rate for Payer: Health EOS Commercial |
$60.16
|
| Rate for Payer: HFN Commercial |
$62.19
|
| Rate for Payer: Multiplan Commercial |
$54.08
|
| Rate for Payer: Preferred Network Access Commercial |
$62.19
|
| Rate for Payer: Quartz Beloit One Network |
$33.12
|
| Rate for Payer: Quartz Commercial |
$40.56
|
| Rate for Payer: WEA Trust Commercial |
$37.18
|
| Rate for Payer: WPS Commercial |
$50.07
|
|
|
Audiogram (OSHA)
|
Professional
|
Both
|
$49.00
|
|
| Hospital Charge Code |
3203482
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$22.42 |
| Max. Negotiated Rate |
$48.41 |
| Rate for Payer: Aetna Commercial |
$48.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$48.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.58
|
| Rate for Payer: Health EOS Commercial |
$46.37
|
| Rate for Payer: HFN Commercial |
$48.41
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: Preferred Network Access Commercial |
$48.41
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$29.05
|
| Rate for Payer: The Alliance Commercial |
$25.48
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
Audiogram (OSHA)
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
3203482
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$24.97 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$30.58
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
Audiogram (OSHA)
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
3203482
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$14.27 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Aetna Managed Medicare |
$14.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.52
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.22
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: NAPHCARE Commercial |
$30.58
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$33.12
|
| Rate for Payer: Quartz Medicare Advantage |
$30.58
|
| Rate for Payer: The Alliance Commercial |
$25.48
|
| Rate for Payer: United Healthcare PPO |
$38.22
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
AUDIOMETRY
|
Facility
|
OP
|
$55.03
|
|
|
Service Code
|
EAPG 00257
|
| Min. Negotiated Rate |
$52.92 |
| Max. Negotiated Rate |
$55.03 |
| Rate for Payer: Anthem Medicaid |
$52.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$52.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.92
|
| Rate for Payer: Dean Health Medicaid |
$52.92
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$52.92
|
| Rate for Payer: Managed Health Services Medicaid |
$55.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$52.92
|
| Rate for Payer: United Healthcare Medicaid |
$52.92
|
|
|
Audiometry Threshold Evaluation; Comprehensive
|
Facility
|
IP
|
$288.00
|
|
|
Service Code
|
CPT 92557
|
| Hospital Charge Code |
1152819
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$146.76 |
| Max. Negotiated Rate |
$275.56 |
| Rate for Payer: Aetna Commercial |
$269.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$257.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$158.75
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cigna Commercial |
$275.56
|
| Rate for Payer: Health EOS Commercial |
$266.57
|
| Rate for Payer: HFN Commercial |
$275.56
|
| Rate for Payer: Multiplan Commercial |
$239.62
|
| Rate for Payer: Preferred Network Access Commercial |
$275.56
|
| Rate for Payer: Quartz Beloit One Network |
$146.76
|
| Rate for Payer: Quartz Commercial |
$179.71
|
| Rate for Payer: WEA Trust Commercial |
$164.74
|
| Rate for Payer: WPS Commercial |
$221.85
|
|
