|
Sertraline (Zoloft)
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 80332
|
| Hospital Charge Code |
983402
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$167.44 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Aetna Managed Medicare |
$50.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$118.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$91.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$87.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$96.46
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$101.85
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$167.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.50
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: NAPHCARE Commercial |
$109.20
|
| Rate for Payer: Preferred Network Access Commercial |
$167.44
|
| Rate for Payer: Quartz Beloit One Network |
$89.18
|
| Rate for Payer: Quartz Commercial |
$118.30
|
| Rate for Payer: Quartz Medicare Advantage |
$109.20
|
| Rate for Payer: The Alliance Commercial |
$91.00
|
| Rate for Payer: United Healthcare PPO |
$136.50
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.80
|
|
|
Sertraline (Zoloft)
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 80332
|
| Hospital Charge Code |
983402
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$89.18 |
| Max. Negotiated Rate |
$167.44 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$96.46
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$167.44
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: Preferred Network Access Commercial |
$167.44
|
| Rate for Payer: Quartz Beloit One Network |
$89.18
|
| Rate for Payer: Quartz Commercial |
$109.20
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.80
|
|
|
SET ANGEL CPRP PROCESSING ABS-10063
|
Facility
|
OP
|
$2,929.00
|
|
| Hospital Charge Code |
6217082
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$852.92 |
| Max. Negotiated Rate |
$2,802.47 |
| Rate for Payer: Aetna Commercial |
$2,741.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,619.70
|
| Rate for Payer: Aetna Managed Medicare |
$852.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,980.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,523.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,462.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,614.46
|
| Rate for Payer: Cash Price |
$878.70
|
| Rate for Payer: Cigna Commercial |
$2,802.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,704.68
|
| Rate for Payer: Health EOS Commercial |
$2,711.08
|
| Rate for Payer: HFN Commercial |
$2,802.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,284.62
|
| Rate for Payer: Multiplan Commercial |
$2,436.93
|
| Rate for Payer: NAPHCARE Commercial |
$1,827.70
|
| Rate for Payer: Preferred Network Access Commercial |
$2,802.47
|
| Rate for Payer: Quartz Beloit One Network |
$1,492.62
|
| Rate for Payer: Quartz Commercial |
$1,980.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,827.70
|
| Rate for Payer: The Alliance Commercial |
$1,523.08
|
| Rate for Payer: WEA Trust Commercial |
$1,675.39
|
| Rate for Payer: WPS Commercial |
$2,256.21
|
|
|
SET ANGEL CPRP PROCESSING ABS-10063
|
Facility
|
IP
|
$2,929.00
|
|
| Hospital Charge Code |
6217082
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,492.62 |
| Max. Negotiated Rate |
$2,802.47 |
| Rate for Payer: Aetna Commercial |
$2,741.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,619.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,614.46
|
| Rate for Payer: Cash Price |
$878.70
|
| Rate for Payer: Cigna Commercial |
$2,802.47
|
| Rate for Payer: Health EOS Commercial |
$2,711.08
|
| Rate for Payer: HFN Commercial |
$2,802.47
|
| Rate for Payer: Multiplan Commercial |
$2,436.93
|
| Rate for Payer: Preferred Network Access Commercial |
$2,802.47
|
| Rate for Payer: Quartz Beloit One Network |
$1,492.62
|
| Rate for Payer: Quartz Commercial |
$1,827.70
|
| Rate for Payer: WEA Trust Commercial |
$1,675.39
|
| Rate for Payer: WPS Commercial |
$2,256.21
|
|
|
SET ASPIRATION/ANTICOAGULATION CELL SAVER A & A ASSEMBLY LINE 208 00208-00
|
Facility
|
OP
|
$526.00
|
|
| Hospital Charge Code |
2962912
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$153.17 |
| Max. Negotiated Rate |
$503.28 |
| Rate for Payer: Aetna Commercial |
$492.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$470.45
|
| Rate for Payer: Aetna Managed Medicare |
$153.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$355.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$273.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$262.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.93
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cigna Commercial |
$503.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$306.13
|
| Rate for Payer: Health EOS Commercial |
$486.87
|
| Rate for Payer: HFN Commercial |
$503.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$410.28
|
| Rate for Payer: Multiplan Commercial |
$437.63
|
| Rate for Payer: NAPHCARE Commercial |
$328.22
|
| Rate for Payer: Preferred Network Access Commercial |
$503.28
|
| Rate for Payer: Quartz Beloit One Network |
$268.05
|
| Rate for Payer: Quartz Commercial |
$355.58
|
| Rate for Payer: Quartz Medicare Advantage |
$328.22
|
| Rate for Payer: The Alliance Commercial |
$273.52
|
| Rate for Payer: WEA Trust Commercial |
$300.87
|
| Rate for Payer: WPS Commercial |
$405.18
|
|
|
SET ASPIRATION/ANTICOAGULATION CELL SAVER A & A ASSEMBLY LINE 208 00208-00
|
Facility
|
IP
|
$526.00
|
|
| Hospital Charge Code |
2962912
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$268.05 |
| Max. Negotiated Rate |
$503.28 |
| Rate for Payer: Aetna Commercial |
$492.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$470.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.93
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cigna Commercial |
$503.28
|
| Rate for Payer: Health EOS Commercial |
$486.87
|
| Rate for Payer: HFN Commercial |
$503.28
|
| Rate for Payer: Multiplan Commercial |
$437.63
|
| Rate for Payer: Preferred Network Access Commercial |
$503.28
|
| Rate for Payer: Quartz Beloit One Network |
$268.05
|
| Rate for Payer: Quartz Commercial |
$328.22
|
| Rate for Payer: WEA Trust Commercial |
$300.87
|
| Rate for Payer: WPS Commercial |
$405.18
|
|
|
SET BENGER LACRIMAL PROBE E4223
|
Facility
|
IP
|
$1,237.00
|
|
| Hospital Charge Code |
4520507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$630.38 |
| Max. Negotiated Rate |
$1,183.56 |
| Rate for Payer: Aetna Commercial |
$1,157.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,106.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$681.83
|
| Rate for Payer: Cash Price |
$371.10
|
| Rate for Payer: Cigna Commercial |
$1,183.56
|
| Rate for Payer: Health EOS Commercial |
$1,144.97
|
| Rate for Payer: HFN Commercial |
$1,183.56
|
| Rate for Payer: Multiplan Commercial |
$1,029.18
|
| Rate for Payer: Preferred Network Access Commercial |
$1,183.56
|
| Rate for Payer: Quartz Beloit One Network |
$630.38
|
| Rate for Payer: Quartz Commercial |
$771.89
|
| Rate for Payer: WEA Trust Commercial |
$707.56
|
| Rate for Payer: WPS Commercial |
$952.86
|
|
|
SET BENGER LACRIMAL PROBE E4223
|
Facility
|
OP
|
$1,237.00
|
|
| Hospital Charge Code |
4520507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$360.21 |
| Max. Negotiated Rate |
$1,183.56 |
| Rate for Payer: Aetna Commercial |
$1,157.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,106.37
|
| Rate for Payer: Aetna Managed Medicare |
$360.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$836.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$643.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$617.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$681.83
|
| Rate for Payer: Cash Price |
$371.10
|
| Rate for Payer: Cigna Commercial |
$1,183.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$719.93
|
| Rate for Payer: Health EOS Commercial |
$1,144.97
|
| Rate for Payer: HFN Commercial |
$1,183.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$964.86
|
| Rate for Payer: Multiplan Commercial |
$1,029.18
|
| Rate for Payer: NAPHCARE Commercial |
$771.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,183.56
|
| Rate for Payer: Quartz Beloit One Network |
$630.38
|
| Rate for Payer: Quartz Commercial |
$836.21
|
| Rate for Payer: Quartz Medicare Advantage |
$771.89
|
| Rate for Payer: The Alliance Commercial |
$643.24
|
| Rate for Payer: WEA Trust Commercial |
$707.56
|
| Rate for Payer: WPS Commercial |
$952.86
|
|
|
SET BLOOD COLLECTION 25G X .75 SAFETY"
|
Facility
|
IP
|
$38.00
|
|
| Hospital Charge Code |
2963558
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.36 |
| Max. Negotiated Rate |
$36.36 |
| Rate for Payer: Aetna Commercial |
$35.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.95
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$36.36
|
| Rate for Payer: Health EOS Commercial |
$35.17
|
| Rate for Payer: HFN Commercial |
$36.36
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: Preferred Network Access Commercial |
$36.36
|
| Rate for Payer: Quartz Beloit One Network |
$19.36
|
| Rate for Payer: Quartz Commercial |
$23.71
|
| Rate for Payer: WEA Trust Commercial |
$21.74
|
| Rate for Payer: WPS Commercial |
$29.27
|
|
|
SET BLOOD COLLECTION 25G X .75 SAFETY"
|
Facility
|
OP
|
$38.00
|
|
| Hospital Charge Code |
2963558
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.07 |
| Max. Negotiated Rate |
$36.36 |
| Rate for Payer: Aetna Commercial |
$35.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.99
|
| Rate for Payer: Aetna Managed Medicare |
$11.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.95
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$36.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.12
|
| Rate for Payer: Health EOS Commercial |
$35.17
|
| Rate for Payer: HFN Commercial |
$36.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.64
|
| Rate for Payer: Multiplan Commercial |
$31.62
|
| Rate for Payer: NAPHCARE Commercial |
$23.71
|
| Rate for Payer: Preferred Network Access Commercial |
$36.36
|
| Rate for Payer: Quartz Beloit One Network |
$19.36
|
| Rate for Payer: Quartz Commercial |
$25.69
|
| Rate for Payer: Quartz Medicare Advantage |
$23.71
|
| Rate for Payer: The Alliance Commercial |
$19.76
|
| Rate for Payer: WEA Trust Commercial |
$21.74
|
| Rate for Payer: WPS Commercial |
$29.27
|
|
|
SET BORE SM EXTENSION 473042
|
Facility
|
OP
|
$114.00
|
|
| Hospital Charge Code |
4595219
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$33.20 |
| Max. Negotiated Rate |
$109.08 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Aetna Managed Medicare |
$33.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$59.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$56.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.84
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$109.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.35
|
| Rate for Payer: Health EOS Commercial |
$105.52
|
| Rate for Payer: HFN Commercial |
$109.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.92
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: NAPHCARE Commercial |
$71.14
|
| Rate for Payer: Preferred Network Access Commercial |
$109.08
|
| Rate for Payer: Quartz Beloit One Network |
$58.09
|
| Rate for Payer: Quartz Commercial |
$77.06
|
| Rate for Payer: Quartz Medicare Advantage |
$71.14
|
| Rate for Payer: The Alliance Commercial |
$59.28
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
|
SET BORE SM EXTENSION 473042
|
Facility
|
IP
|
$114.00
|
|
| Hospital Charge Code |
4595219
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$58.09 |
| Max. Negotiated Rate |
$109.08 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.84
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$109.08
|
| Rate for Payer: Health EOS Commercial |
$105.52
|
| Rate for Payer: HFN Commercial |
$109.08
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: Preferred Network Access Commercial |
$109.08
|
| Rate for Payer: Quartz Beloit One Network |
$58.09
|
| Rate for Payer: Quartz Commercial |
$71.14
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
|
SET CRICOTHYROTOMY CATH. 3.5MM
|
Facility
|
IP
|
$1,707.00
|
|
| Hospital Charge Code |
2963099
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$869.89 |
| Max. Negotiated Rate |
$1,633.26 |
| Rate for Payer: Aetna Commercial |
$1,597.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,526.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$940.90
|
| Rate for Payer: Cash Price |
$512.10
|
| Rate for Payer: Cigna Commercial |
$1,633.26
|
| Rate for Payer: Health EOS Commercial |
$1,580.00
|
| Rate for Payer: HFN Commercial |
$1,633.26
|
| Rate for Payer: Multiplan Commercial |
$1,420.22
|
| Rate for Payer: Preferred Network Access Commercial |
$1,633.26
|
| Rate for Payer: Quartz Beloit One Network |
$869.89
|
| Rate for Payer: Quartz Commercial |
$1,065.17
|
| Rate for Payer: WEA Trust Commercial |
$976.40
|
| Rate for Payer: WPS Commercial |
$1,314.90
|
|
|
SET CRICOTHYROTOMY CATH. 3.5MM
|
Facility
|
OP
|
$1,707.00
|
|
| Hospital Charge Code |
2963099
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$497.08 |
| Max. Negotiated Rate |
$1,633.26 |
| Rate for Payer: Aetna Commercial |
$1,597.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,526.74
|
| Rate for Payer: Aetna Managed Medicare |
$497.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,153.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$887.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$852.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$940.90
|
| Rate for Payer: Cash Price |
$512.10
|
| Rate for Payer: Cigna Commercial |
$1,633.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$993.47
|
| Rate for Payer: Health EOS Commercial |
$1,580.00
|
| Rate for Payer: HFN Commercial |
$1,633.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,331.46
|
| Rate for Payer: Multiplan Commercial |
$1,420.22
|
| Rate for Payer: NAPHCARE Commercial |
$1,065.17
|
| Rate for Payer: Preferred Network Access Commercial |
$1,633.26
|
| Rate for Payer: Quartz Beloit One Network |
$869.89
|
| Rate for Payer: Quartz Commercial |
$1,153.93
|
| Rate for Payer: Quartz Medicare Advantage |
$1,065.17
|
| Rate for Payer: The Alliance Commercial |
$887.64
|
| Rate for Payer: WEA Trust Commercial |
$976.40
|
| Rate for Payer: WPS Commercial |
$1,314.90
|
|
|
SET CRICOTHYROTOMY CATH. 6MM
|
Facility
|
IP
|
$1,904.00
|
|
| Hospital Charge Code |
2963116
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$970.28 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,188.10
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
SET CRICOTHYROTOMY CATH. 6MM
|
Facility
|
OP
|
$1,904.00
|
|
| Hospital Charge Code |
2963116
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$554.44 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Aetna Managed Medicare |
$554.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,287.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$990.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$950.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,108.13
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,485.12
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: NAPHCARE Commercial |
$1,188.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,287.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,188.10
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
SET CYSTO IRRIGATION DYND19120
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
HCPCS A4355
|
| Hospital Charge Code |
2962814
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$33.49 |
| Max. Negotiated Rate |
$110.03 |
| Rate for Payer: Aetna Commercial |
$107.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.86
|
| Rate for Payer: Aetna Managed Medicare |
$33.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$59.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$57.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.39
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$110.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.93
|
| Rate for Payer: Health EOS Commercial |
$106.44
|
| Rate for Payer: HFN Commercial |
$110.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$89.70
|
| Rate for Payer: Multiplan Commercial |
$95.68
|
| Rate for Payer: NAPHCARE Commercial |
$71.76
|
| Rate for Payer: Preferred Network Access Commercial |
$110.03
|
| Rate for Payer: Quartz Beloit One Network |
$58.60
|
| Rate for Payer: Quartz Commercial |
$77.74
|
| Rate for Payer: Quartz Medicare Advantage |
$71.76
|
| Rate for Payer: The Alliance Commercial |
$52.87
|
| Rate for Payer: WEA Trust Commercial |
$65.78
|
| Rate for Payer: WPS Commercial |
$88.58
|
|
|
SET CYSTO IRRIGATION DYND19120
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
HCPCS A4355
|
| Hospital Charge Code |
2962814
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$58.60 |
| Max. Negotiated Rate |
$110.03 |
| Rate for Payer: Aetna Commercial |
$107.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.39
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$110.03
|
| Rate for Payer: Health EOS Commercial |
$106.44
|
| Rate for Payer: HFN Commercial |
$110.03
|
| Rate for Payer: Multiplan Commercial |
$95.68
|
| Rate for Payer: Preferred Network Access Commercial |
$110.03
|
| Rate for Payer: Quartz Beloit One Network |
$58.60
|
| Rate for Payer: Quartz Commercial |
$71.76
|
| Rate for Payer: WEA Trust Commercial |
$65.78
|
| Rate for Payer: WPS Commercial |
$88.58
|
|
|
SET EASY SPRAY TISSEEL 0600065
|
Facility
|
IP
|
$937.00
|
|
| Hospital Charge Code |
4294561
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$477.50 |
| Max. Negotiated Rate |
$896.52 |
| Rate for Payer: Aetna Commercial |
$877.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$838.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$516.47
|
| Rate for Payer: Cash Price |
$281.10
|
| Rate for Payer: Cigna Commercial |
$896.52
|
| Rate for Payer: Health EOS Commercial |
$867.29
|
| Rate for Payer: HFN Commercial |
$896.52
|
| Rate for Payer: Multiplan Commercial |
$779.58
|
| Rate for Payer: Preferred Network Access Commercial |
$896.52
|
| Rate for Payer: Quartz Beloit One Network |
$477.50
|
| Rate for Payer: Quartz Commercial |
$584.69
|
| Rate for Payer: WEA Trust Commercial |
$535.96
|
| Rate for Payer: WPS Commercial |
$721.77
|
|
|
SET EASY SPRAY TISSEEL 0600065
|
Facility
|
OP
|
$937.00
|
|
| Hospital Charge Code |
4294561
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$272.85 |
| Max. Negotiated Rate |
$896.52 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$545.33
|
| Rate for Payer: Health EOS Commercial |
$867.29
|
| Rate for Payer: HFN Commercial |
$896.52
|
| Rate for Payer: Aetna Commercial |
$877.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$838.05
|
| Rate for Payer: Aetna Managed Medicare |
$272.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$633.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$487.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$467.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$516.47
|
| Rate for Payer: Cash Price |
$281.10
|
| Rate for Payer: Cigna Commercial |
$896.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$730.86
|
| Rate for Payer: Multiplan Commercial |
$779.58
|
| Rate for Payer: NAPHCARE Commercial |
$584.69
|
| Rate for Payer: Preferred Network Access Commercial |
$896.52
|
| Rate for Payer: Quartz Beloit One Network |
$477.50
|
| Rate for Payer: Quartz Commercial |
$633.41
|
| Rate for Payer: Quartz Medicare Advantage |
$584.69
|
| Rate for Payer: The Alliance Commercial |
$487.24
|
| Rate for Payer: WEA Trust Commercial |
$535.96
|
| Rate for Payer: WPS Commercial |
$721.77
|
|
|
SET FRANKLIN ENDOSCOPIC CHOLOANGIOGRAPHIC G10456
|
Facility
|
IP
|
$932.00
|
|
| Hospital Charge Code |
5178711
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$474.95 |
| Max. Negotiated Rate |
$891.74 |
| Rate for Payer: Aetna Commercial |
$872.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$833.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$513.72
|
| Rate for Payer: Cash Price |
$279.60
|
| Rate for Payer: Cigna Commercial |
$891.74
|
| Rate for Payer: Health EOS Commercial |
$862.66
|
| Rate for Payer: HFN Commercial |
$891.74
|
| Rate for Payer: Multiplan Commercial |
$775.42
|
| Rate for Payer: Preferred Network Access Commercial |
$891.74
|
| Rate for Payer: Quartz Beloit One Network |
$474.95
|
| Rate for Payer: Quartz Commercial |
$581.57
|
| Rate for Payer: WEA Trust Commercial |
$533.10
|
| Rate for Payer: WPS Commercial |
$717.92
|
|
|
SET FRANKLIN ENDOSCOPIC CHOLOANGIOGRAPHIC G10456
|
Facility
|
OP
|
$932.00
|
|
| Hospital Charge Code |
5178711
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$271.40 |
| Max. Negotiated Rate |
$891.74 |
| Rate for Payer: Aetna Commercial |
$872.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$833.58
|
| Rate for Payer: Aetna Managed Medicare |
$271.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$630.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$484.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$465.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$513.72
|
| Rate for Payer: Cash Price |
$279.60
|
| Rate for Payer: Cigna Commercial |
$891.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$542.42
|
| Rate for Payer: Health EOS Commercial |
$862.66
|
| Rate for Payer: HFN Commercial |
$891.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$726.96
|
| Rate for Payer: Multiplan Commercial |
$775.42
|
| Rate for Payer: NAPHCARE Commercial |
$581.57
|
| Rate for Payer: Preferred Network Access Commercial |
$891.74
|
| Rate for Payer: Quartz Beloit One Network |
$474.95
|
| Rate for Payer: Quartz Commercial |
$630.03
|
| Rate for Payer: Quartz Medicare Advantage |
$581.57
|
| Rate for Payer: The Alliance Commercial |
$484.64
|
| Rate for Payer: WEA Trust Commercial |
$533.10
|
| Rate for Payer: WPS Commercial |
$717.92
|
|
|
SET GASTROINTESTINAL ANCHOR SET 98701
|
Facility
|
IP
|
$1,678.00
|
|
| Hospital Charge Code |
5286777
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$855.11 |
| Max. Negotiated Rate |
$1,605.51 |
| Rate for Payer: Aetna Commercial |
$1,570.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,500.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$924.91
|
| Rate for Payer: Cash Price |
$503.40
|
| Rate for Payer: Cigna Commercial |
$1,605.51
|
| Rate for Payer: Health EOS Commercial |
$1,553.16
|
| Rate for Payer: HFN Commercial |
$1,605.51
|
| Rate for Payer: Multiplan Commercial |
$1,396.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,605.51
|
| Rate for Payer: Quartz Beloit One Network |
$855.11
|
| Rate for Payer: Quartz Commercial |
$1,047.07
|
| Rate for Payer: WEA Trust Commercial |
$959.82
|
| Rate for Payer: WPS Commercial |
$1,292.56
|
|
|
SET GASTROINTESTINAL ANCHOR SET 98701
|
Facility
|
OP
|
$1,678.00
|
|
| Hospital Charge Code |
5286777
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$488.63 |
| Max. Negotiated Rate |
$1,605.51 |
| Rate for Payer: Aetna Commercial |
$1,570.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,500.80
|
| Rate for Payer: Aetna Managed Medicare |
$488.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,134.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$872.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$837.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$924.91
|
| Rate for Payer: Cash Price |
$503.40
|
| Rate for Payer: Cigna Commercial |
$1,605.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$976.60
|
| Rate for Payer: Health EOS Commercial |
$1,553.16
|
| Rate for Payer: HFN Commercial |
$1,605.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,308.84
|
| Rate for Payer: Multiplan Commercial |
$1,396.10
|
| Rate for Payer: NAPHCARE Commercial |
$1,047.07
|
| Rate for Payer: Preferred Network Access Commercial |
$1,605.51
|
| Rate for Payer: Quartz Beloit One Network |
$855.11
|
| Rate for Payer: Quartz Commercial |
$1,134.33
|
| Rate for Payer: Quartz Medicare Advantage |
$1,047.07
|
| Rate for Payer: The Alliance Commercial |
$872.56
|
| Rate for Payer: WEA Trust Commercial |
$959.82
|
| Rate for Payer: WPS Commercial |
$1,292.56
|
|
|
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 |
$726.18 |
| Max. Negotiated Rate |
$1,363.44 |
| Rate for Payer: Aetna Commercial |
$1,333.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,274.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$785.46
|
| Rate for Payer: Cash Price |
$427.50
|
| Rate for Payer: Cigna Commercial |
$1,363.44
|
| Rate for Payer: Health EOS Commercial |
$1,318.98
|
| Rate for Payer: HFN Commercial |
$1,363.44
|
| Rate for Payer: Multiplan Commercial |
$1,185.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,363.44
|
| Rate for Payer: Quartz Beloit One Network |
$726.18
|
| Rate for Payer: Quartz Commercial |
$889.20
|
| Rate for Payer: WEA Trust Commercial |
$815.10
|
| Rate for Payer: WPS Commercial |
$1,097.68
|
|
