|
SHEATH SAFESHEATH LONG
|
Facility
|
OP
|
$1,336.00
|
|
| Hospital Charge Code |
2972183
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$374.08 |
| Max. Negotiated Rate |
$5,344.00 |
| Rate for Payer: Aetna Commercial |
$1,202.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,148.96
|
| Rate for Payer: Aetna Managed Medicare |
$374.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$868.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$668.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$641.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$708.08
|
| Rate for Payer: Cash Price |
$400.80
|
| Rate for Payer: Cigna Commercial |
$1,229.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$747.63
|
| Rate for Payer: Health EOS Commercial |
$1,189.04
|
| Rate for Payer: HFN Commercial |
$1,229.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,002.00
|
| Rate for Payer: Multiplan Commercial |
$1,068.80
|
| Rate for Payer: NAPHCARE Commercial |
$801.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,229.12
|
| Rate for Payer: Quartz Beloit One Network |
$654.64
|
| Rate for Payer: Quartz Commercial |
$868.40
|
| Rate for Payer: Quartz Medicare Advantage |
$801.60
|
| Rate for Payer: The Alliance Commercial |
$5,344.00
|
| Rate for Payer: WEA Trust Commercial |
$734.80
|
| Rate for Payer: WPS Commercial |
$989.58
|
|
|
SHEATH SET MICROPUNCTURE PEDIATRIC
|
Facility
|
IP
|
$783.00
|
|
|
Service Code
|
HCPCS C1766
|
| Hospital Charge Code |
2971632
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$383.67 |
| Max. Negotiated Rate |
$720.36 |
| Rate for Payer: Aetna Commercial |
$704.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$673.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$414.99
|
| Rate for Payer: Cash Price |
$234.90
|
| Rate for Payer: Cigna Commercial |
$720.36
|
| Rate for Payer: Health EOS Commercial |
$696.87
|
| Rate for Payer: HFN Commercial |
$720.36
|
| Rate for Payer: Multiplan Commercial |
$626.40
|
| Rate for Payer: NAPHCARE Commercial |
$469.80
|
| Rate for Payer: Preferred Network Access Commercial |
$720.36
|
| Rate for Payer: Quartz Beloit One Network |
$383.67
|
| Rate for Payer: Quartz Commercial |
$469.80
|
| Rate for Payer: WEA Trust Commercial |
$430.65
|
| Rate for Payer: WPS Commercial |
$579.97
|
|
|
SHEATH SET MICROPUNCTURE PEDIATRIC
|
Facility
|
OP
|
$783.00
|
|
|
Service Code
|
HCPCS C1766
|
| Hospital Charge Code |
2971632
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$219.24 |
| Max. Negotiated Rate |
$3,132.00 |
| Rate for Payer: Aetna Commercial |
$704.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$673.38
|
| Rate for Payer: Aetna Managed Medicare |
$219.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$508.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$391.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$375.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$414.99
|
| Rate for Payer: Cash Price |
$234.90
|
| Rate for Payer: Cigna Commercial |
$720.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$438.17
|
| Rate for Payer: Health EOS Commercial |
$696.87
|
| Rate for Payer: HFN Commercial |
$720.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$587.25
|
| Rate for Payer: Multiplan Commercial |
$626.40
|
| Rate for Payer: NAPHCARE Commercial |
$469.80
|
| Rate for Payer: Preferred Network Access Commercial |
$720.36
|
| Rate for Payer: Quartz Beloit One Network |
$383.67
|
| Rate for Payer: Quartz Commercial |
$508.95
|
| Rate for Payer: Quartz Medicare Advantage |
$469.80
|
| Rate for Payer: The Alliance Commercial |
$3,132.00
|
| Rate for Payer: WEA Trust Commercial |
$430.65
|
| Rate for Payer: WPS Commercial |
$579.97
|
|
|
SHEATH STRAIGHT 7 FR 45CM
|
Facility
|
IP
|
$1,593.00
|
|
| Hospital Charge Code |
2972555
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$780.57 |
| Max. Negotiated Rate |
$1,465.56 |
| Rate for Payer: Aetna Commercial |
$1,433.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,369.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$844.29
|
| Rate for Payer: Cash Price |
$477.90
|
| Rate for Payer: Cigna Commercial |
$1,465.56
|
| Rate for Payer: Health EOS Commercial |
$1,417.77
|
| Rate for Payer: HFN Commercial |
$1,465.56
|
| Rate for Payer: Multiplan Commercial |
$1,274.40
|
| Rate for Payer: NAPHCARE Commercial |
$955.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,465.56
|
| Rate for Payer: Quartz Beloit One Network |
$780.57
|
| Rate for Payer: Quartz Commercial |
$955.80
|
| Rate for Payer: WEA Trust Commercial |
$876.15
|
| Rate for Payer: WPS Commercial |
$1,179.94
|
|
|
SHEATH STRAIGHT 7 FR 45CM
|
Facility
|
OP
|
$1,593.00
|
|
| Hospital Charge Code |
2972555
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$446.04 |
| Max. Negotiated Rate |
$6,372.00 |
| Rate for Payer: Aetna Commercial |
$1,433.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,369.98
|
| Rate for Payer: Aetna Managed Medicare |
$446.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,035.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$796.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$764.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$844.29
|
| Rate for Payer: Cash Price |
$477.90
|
| Rate for Payer: Cigna Commercial |
$1,465.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$891.44
|
| Rate for Payer: Health EOS Commercial |
$1,417.77
|
| Rate for Payer: HFN Commercial |
$1,465.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,194.75
|
| Rate for Payer: Multiplan Commercial |
$1,274.40
|
| Rate for Payer: NAPHCARE Commercial |
$955.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,465.56
|
| Rate for Payer: Quartz Beloit One Network |
$780.57
|
| Rate for Payer: Quartz Commercial |
$1,035.45
|
| Rate for Payer: Quartz Medicare Advantage |
$955.80
|
| Rate for Payer: The Alliance Commercial |
$6,372.00
|
| Rate for Payer: WEA Trust Commercial |
$876.15
|
| Rate for Payer: WPS Commercial |
$1,179.94
|
|
|
SHEATH URETERAL ACCESS 12FR (ID) 14FR (OD) X 20CM G19173
|
Facility
|
OP
|
$394.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2965867
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$110.32 |
| Max. Negotiated Rate |
$1,576.00 |
| Rate for Payer: Aetna Commercial |
$354.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$338.84
|
| Rate for Payer: Aetna Managed Medicare |
$110.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$256.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$197.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$189.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.82
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$362.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$220.48
|
| Rate for Payer: Health EOS Commercial |
$350.66
|
| Rate for Payer: HFN Commercial |
$362.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$295.50
|
| Rate for Payer: Multiplan Commercial |
$315.20
|
| Rate for Payer: NAPHCARE Commercial |
$236.40
|
| Rate for Payer: Preferred Network Access Commercial |
$362.48
|
| Rate for Payer: Quartz Beloit One Network |
$193.06
|
| Rate for Payer: Quartz Commercial |
$256.10
|
| Rate for Payer: Quartz Medicare Advantage |
$236.40
|
| Rate for Payer: The Alliance Commercial |
$1,576.00
|
| Rate for Payer: WEA Trust Commercial |
$216.70
|
| Rate for Payer: WPS Commercial |
$291.84
|
|
|
SHEATH URETERAL ACCESS 12FR (ID) 14FR (OD) X 20CM G19173
|
Facility
|
IP
|
$394.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2965867
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$193.06 |
| Max. Negotiated Rate |
$362.48 |
| Rate for Payer: Aetna Commercial |
$354.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$338.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.82
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$362.48
|
| Rate for Payer: Health EOS Commercial |
$350.66
|
| Rate for Payer: HFN Commercial |
$362.48
|
| Rate for Payer: Multiplan Commercial |
$315.20
|
| Rate for Payer: NAPHCARE Commercial |
$236.40
|
| Rate for Payer: Preferred Network Access Commercial |
$362.48
|
| Rate for Payer: Quartz Beloit One Network |
$193.06
|
| Rate for Payer: Quartz Commercial |
$236.40
|
| Rate for Payer: WEA Trust Commercial |
$216.70
|
| Rate for Payer: WPS Commercial |
$291.84
|
|
|
SHEEPSKIN DECUBITIS PAD
|
Facility
|
IP
|
$222.00
|
|
| Hospital Charge Code |
2963957
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$108.78 |
| Max. Negotiated Rate |
$204.24 |
| Rate for Payer: Aetna Commercial |
$199.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.66
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna Commercial |
$204.24
|
| Rate for Payer: Health EOS Commercial |
$197.58
|
| Rate for Payer: HFN Commercial |
$204.24
|
| Rate for Payer: Multiplan Commercial |
$177.60
|
| Rate for Payer: NAPHCARE Commercial |
$133.20
|
| Rate for Payer: Preferred Network Access Commercial |
$204.24
|
| Rate for Payer: Quartz Beloit One Network |
$108.78
|
| Rate for Payer: Quartz Commercial |
$133.20
|
| Rate for Payer: WEA Trust Commercial |
$122.10
|
| Rate for Payer: WPS Commercial |
$164.44
|
|
|
SHEEPSKIN DECUBITIS PAD
|
Facility
|
OP
|
$222.00
|
|
| Hospital Charge Code |
2963957
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$62.16 |
| Max. Negotiated Rate |
$888.00 |
| Rate for Payer: Aetna Commercial |
$199.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.92
|
| Rate for Payer: Aetna Managed Medicare |
$62.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$144.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$111.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$106.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.66
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna Commercial |
$204.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.23
|
| Rate for Payer: Health EOS Commercial |
$197.58
|
| Rate for Payer: HFN Commercial |
$204.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.50
|
| Rate for Payer: Multiplan Commercial |
$177.60
|
| Rate for Payer: NAPHCARE Commercial |
$133.20
|
| Rate for Payer: Preferred Network Access Commercial |
$204.24
|
| Rate for Payer: Quartz Beloit One Network |
$108.78
|
| Rate for Payer: Quartz Commercial |
$144.30
|
| Rate for Payer: Quartz Medicare Advantage |
$133.20
|
| Rate for Payer: The Alliance Commercial |
$888.00
|
| Rate for Payer: WEA Trust Commercial |
$122.10
|
| Rate for Payer: WPS Commercial |
$164.44
|
|
|
SHEET BILATERAL EXTREMITY 89291
|
Facility
|
OP
|
$277.00
|
|
| Hospital Charge Code |
2963192
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$77.56 |
| Max. Negotiated Rate |
$1,108.00 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Aetna Managed Medicare |
$77.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$180.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$138.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$132.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.81
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$254.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$155.01
|
| Rate for Payer: Health EOS Commercial |
$246.53
|
| Rate for Payer: HFN Commercial |
$254.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$207.75
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: NAPHCARE Commercial |
$166.20
|
| Rate for Payer: Preferred Network Access Commercial |
$254.84
|
| Rate for Payer: Quartz Beloit One Network |
$135.73
|
| Rate for Payer: Quartz Commercial |
$180.05
|
| Rate for Payer: Quartz Medicare Advantage |
$166.20
|
| Rate for Payer: The Alliance Commercial |
$1,108.00
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
SHEET BILATERAL EXTREMITY 89291
|
Facility
|
IP
|
$277.00
|
|
| Hospital Charge Code |
2963192
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$135.73 |
| Max. Negotiated Rate |
$254.84 |
| Rate for Payer: Aetna Commercial |
$249.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$238.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.81
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$254.84
|
| Rate for Payer: Health EOS Commercial |
$246.53
|
| Rate for Payer: HFN Commercial |
$254.84
|
| Rate for Payer: Multiplan Commercial |
$221.60
|
| Rate for Payer: NAPHCARE Commercial |
$166.20
|
| Rate for Payer: Preferred Network Access Commercial |
$254.84
|
| Rate for Payer: Quartz Beloit One Network |
$135.73
|
| Rate for Payer: Quartz Commercial |
$166.20
|
| Rate for Payer: WEA Trust Commercial |
$152.35
|
| Rate for Payer: WPS Commercial |
$205.17
|
|
|
SHEET EXTREMITY LOWER 88 x 131 89276
|
Facility
|
OP
|
$214.00
|
|
| Hospital Charge Code |
2963253
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$59.92 |
| Max. Negotiated Rate |
$856.00 |
| Rate for Payer: Aetna Commercial |
$192.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Aetna Managed Medicare |
$59.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$139.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$107.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$102.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.42
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$196.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.75
|
| Rate for Payer: Health EOS Commercial |
$190.46
|
| Rate for Payer: HFN Commercial |
$196.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$160.50
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: NAPHCARE Commercial |
$128.40
|
| Rate for Payer: Preferred Network Access Commercial |
$196.88
|
| Rate for Payer: Quartz Beloit One Network |
$104.86
|
| Rate for Payer: Quartz Commercial |
$139.10
|
| Rate for Payer: Quartz Medicare Advantage |
$128.40
|
| Rate for Payer: The Alliance Commercial |
$856.00
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
SHEET EXTREMITY LOWER 88 x 131 89276
|
Facility
|
IP
|
$214.00
|
|
| Hospital Charge Code |
2963253
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$104.86 |
| Max. Negotiated Rate |
$196.88 |
| Rate for Payer: Aetna Commercial |
$192.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.42
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$196.88
|
| Rate for Payer: Health EOS Commercial |
$190.46
|
| Rate for Payer: HFN Commercial |
$196.88
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: NAPHCARE Commercial |
$128.40
|
| Rate for Payer: Preferred Network Access Commercial |
$196.88
|
| Rate for Payer: Quartz Beloit One Network |
$104.86
|
| Rate for Payer: Quartz Commercial |
$128.40
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
SHEETING PHARMELAST SILICONE #20-05
|
Facility
|
IP
|
$1,211.00
|
|
| Hospital Charge Code |
2967368
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$593.39 |
| Max. Negotiated Rate |
$1,114.12 |
| Rate for Payer: Aetna Commercial |
$1,089.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,041.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$641.83
|
| Rate for Payer: Cash Price |
$363.30
|
| Rate for Payer: Cigna Commercial |
$1,114.12
|
| Rate for Payer: Health EOS Commercial |
$1,077.79
|
| Rate for Payer: HFN Commercial |
$1,114.12
|
| Rate for Payer: Multiplan Commercial |
$968.80
|
| Rate for Payer: NAPHCARE Commercial |
$726.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,114.12
|
| Rate for Payer: Quartz Beloit One Network |
$593.39
|
| Rate for Payer: Quartz Commercial |
$726.60
|
| Rate for Payer: WEA Trust Commercial |
$666.05
|
| Rate for Payer: WPS Commercial |
$896.99
|
|
|
SHEETING PHARMELAST SILICONE #20-05
|
Facility
|
OP
|
$1,211.00
|
|
| Hospital Charge Code |
2967368
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$339.08 |
| Max. Negotiated Rate |
$4,844.00 |
| Rate for Payer: Aetna Commercial |
$1,089.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,041.46
|
| Rate for Payer: Aetna Managed Medicare |
$339.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$787.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$605.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$581.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$641.83
|
| Rate for Payer: Cash Price |
$363.30
|
| Rate for Payer: Cigna Commercial |
$1,114.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$677.68
|
| Rate for Payer: Health EOS Commercial |
$1,077.79
|
| Rate for Payer: HFN Commercial |
$1,114.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$908.25
|
| Rate for Payer: Multiplan Commercial |
$968.80
|
| Rate for Payer: NAPHCARE Commercial |
$726.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,114.12
|
| Rate for Payer: Quartz Beloit One Network |
$593.39
|
| Rate for Payer: Quartz Commercial |
$787.15
|
| Rate for Payer: Quartz Medicare Advantage |
$726.60
|
| Rate for Payer: The Alliance Commercial |
$4,844.00
|
| Rate for Payer: WEA Trust Commercial |
$666.05
|
| Rate for Payer: WPS Commercial |
$896.99
|
|
|
SHEETING PHARMELAST SILICONE #20-10
|
Facility
|
OP
|
$1,315.00
|
|
| Hospital Charge Code |
2967369
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$368.20 |
| Max. Negotiated Rate |
$5,260.00 |
| Rate for Payer: Aetna Commercial |
$1,183.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,130.90
|
| Rate for Payer: Aetna Managed Medicare |
$368.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$854.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$657.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$631.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$696.95
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$1,209.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$735.87
|
| Rate for Payer: Health EOS Commercial |
$1,170.35
|
| Rate for Payer: HFN Commercial |
$1,209.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$986.25
|
| Rate for Payer: Multiplan Commercial |
$1,052.00
|
| Rate for Payer: NAPHCARE Commercial |
$789.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,209.80
|
| Rate for Payer: Quartz Beloit One Network |
$644.35
|
| Rate for Payer: Quartz Commercial |
$854.75
|
| Rate for Payer: Quartz Medicare Advantage |
$789.00
|
| Rate for Payer: The Alliance Commercial |
$5,260.00
|
| Rate for Payer: WEA Trust Commercial |
$723.25
|
| Rate for Payer: WPS Commercial |
$974.02
|
|
|
SHEETING PHARMELAST SILICONE #20-10
|
Facility
|
IP
|
$1,315.00
|
|
| Hospital Charge Code |
2967369
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$644.35 |
| Max. Negotiated Rate |
$1,209.80 |
| Rate for Payer: Aetna Commercial |
$1,183.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,130.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$696.95
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$1,209.80
|
| Rate for Payer: Health EOS Commercial |
$1,170.35
|
| Rate for Payer: HFN Commercial |
$1,209.80
|
| Rate for Payer: Multiplan Commercial |
$1,052.00
|
| Rate for Payer: NAPHCARE Commercial |
$789.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,209.80
|
| Rate for Payer: Quartz Beloit One Network |
$644.35
|
| Rate for Payer: Quartz Commercial |
$789.00
|
| Rate for Payer: WEA Trust Commercial |
$723.25
|
| Rate for Payer: WPS Commercial |
$974.02
|
|
|
SHEETING PHARMELAST SILICONE #20-20
|
Facility
|
IP
|
$1,440.00
|
|
| Hospital Charge Code |
2967370
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$705.60 |
| Max. Negotiated Rate |
$1,324.80 |
| Rate for Payer: Aetna Commercial |
$1,296.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,238.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$763.20
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna Commercial |
$1,324.80
|
| Rate for Payer: Health EOS Commercial |
$1,281.60
|
| Rate for Payer: HFN Commercial |
$1,324.80
|
| Rate for Payer: Multiplan Commercial |
$1,152.00
|
| Rate for Payer: NAPHCARE Commercial |
$864.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,324.80
|
| Rate for Payer: Quartz Beloit One Network |
$705.60
|
| Rate for Payer: Quartz Commercial |
$864.00
|
| Rate for Payer: WEA Trust Commercial |
$792.00
|
| Rate for Payer: WPS Commercial |
$1,066.61
|
|
|
SHEETING PHARMELAST SILICONE #20-20
|
Facility
|
OP
|
$1,440.00
|
|
| Hospital Charge Code |
2967370
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$403.20 |
| Max. Negotiated Rate |
$5,760.00 |
| Rate for Payer: Aetna Commercial |
$1,296.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,238.40
|
| Rate for Payer: Aetna Managed Medicare |
$403.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$936.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$720.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$691.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$763.20
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna Commercial |
$1,324.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$805.82
|
| Rate for Payer: Health EOS Commercial |
$1,281.60
|
| Rate for Payer: HFN Commercial |
$1,324.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,080.00
|
| Rate for Payer: Multiplan Commercial |
$1,152.00
|
| Rate for Payer: NAPHCARE Commercial |
$864.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,324.80
|
| Rate for Payer: Quartz Beloit One Network |
$705.60
|
| Rate for Payer: Quartz Commercial |
$936.00
|
| Rate for Payer: Quartz Medicare Advantage |
$864.00
|
| Rate for Payer: The Alliance Commercial |
$5,760.00
|
| Rate for Payer: WEA Trust Commercial |
$792.00
|
| Rate for Payer: WPS Commercial |
$1,066.61
|
|
|
SHEETING SILICONE 6X8 .040
|
Facility
|
IP
|
$2,623.00
|
|
| Hospital Charge Code |
2974002
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,285.27 |
| Max. Negotiated Rate |
$2,413.16 |
| Rate for Payer: Aetna Commercial |
$2,360.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,255.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,390.19
|
| Rate for Payer: Cash Price |
$786.90
|
| Rate for Payer: Cigna Commercial |
$2,413.16
|
| Rate for Payer: Health EOS Commercial |
$2,334.47
|
| Rate for Payer: HFN Commercial |
$2,413.16
|
| Rate for Payer: Multiplan Commercial |
$2,098.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,573.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,413.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,285.27
|
| Rate for Payer: Quartz Commercial |
$1,573.80
|
| Rate for Payer: WEA Trust Commercial |
$1,442.65
|
| Rate for Payer: WPS Commercial |
$1,942.86
|
|
|
SHEETING SILICONE 6X8 .040
|
Facility
|
OP
|
$2,623.00
|
|
| Hospital Charge Code |
2974002
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$734.44 |
| Max. Negotiated Rate |
$10,492.00 |
| Rate for Payer: Aetna Commercial |
$2,360.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,255.78
|
| Rate for Payer: Aetna Managed Medicare |
$734.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,704.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,311.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,259.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,390.19
|
| Rate for Payer: Cash Price |
$786.90
|
| Rate for Payer: Cigna Commercial |
$2,413.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,467.83
|
| Rate for Payer: Health EOS Commercial |
$2,334.47
|
| Rate for Payer: HFN Commercial |
$2,413.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,967.25
|
| Rate for Payer: Multiplan Commercial |
$2,098.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,573.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,413.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,285.27
|
| Rate for Payer: Quartz Commercial |
$1,704.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,573.80
|
| Rate for Payer: The Alliance Commercial |
$10,492.00
|
| Rate for Payer: WEA Trust Commercial |
$1,442.65
|
| Rate for Payer: WPS Commercial |
$1,942.86
|
|
|
SHEET SILICONE 6 X 8 .040 25-40
|
Facility
|
IP
|
$984.00
|
|
| Hospital Charge Code |
2969466
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$482.16 |
| Max. Negotiated Rate |
$905.28 |
| Rate for Payer: Aetna Commercial |
$885.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$846.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$521.52
|
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Cigna Commercial |
$905.28
|
| Rate for Payer: Health EOS Commercial |
$875.76
|
| Rate for Payer: HFN Commercial |
$905.28
|
| Rate for Payer: Multiplan Commercial |
$787.20
|
| Rate for Payer: NAPHCARE Commercial |
$590.40
|
| Rate for Payer: Preferred Network Access Commercial |
$905.28
|
| Rate for Payer: Quartz Beloit One Network |
$482.16
|
| Rate for Payer: Quartz Commercial |
$590.40
|
| Rate for Payer: WEA Trust Commercial |
$541.20
|
| Rate for Payer: WPS Commercial |
$728.85
|
|
|
SHEET SILICONE 6 X 8 .040 25-40
|
Facility
|
OP
|
$984.00
|
|
| Hospital Charge Code |
2969466
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$275.52 |
| Max. Negotiated Rate |
$3,936.00 |
| Rate for Payer: Aetna Commercial |
$885.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$846.24
|
| Rate for Payer: Aetna Managed Medicare |
$275.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$639.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$492.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$472.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$521.52
|
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Cigna Commercial |
$905.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$550.65
|
| Rate for Payer: Health EOS Commercial |
$875.76
|
| Rate for Payer: HFN Commercial |
$905.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$738.00
|
| Rate for Payer: Multiplan Commercial |
$787.20
|
| Rate for Payer: NAPHCARE Commercial |
$590.40
|
| Rate for Payer: Preferred Network Access Commercial |
$905.28
|
| Rate for Payer: Quartz Beloit One Network |
$482.16
|
| Rate for Payer: Quartz Commercial |
$639.60
|
| Rate for Payer: Quartz Medicare Advantage |
$590.40
|
| Rate for Payer: The Alliance Commercial |
$3,936.00
|
| Rate for Payer: WEA Trust Commercial |
$541.20
|
| Rate for Payer: WPS Commercial |
$728.85
|
|
|
SHEET SPLIT ARTHROSCOPY 60x70 89331
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2963306
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
SHEET SPLIT ARTHROSCOPY 60x70 89331
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
2963306
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.17
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$42.00
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
