|
SINUS BALLOON SEEKER EM MAXILLARY 6 X 7MM MEDTRONIC 1830607MAX
|
Facility
|
IP
|
$3,693.00
|
|
| Hospital Charge Code |
4230452
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,881.95 |
| Max. Negotiated Rate |
$3,533.46 |
| Rate for Payer: Aetna Commercial |
$3,456.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,303.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,035.58
|
| Rate for Payer: Cash Price |
$1,107.90
|
| Rate for Payer: Cigna Commercial |
$3,533.46
|
| Rate for Payer: Health EOS Commercial |
$3,418.24
|
| Rate for Payer: HFN Commercial |
$3,533.46
|
| Rate for Payer: Multiplan Commercial |
$3,072.58
|
| Rate for Payer: Preferred Network Access Commercial |
$3,533.46
|
| Rate for Payer: Quartz Beloit One Network |
$1,881.95
|
| Rate for Payer: Quartz Commercial |
$2,304.43
|
| Rate for Payer: WEA Trust Commercial |
$2,112.40
|
| Rate for Payer: WPS Commercial |
$2,844.72
|
|
|
SINUS BALLOON SEEKER EM SPHENOID 6 X 17MM MEDTRONIC 1830617SPH
|
Facility
|
OP
|
$3,888.00
|
|
| Hospital Charge Code |
4230454
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,132.19 |
| Max. Negotiated Rate |
$3,720.04 |
| Rate for Payer: Aetna Commercial |
$3,639.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,477.43
|
| Rate for Payer: Aetna Managed Medicare |
$1,132.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,628.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,021.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,940.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,143.07
|
| Rate for Payer: Cash Price |
$1,166.40
|
| Rate for Payer: Cigna Commercial |
$3,720.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,262.82
|
| Rate for Payer: Health EOS Commercial |
$3,598.73
|
| Rate for Payer: HFN Commercial |
$3,720.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,032.64
|
| Rate for Payer: Multiplan Commercial |
$3,234.82
|
| Rate for Payer: NAPHCARE Commercial |
$2,426.11
|
| Rate for Payer: Preferred Network Access Commercial |
$3,720.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,981.32
|
| Rate for Payer: Quartz Commercial |
$2,628.29
|
| Rate for Payer: Quartz Medicare Advantage |
$2,426.11
|
| Rate for Payer: The Alliance Commercial |
$2,021.76
|
| Rate for Payer: WEA Trust Commercial |
$2,223.94
|
| Rate for Payer: WPS Commercial |
$2,994.93
|
|
|
SINUS BALLOON SEEKER EM SPHENOID 6 X 17MM MEDTRONIC 1830617SPH
|
Facility
|
IP
|
$3,888.00
|
|
| Hospital Charge Code |
4230454
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,981.32 |
| Max. Negotiated Rate |
$3,720.04 |
| Rate for Payer: Aetna Commercial |
$3,639.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,477.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,143.07
|
| Rate for Payer: Cash Price |
$1,166.40
|
| Rate for Payer: Cigna Commercial |
$3,720.04
|
| Rate for Payer: Health EOS Commercial |
$3,598.73
|
| Rate for Payer: HFN Commercial |
$3,720.04
|
| Rate for Payer: Multiplan Commercial |
$3,234.82
|
| Rate for Payer: Preferred Network Access Commercial |
$3,720.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,981.32
|
| Rate for Payer: Quartz Commercial |
$2,426.11
|
| Rate for Payer: WEA Trust Commercial |
$2,223.94
|
| Rate for Payer: WPS Commercial |
$2,994.93
|
|
|
SINUS BALLOON SYSTEM RELIEVA SPINPLUS SINUPLASTY BALLOON 6 X 16MM ACCLARENT RSP0616MFS
|
Facility
|
OP
|
$11,435.00
|
|
| Hospital Charge Code |
5178632
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,329.87 |
| Max. Negotiated Rate |
$10,941.01 |
| Rate for Payer: Aetna Commercial |
$10,703.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,227.46
|
| Rate for Payer: Aetna Managed Medicare |
$3,329.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,730.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,946.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,708.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,302.97
|
| Rate for Payer: Cash Price |
$3,430.50
|
| Rate for Payer: Cigna Commercial |
$10,941.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,655.17
|
| Rate for Payer: Health EOS Commercial |
$10,584.24
|
| Rate for Payer: HFN Commercial |
$10,941.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,919.30
|
| Rate for Payer: Multiplan Commercial |
$9,513.92
|
| Rate for Payer: NAPHCARE Commercial |
$7,135.44
|
| Rate for Payer: Preferred Network Access Commercial |
$10,941.01
|
| Rate for Payer: Quartz Beloit One Network |
$5,827.28
|
| Rate for Payer: Quartz Commercial |
$7,730.06
|
| Rate for Payer: Quartz Medicare Advantage |
$7,135.44
|
| Rate for Payer: The Alliance Commercial |
$5,946.20
|
| Rate for Payer: WEA Trust Commercial |
$6,540.82
|
| Rate for Payer: WPS Commercial |
$8,808.38
|
|
|
SINUS BALLOON SYSTEM RELIEVA SPINPLUS SINUPLASTY BALLOON 6 X 16MM ACCLARENT RSP0616MFS
|
Facility
|
IP
|
$11,435.00
|
|
| Hospital Charge Code |
5178632
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,827.28 |
| Max. Negotiated Rate |
$10,941.01 |
| Rate for Payer: Aetna Commercial |
$10,703.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,227.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,302.97
|
| Rate for Payer: Cash Price |
$3,430.50
|
| Rate for Payer: Cigna Commercial |
$10,941.01
|
| Rate for Payer: Health EOS Commercial |
$10,584.24
|
| Rate for Payer: HFN Commercial |
$10,941.01
|
| Rate for Payer: Multiplan Commercial |
$9,513.92
|
| Rate for Payer: Preferred Network Access Commercial |
$10,941.01
|
| Rate for Payer: Quartz Beloit One Network |
$5,827.28
|
| Rate for Payer: Quartz Commercial |
$7,135.44
|
| Rate for Payer: WEA Trust Commercial |
$6,540.82
|
| Rate for Payer: WPS Commercial |
$8,808.38
|
|
|
SINUS PACK BARON REG 400407
|
Facility
|
OP
|
$356.00
|
|
| Hospital Charge Code |
2965313
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$103.67 |
| Max. Negotiated Rate |
$340.62 |
| Rate for Payer: Aetna Commercial |
$333.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Aetna Managed Medicare |
$103.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$240.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$185.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$177.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.19
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$277.68
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: NAPHCARE Commercial |
$222.14
|
| Rate for Payer: Preferred Network Access Commercial |
$340.62
|
| Rate for Payer: Quartz Beloit One Network |
$181.42
|
| Rate for Payer: Quartz Commercial |
$240.66
|
| Rate for Payer: Quartz Medicare Advantage |
$222.14
|
| Rate for Payer: The Alliance Commercial |
$185.12
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
|
SINUS PACK BARON REG 400407
|
Facility
|
IP
|
$356.00
|
|
| Hospital Charge Code |
2965313
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$181.42 |
| Max. Negotiated Rate |
$340.62 |
| Rate for Payer: Aetna Commercial |
$333.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: Preferred Network Access Commercial |
$340.62
|
| Rate for Payer: Quartz Beloit One Network |
$181.42
|
| Rate for Payer: Quartz Commercial |
$222.14
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
|
SINUS PACK BARON SLIM 400427
|
Facility
|
IP
|
$356.00
|
|
| Hospital Charge Code |
2965314
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$181.42 |
| Max. Negotiated Rate |
$340.62 |
| Rate for Payer: Aetna Commercial |
$333.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: Preferred Network Access Commercial |
$340.62
|
| Rate for Payer: Quartz Beloit One Network |
$181.42
|
| Rate for Payer: Quartz Commercial |
$222.14
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
|
SINUS PACK BARON SLIM 400427
|
Facility
|
OP
|
$356.00
|
|
| Hospital Charge Code |
2965314
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$103.67 |
| Max. Negotiated Rate |
$340.62 |
| Rate for Payer: Aetna Commercial |
$333.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Aetna Managed Medicare |
$103.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$240.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$185.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$177.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.19
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$277.68
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: NAPHCARE Commercial |
$222.14
|
| Rate for Payer: Preferred Network Access Commercial |
$340.62
|
| Rate for Payer: Quartz Beloit One Network |
$181.42
|
| Rate for Payer: Quartz Commercial |
$240.66
|
| Rate for Payer: Quartz Medicare Advantage |
$222.14
|
| Rate for Payer: The Alliance Commercial |
$185.12
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
|
Size 6 - Percutaneous Tracheostomy Kit
|
Facility
|
OP
|
$3,659.00
|
|
| Hospital Charge Code |
5707630
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,065.50 |
| Max. Negotiated Rate |
$3,500.93 |
| Rate for Payer: Aetna Commercial |
$3,424.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,272.61
|
| Rate for Payer: Aetna Managed Medicare |
$1,065.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,473.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,902.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,826.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,016.84
|
| Rate for Payer: Cash Price |
$1,097.70
|
| Rate for Payer: Cigna Commercial |
$3,500.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,129.54
|
| Rate for Payer: Health EOS Commercial |
$3,386.77
|
| Rate for Payer: HFN Commercial |
$3,500.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,854.02
|
| Rate for Payer: Multiplan Commercial |
$3,044.29
|
| Rate for Payer: NAPHCARE Commercial |
$2,283.22
|
| Rate for Payer: Preferred Network Access Commercial |
$3,500.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,864.63
|
| Rate for Payer: Quartz Commercial |
$2,473.48
|
| Rate for Payer: Quartz Medicare Advantage |
$2,283.22
|
| Rate for Payer: The Alliance Commercial |
$1,902.68
|
| Rate for Payer: WEA Trust Commercial |
$2,092.95
|
| Rate for Payer: WPS Commercial |
$2,818.53
|
|
|
Size 6 - Percutaneous Tracheostomy Kit
|
Facility
|
IP
|
$3,659.00
|
|
| Hospital Charge Code |
5707630
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,864.63 |
| Max. Negotiated Rate |
$3,500.93 |
| Rate for Payer: Aetna Commercial |
$3,424.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,272.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,016.84
|
| Rate for Payer: Cash Price |
$1,097.70
|
| Rate for Payer: Cigna Commercial |
$3,500.93
|
| Rate for Payer: Health EOS Commercial |
$3,386.77
|
| Rate for Payer: HFN Commercial |
$3,500.93
|
| Rate for Payer: Multiplan Commercial |
$3,044.29
|
| Rate for Payer: Preferred Network Access Commercial |
$3,500.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,864.63
|
| Rate for Payer: Quartz Commercial |
$2,283.22
|
| Rate for Payer: WEA Trust Commercial |
$2,092.95
|
| Rate for Payer: WPS Commercial |
$2,818.53
|
|
|
Size 8 - Percutaneous Tracheostomy Kit
|
Facility
|
OP
|
$3,659.00
|
|
| Hospital Charge Code |
5707629
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,065.50 |
| Max. Negotiated Rate |
$3,500.93 |
| Rate for Payer: Aetna Commercial |
$3,424.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,272.61
|
| Rate for Payer: Aetna Managed Medicare |
$1,065.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,473.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,902.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,826.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,016.84
|
| Rate for Payer: Cash Price |
$1,097.70
|
| Rate for Payer: Cigna Commercial |
$3,500.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,129.54
|
| Rate for Payer: Health EOS Commercial |
$3,386.77
|
| Rate for Payer: HFN Commercial |
$3,500.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,854.02
|
| Rate for Payer: Multiplan Commercial |
$3,044.29
|
| Rate for Payer: NAPHCARE Commercial |
$2,283.22
|
| Rate for Payer: Preferred Network Access Commercial |
$3,500.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,864.63
|
| Rate for Payer: Quartz Commercial |
$2,473.48
|
| Rate for Payer: Quartz Medicare Advantage |
$2,283.22
|
| Rate for Payer: The Alliance Commercial |
$1,902.68
|
| Rate for Payer: WEA Trust Commercial |
$2,092.95
|
| Rate for Payer: WPS Commercial |
$2,818.53
|
|
|
Size 8 - Percutaneous Tracheostomy Kit
|
Facility
|
IP
|
$3,659.00
|
|
| Hospital Charge Code |
5707629
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,864.63 |
| Max. Negotiated Rate |
$3,500.93 |
| Rate for Payer: Aetna Commercial |
$3,424.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,272.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,016.84
|
| Rate for Payer: Cash Price |
$1,097.70
|
| Rate for Payer: Cigna Commercial |
$3,500.93
|
| Rate for Payer: Health EOS Commercial |
$3,386.77
|
| Rate for Payer: HFN Commercial |
$3,500.93
|
| Rate for Payer: Multiplan Commercial |
$3,044.29
|
| Rate for Payer: Preferred Network Access Commercial |
$3,500.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,864.63
|
| Rate for Payer: Quartz Commercial |
$2,283.22
|
| Rate for Payer: WEA Trust Commercial |
$2,092.95
|
| Rate for Payer: WPS Commercial |
$2,818.53
|
|
|
SIZER 390CC BREAST IMPLANT
|
Facility
|
OP
|
$963.00
|
|
| Hospital Charge Code |
2964640
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$280.43 |
| Max. Negotiated Rate |
$921.40 |
| Rate for Payer: Aetna Commercial |
$901.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$861.31
|
| Rate for Payer: Aetna Managed Medicare |
$280.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$650.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$500.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$480.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$530.81
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cigna Commercial |
$921.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$560.47
|
| Rate for Payer: Health EOS Commercial |
$891.35
|
| Rate for Payer: HFN Commercial |
$921.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$751.14
|
| Rate for Payer: Multiplan Commercial |
$801.22
|
| Rate for Payer: NAPHCARE Commercial |
$600.91
|
| Rate for Payer: Preferred Network Access Commercial |
$921.40
|
| Rate for Payer: Quartz Beloit One Network |
$490.74
|
| Rate for Payer: Quartz Commercial |
$650.99
|
| Rate for Payer: Quartz Medicare Advantage |
$600.91
|
| Rate for Payer: The Alliance Commercial |
$500.76
|
| Rate for Payer: WEA Trust Commercial |
$550.84
|
| Rate for Payer: WPS Commercial |
$741.80
|
|
|
SIZER 390CC BREAST IMPLANT
|
Facility
|
IP
|
$963.00
|
|
| Hospital Charge Code |
2964640
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$490.74 |
| Max. Negotiated Rate |
$921.40 |
| Rate for Payer: Aetna Commercial |
$901.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$861.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$530.81
|
| Rate for Payer: Cash Price |
$288.90
|
| Rate for Payer: Cigna Commercial |
$921.40
|
| Rate for Payer: Health EOS Commercial |
$891.35
|
| Rate for Payer: HFN Commercial |
$921.40
|
| Rate for Payer: Multiplan Commercial |
$801.22
|
| Rate for Payer: Preferred Network Access Commercial |
$921.40
|
| Rate for Payer: Quartz Beloit One Network |
$490.74
|
| Rate for Payer: Quartz Commercial |
$600.91
|
| Rate for Payer: WEA Trust Commercial |
$550.84
|
| Rate for Payer: WPS Commercial |
$741.80
|
|
|
SIZER CAGE SCREW ECLIPSE AR-9401-08S
|
Facility
|
OP
|
$1,464.00
|
|
| Hospital Charge Code |
5563220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$426.32 |
| Max. Negotiated Rate |
$1,400.76 |
| Rate for Payer: Aetna Commercial |
$1,370.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,309.40
|
| Rate for Payer: Aetna Managed Medicare |
$426.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$989.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$761.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$730.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$806.96
|
| Rate for Payer: Cash Price |
$439.20
|
| Rate for Payer: Cigna Commercial |
$1,400.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$852.05
|
| Rate for Payer: Health EOS Commercial |
$1,355.08
|
| Rate for Payer: HFN Commercial |
$1,400.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,141.92
|
| Rate for Payer: Multiplan Commercial |
$1,218.05
|
| Rate for Payer: NAPHCARE Commercial |
$913.54
|
| Rate for Payer: Preferred Network Access Commercial |
$1,400.76
|
| Rate for Payer: Quartz Beloit One Network |
$746.05
|
| Rate for Payer: Quartz Commercial |
$989.66
|
| Rate for Payer: Quartz Medicare Advantage |
$913.54
|
| Rate for Payer: The Alliance Commercial |
$761.28
|
| Rate for Payer: WEA Trust Commercial |
$837.41
|
| Rate for Payer: WPS Commercial |
$1,127.72
|
|
|
SIZER CAGE SCREW ECLIPSE AR-9401-08S
|
Facility
|
IP
|
$1,464.00
|
|
| Hospital Charge Code |
5563220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$746.05 |
| Max. Negotiated Rate |
$1,400.76 |
| Rate for Payer: Aetna Commercial |
$1,370.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,309.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$806.96
|
| Rate for Payer: Cash Price |
$439.20
|
| Rate for Payer: Cigna Commercial |
$1,400.76
|
| Rate for Payer: Health EOS Commercial |
$1,355.08
|
| Rate for Payer: HFN Commercial |
$1,400.76
|
| Rate for Payer: Multiplan Commercial |
$1,218.05
|
| Rate for Payer: Preferred Network Access Commercial |
$1,400.76
|
| Rate for Payer: Quartz Beloit One Network |
$746.05
|
| Rate for Payer: Quartz Commercial |
$913.54
|
| Rate for Payer: WEA Trust Commercial |
$837.41
|
| Rate for Payer: WPS Commercial |
$1,127.72
|
|
|
SIZER GRAFT LARGE 24MM - 38MM M0023632000211
|
Facility
|
IP
|
$213.00
|
|
| Hospital Charge Code |
5813673
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$108.54 |
| Max. Negotiated Rate |
$203.80 |
| Rate for Payer: Aetna Commercial |
$199.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.41
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$203.80
|
| Rate for Payer: Health EOS Commercial |
$197.15
|
| Rate for Payer: HFN Commercial |
$203.80
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: Preferred Network Access Commercial |
$203.80
|
| Rate for Payer: Quartz Beloit One Network |
$108.54
|
| Rate for Payer: Quartz Commercial |
$132.91
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
SIZER GRAFT LARGE 24MM - 38MM M0023632000211
|
Facility
|
OP
|
$213.00
|
|
| Hospital Charge Code |
5813673
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$62.03 |
| Max. Negotiated Rate |
$203.80 |
| Rate for Payer: Aetna Commercial |
$199.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Aetna Managed Medicare |
$62.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$143.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$106.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.41
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$203.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.97
|
| Rate for Payer: Health EOS Commercial |
$197.15
|
| Rate for Payer: HFN Commercial |
$203.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.14
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: NAPHCARE Commercial |
$132.91
|
| Rate for Payer: Preferred Network Access Commercial |
$203.80
|
| Rate for Payer: Quartz Beloit One Network |
$108.54
|
| Rate for Payer: Quartz Commercial |
$143.99
|
| Rate for Payer: Quartz Medicare Advantage |
$132.91
|
| Rate for Payer: The Alliance Commercial |
$110.76
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
SIZER GRAFT SMALL 5MM - 24MM M0023632000201
|
Facility
|
IP
|
$213.00
|
|
| Hospital Charge Code |
5813672
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$108.54 |
| Max. Negotiated Rate |
$203.80 |
| Rate for Payer: Aetna Commercial |
$199.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.41
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$203.80
|
| Rate for Payer: Health EOS Commercial |
$197.15
|
| Rate for Payer: HFN Commercial |
$203.80
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: Preferred Network Access Commercial |
$203.80
|
| Rate for Payer: Quartz Beloit One Network |
$108.54
|
| Rate for Payer: Quartz Commercial |
$132.91
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
SIZER GRAFT SMALL 5MM - 24MM M0023632000201
|
Facility
|
OP
|
$213.00
|
|
| Hospital Charge Code |
5813672
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$62.03 |
| Max. Negotiated Rate |
$203.80 |
| Rate for Payer: Aetna Commercial |
$199.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$190.51
|
| Rate for Payer: Aetna Managed Medicare |
$62.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$143.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$106.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.41
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cigna Commercial |
$203.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$123.97
|
| Rate for Payer: Health EOS Commercial |
$197.15
|
| Rate for Payer: HFN Commercial |
$203.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.14
|
| Rate for Payer: Multiplan Commercial |
$177.22
|
| Rate for Payer: NAPHCARE Commercial |
$132.91
|
| Rate for Payer: Preferred Network Access Commercial |
$203.80
|
| Rate for Payer: Quartz Beloit One Network |
$108.54
|
| Rate for Payer: Quartz Commercial |
$143.99
|
| Rate for Payer: Quartz Medicare Advantage |
$132.91
|
| Rate for Payer: The Alliance Commercial |
$110.76
|
| Rate for Payer: WEA Trust Commercial |
$121.84
|
| Rate for Payer: WPS Commercial |
$164.07
|
|
|
Sjogern's Antibody (SSA)
|
Facility
|
OP
|
$303.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942857
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.65 |
| Max. Negotiated Rate |
$289.91 |
| Rate for Payer: Aetna Commercial |
$283.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$271.00
|
| Rate for Payer: Aetna Managed Medicare |
$18.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.63
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.95
|
| Rate for Payer: Anthem Medicare Advantage |
$18.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$167.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.65
|
| Rate for Payer: Cash Price |
$90.90
|
| Rate for Payer: Cash Price |
$90.90
|
| Rate for Payer: Cigna Commercial |
$289.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$176.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.65
|
| Rate for Payer: Health EOS Commercial |
$280.46
|
| Rate for Payer: HFN Commercial |
$289.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.65
|
| Rate for Payer: Multiplan Commercial |
$252.10
|
| Rate for Payer: NAPHCARE Commercial |
$27.97
|
| Rate for Payer: Preferred Network Access Commercial |
$289.91
|
| Rate for Payer: Quartz Beloit One Network |
$154.41
|
| Rate for Payer: Quartz Commercial |
$204.83
|
| Rate for Payer: Quartz Medicare Advantage |
$18.65
|
| Rate for Payer: The Alliance Commercial |
$74.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.65
|
| Rate for Payer: United Healthcare PPO |
$236.34
|
| Rate for Payer: WEA Trust Commercial |
$173.32
|
| Rate for Payer: Wellcare Medicare |
$18.65
|
| Rate for Payer: WPS Commercial |
$233.40
|
|
|
Sjogern's Antibody (SSA)
|
Facility
|
IP
|
$303.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942857
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$154.41 |
| Max. Negotiated Rate |
$289.91 |
| Rate for Payer: Aetna Commercial |
$283.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$271.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$167.01
|
| Rate for Payer: Cash Price |
$90.90
|
| Rate for Payer: Cigna Commercial |
$289.91
|
| Rate for Payer: Health EOS Commercial |
$280.46
|
| Rate for Payer: HFN Commercial |
$289.91
|
| Rate for Payer: Multiplan Commercial |
$252.10
|
| Rate for Payer: Preferred Network Access Commercial |
$289.91
|
| Rate for Payer: Quartz Beloit One Network |
$154.41
|
| Rate for Payer: Quartz Commercial |
$189.07
|
| Rate for Payer: WEA Trust Commercial |
$173.32
|
| Rate for Payer: WPS Commercial |
$233.40
|
|
|
Sjogern's Antibody (SSA)
|
Professional
|
Both
|
$303.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942857
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.65 |
| Max. Negotiated Rate |
$299.36 |
| Rate for Payer: Aetna Commercial |
$299.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$271.00
|
| Rate for Payer: Aetna Managed Medicare |
$18.65
|
| Rate for Payer: Anthem Medicare Advantage |
$18.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.65
|
| Rate for Payer: Cash Price |
$90.90
|
| Rate for Payer: Cash Price |
$90.90
|
| Rate for Payer: Cigna Commercial |
$299.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$157.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.65
|
| Rate for Payer: Health EOS Commercial |
$286.76
|
| Rate for Payer: HFN Commercial |
$299.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.65
|
| Rate for Payer: Multiplan Commercial |
$252.10
|
| Rate for Payer: NAPHCARE Commercial |
$27.97
|
| Rate for Payer: Preferred Network Access Commercial |
$299.36
|
| Rate for Payer: Quartz Beloit One Network |
$138.65
|
| Rate for Payer: Quartz Commercial |
$179.62
|
| Rate for Payer: Quartz Medicare Advantage |
$18.65
|
| Rate for Payer: The Alliance Commercial |
$73.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.65
|
| Rate for Payer: WEA Trust Commercial |
$173.32
|
| Rate for Payer: WPS Commercial |
$82.05
|
|
|
Sjogern's Antibody (SS-A,SS-B)
|
Professional
|
Both
|
$197.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
983404
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.65 |
| Max. Negotiated Rate |
$194.64 |
| Rate for Payer: Aetna Commercial |
$194.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.20
|
| Rate for Payer: Aetna Managed Medicare |
$18.65
|
| Rate for Payer: Anthem Medicare Advantage |
$18.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.65
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$194.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$102.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.65
|
| Rate for Payer: Health EOS Commercial |
$186.44
|
| Rate for Payer: HFN Commercial |
$194.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.65
|
| Rate for Payer: Multiplan Commercial |
$163.90
|
| Rate for Payer: NAPHCARE Commercial |
$27.97
|
| Rate for Payer: Preferred Network Access Commercial |
$194.64
|
| Rate for Payer: Quartz Beloit One Network |
$90.15
|
| Rate for Payer: Quartz Commercial |
$116.78
|
| Rate for Payer: Quartz Medicare Advantage |
$18.65
|
| Rate for Payer: The Alliance Commercial |
$73.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.65
|
| Rate for Payer: WEA Trust Commercial |
$112.68
|
| Rate for Payer: WPS Commercial |
$82.05
|
|
