|
Small Joint 20600 - Admin Intra-articular Injection Charge
|
Facility
|
IP
|
$493.00
|
|
|
Service Code
|
CPT 20600
|
| Hospital Charge Code |
3475535
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$241.57 |
| Max. Negotiated Rate |
$453.56 |
| Rate for Payer: Aetna Commercial |
$443.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$423.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$261.29
|
| Rate for Payer: Cash Price |
$147.90
|
| Rate for Payer: Cigna Commercial |
$453.56
|
| Rate for Payer: Health EOS Commercial |
$438.77
|
| Rate for Payer: HFN Commercial |
$453.56
|
| Rate for Payer: Multiplan Commercial |
$394.40
|
| Rate for Payer: NAPHCARE Commercial |
$295.80
|
| Rate for Payer: Preferred Network Access Commercial |
$453.56
|
| Rate for Payer: Quartz Beloit One Network |
$241.57
|
| Rate for Payer: Quartz Commercial |
$295.80
|
| Rate for Payer: WEA Trust Commercial |
$271.15
|
| Rate for Payer: WPS Commercial |
$365.17
|
|
|
Small Joint 20600 - Admin Intra-articular Injection Charge
|
Facility
|
OP
|
$493.00
|
|
|
Service Code
|
CPT 20600
|
| Hospital Charge Code |
3475535
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$236.64 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$443.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$423.98
|
| Rate for Payer: Aetna Managed Medicare |
$292.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$320.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$246.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$236.64
|
| Rate for Payer: Anthem Medicare Advantage |
$292.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$261.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$292.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$292.75
|
| Rate for Payer: Cash Price |
$147.90
|
| Rate for Payer: Cash Price |
$147.90
|
| Rate for Payer: Cigna Commercial |
$453.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$292.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$292.75
|
| Rate for Payer: Health EOS Commercial |
$438.77
|
| Rate for Payer: HFN Commercial |
$453.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,089.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$292.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$292.75
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$292.75
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$292.75
|
| Rate for Payer: Multiplan Commercial |
$394.40
|
| Rate for Payer: NAPHCARE Commercial |
$439.12
|
| Rate for Payer: Preferred Network Access Commercial |
$453.56
|
| Rate for Payer: Quartz Beloit One Network |
$241.57
|
| Rate for Payer: Quartz Commercial |
$320.45
|
| Rate for Payer: Quartz Medicare Advantage |
$292.75
|
| Rate for Payer: The Alliance Commercial |
$1,171.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$292.75
|
| Rate for Payer: WEA Trust Commercial |
$271.15
|
| Rate for Payer: Wellcare Medicare |
$292.75
|
| Rate for Payer: WPS Commercial |
$365.17
|
|
|
Small joint or bursa w/ultrasound guidance 20604
|
Professional
|
Both
|
$1,424.00
|
|
|
Service Code
|
CPT 20604
|
| Hospital Charge Code |
4500691
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$55.62 |
| Max. Negotiated Rate |
$1,352.80 |
| Rate for Payer: Aetna Commercial |
$1,352.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,224.64
|
| Rate for Payer: Cash Price |
$427.20
|
| Rate for Payer: Cash Price |
$427.20
|
| Rate for Payer: Cigna Commercial |
$1,352.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$55.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$854.40
|
| Rate for Payer: Health EOS Commercial |
$1,295.84
|
| Rate for Payer: HFN Commercial |
$1,352.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$155.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$155.04
|
| Rate for Payer: Multiplan Commercial |
$1,139.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,352.80
|
| Rate for Payer: Quartz Beloit One Network |
$626.56
|
| Rate for Payer: Quartz Commercial |
$811.68
|
| Rate for Payer: The Alliance Commercial |
$712.00
|
| Rate for Payer: United Healthcare Medicaid |
$55.62
|
| Rate for Payer: WEA Trust Commercial |
$783.20
|
| Rate for Payer: WPS Commercial |
$1,054.76
|
|
|
Small joint w/ultrasound guidance 2060450
|
Professional
|
Both
|
$2,845.00
|
|
|
Service Code
|
CPT 20604 50
|
| Hospital Charge Code |
5388753
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$55.62 |
| Max. Negotiated Rate |
$2,702.75 |
| Rate for Payer: Aetna Commercial |
$2,702.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,446.70
|
| Rate for Payer: Cash Price |
$853.50
|
| Rate for Payer: Cash Price |
$853.50
|
| Rate for Payer: Cigna Commercial |
$2,702.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$55.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,707.00
|
| Rate for Payer: Health EOS Commercial |
$2,588.95
|
| Rate for Payer: HFN Commercial |
$2,702.75
|
| Rate for Payer: Multiplan Commercial |
$2,276.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,702.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,251.80
|
| Rate for Payer: Quartz Commercial |
$1,621.65
|
| Rate for Payer: The Alliance Commercial |
$1,422.50
|
| Rate for Payer: United Healthcare Medicaid |
$55.62
|
| Rate for Payer: WEA Trust Commercial |
$1,564.75
|
| Rate for Payer: WPS Commercial |
$2,107.29
|
|
|
Small white foam
|
Facility
|
OP
|
$191.00
|
|
| Hospital Charge Code |
3006896
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$53.48 |
| Max. Negotiated Rate |
$764.00 |
| Rate for Payer: Aetna Commercial |
$171.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.26
|
| Rate for Payer: Aetna Managed Medicare |
$53.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$124.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$95.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$91.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.23
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$175.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$106.88
|
| Rate for Payer: Health EOS Commercial |
$169.99
|
| Rate for Payer: HFN Commercial |
$175.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$143.25
|
| Rate for Payer: Multiplan Commercial |
$152.80
|
| Rate for Payer: NAPHCARE Commercial |
$114.60
|
| Rate for Payer: Preferred Network Access Commercial |
$175.72
|
| Rate for Payer: Quartz Beloit One Network |
$93.59
|
| Rate for Payer: Quartz Commercial |
$124.15
|
| Rate for Payer: Quartz Medicare Advantage |
$114.60
|
| Rate for Payer: The Alliance Commercial |
$764.00
|
| Rate for Payer: WEA Trust Commercial |
$105.05
|
| Rate for Payer: WPS Commercial |
$141.47
|
|
|
Small white foam
|
Facility
|
IP
|
$191.00
|
|
| Hospital Charge Code |
3006896
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$93.59 |
| Max. Negotiated Rate |
$175.72 |
| Rate for Payer: Aetna Commercial |
$171.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.23
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$175.72
|
| Rate for Payer: Health EOS Commercial |
$169.99
|
| Rate for Payer: HFN Commercial |
$175.72
|
| Rate for Payer: Multiplan Commercial |
$152.80
|
| Rate for Payer: NAPHCARE Commercial |
$114.60
|
| Rate for Payer: Preferred Network Access Commercial |
$175.72
|
| Rate for Payer: Quartz Beloit One Network |
$93.59
|
| Rate for Payer: Quartz Commercial |
$114.60
|
| Rate for Payer: WEA Trust Commercial |
$105.05
|
| Rate for Payer: WPS Commercial |
$141.47
|
|
|
SM Antibody
|
Professional
|
Both
|
$244.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942855
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.29 |
| Max. Negotiated Rate |
$231.80 |
| Rate for Payer: Aetna Commercial |
$231.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$231.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$122.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.40
|
| Rate for Payer: Health EOS Commercial |
$222.04
|
| Rate for Payer: HFN Commercial |
$231.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.29
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: Preferred Network Access Commercial |
$231.80
|
| Rate for Payer: Quartz Beloit One Network |
$107.36
|
| Rate for Payer: Quartz Commercial |
$139.08
|
| Rate for Payer: The Alliance Commercial |
$122.00
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
SM Antibody
|
Facility
|
OP
|
$244.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942855
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.93 |
| Max. Negotiated Rate |
$224.48 |
| Rate for Payer: Aetna Commercial |
$219.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Aetna Managed Medicare |
$17.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.38
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.76
|
| Rate for Payer: Anthem Medicaid |
$18.53
|
| Rate for Payer: Anthem Medicare Advantage |
$17.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.93
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$224.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.54
|
| Rate for Payer: Dean Health Medicaid |
$18.53
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.93
|
| Rate for Payer: Health EOS Commercial |
$217.16
|
| Rate for Payer: HFN Commercial |
$224.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.93
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.93
|
| Rate for Payer: Managed Health Services Medicaid |
$19.27
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.93
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.93
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.90
|
| Rate for Payer: Preferred Network Access Commercial |
$224.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18.53
|
| Rate for Payer: Quartz Beloit One Network |
$119.56
|
| Rate for Payer: Quartz Commercial |
$158.60
|
| Rate for Payer: Quartz Medicare Advantage |
$17.93
|
| Rate for Payer: The Alliance Commercial |
$71.72
|
| Rate for Payer: United Healthcare Medicaid |
$18.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.93
|
| Rate for Payer: United Healthcare PPO |
$183.00
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: Wellcare Medicare |
$17.93
|
| Rate for Payer: WMAP Medicaid |
$18.53
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
SM Antibody
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942855
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$119.56 |
| Max. Negotiated Rate |
$224.48 |
| Rate for Payer: Aetna Commercial |
$219.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.32
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$224.48
|
| Rate for Payer: Health EOS Commercial |
$217.16
|
| Rate for Payer: HFN Commercial |
$224.48
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: NAPHCARE Commercial |
$146.40
|
| Rate for Payer: Preferred Network Access Commercial |
$224.48
|
| Rate for Payer: Quartz Beloit One Network |
$119.56
|
| Rate for Payer: Quartz Commercial |
$146.40
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
SMART NAIL 1.5x16MM
|
Facility
|
OP
|
$2,518.00
|
|
| Hospital Charge Code |
2964954
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$705.04 |
| Max. Negotiated Rate |
$10,072.00 |
| Rate for Payer: Aetna Commercial |
$2,266.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,165.48
|
| Rate for Payer: Aetna Managed Medicare |
$705.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,636.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,259.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,208.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,334.54
|
| Rate for Payer: Cash Price |
$755.40
|
| Rate for Payer: Cigna Commercial |
$2,316.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,409.07
|
| Rate for Payer: Health EOS Commercial |
$2,241.02
|
| Rate for Payer: HFN Commercial |
$2,316.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,888.50
|
| Rate for Payer: Multiplan Commercial |
$2,014.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,510.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,316.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,233.82
|
| Rate for Payer: Quartz Commercial |
$1,636.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,510.80
|
| Rate for Payer: The Alliance Commercial |
$10,072.00
|
| Rate for Payer: WEA Trust Commercial |
$1,384.90
|
| Rate for Payer: WPS Commercial |
$1,865.08
|
|
|
SMART NAIL 1.5x16MM
|
Facility
|
IP
|
$2,518.00
|
|
| Hospital Charge Code |
2964954
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,233.82 |
| Max. Negotiated Rate |
$2,316.56 |
| Rate for Payer: Aetna Commercial |
$2,266.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,165.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,334.54
|
| Rate for Payer: Cash Price |
$755.40
|
| Rate for Payer: Cigna Commercial |
$2,316.56
|
| Rate for Payer: Health EOS Commercial |
$2,241.02
|
| Rate for Payer: HFN Commercial |
$2,316.56
|
| Rate for Payer: Multiplan Commercial |
$2,014.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,510.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,316.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,233.82
|
| Rate for Payer: Quartz Commercial |
$1,510.80
|
| Rate for Payer: WEA Trust Commercial |
$1,384.90
|
| Rate for Payer: WPS Commercial |
$1,865.08
|
|
|
SMART TOE 19MM 10DEG STOA-19P
|
Facility
|
IP
|
$6,362.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3072479
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,117.38 |
| Max. Negotiated Rate |
$5,853.04 |
| Rate for Payer: Aetna Commercial |
$5,725.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,471.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,371.86
|
| Rate for Payer: Cash Price |
$1,908.60
|
| Rate for Payer: Cigna Commercial |
$5,853.04
|
| Rate for Payer: Health EOS Commercial |
$5,662.18
|
| Rate for Payer: HFN Commercial |
$5,853.04
|
| Rate for Payer: Multiplan Commercial |
$5,089.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,817.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,853.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,117.38
|
| Rate for Payer: Quartz Commercial |
$3,817.20
|
| Rate for Payer: WEA Trust Commercial |
$3,499.10
|
| Rate for Payer: WPS Commercial |
$4,712.33
|
|
|
SMART TOE 19MM 10DEG STOA-19P
|
Facility
|
OP
|
$6,362.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3072479
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,781.36 |
| Max. Negotiated Rate |
$25,448.00 |
| Rate for Payer: Aetna Commercial |
$5,725.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,471.32
|
| Rate for Payer: Aetna Managed Medicare |
$1,781.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,135.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,181.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,053.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,371.86
|
| Rate for Payer: Cash Price |
$1,908.60
|
| Rate for Payer: Cigna Commercial |
$5,853.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,560.18
|
| Rate for Payer: Health EOS Commercial |
$5,662.18
|
| Rate for Payer: HFN Commercial |
$5,853.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,771.50
|
| Rate for Payer: Multiplan Commercial |
$5,089.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,817.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,853.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,117.38
|
| Rate for Payer: Quartz Commercial |
$4,135.30
|
| Rate for Payer: Quartz Medicare Advantage |
$3,817.20
|
| Rate for Payer: The Alliance Commercial |
$25,448.00
|
| Rate for Payer: WEA Trust Commercial |
$3,499.10
|
| Rate for Payer: WPS Commercial |
$4,712.33
|
|
|
SMARTWIRE II XT (VOLCANO) 185cm #6603
|
Facility
|
IP
|
$5,445.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2973656
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,668.05 |
| Max. Negotiated Rate |
$5,009.40 |
| Rate for Payer: Aetna Commercial |
$4,900.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,682.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,885.85
|
| Rate for Payer: Cash Price |
$1,633.50
|
| Rate for Payer: Cigna Commercial |
$5,009.40
|
| Rate for Payer: Health EOS Commercial |
$4,846.05
|
| Rate for Payer: HFN Commercial |
$5,009.40
|
| Rate for Payer: Multiplan Commercial |
$4,356.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,009.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,668.05
|
| Rate for Payer: Quartz Commercial |
$3,267.00
|
| Rate for Payer: WEA Trust Commercial |
$2,994.75
|
| Rate for Payer: WPS Commercial |
$4,033.11
|
|
|
SMARTWIRE II XT (VOLCANO) 185cm #6603
|
Facility
|
OP
|
$5,445.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2973656
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,524.60 |
| Max. Negotiated Rate |
$21,780.00 |
| Rate for Payer: Aetna Commercial |
$4,900.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,682.70
|
| Rate for Payer: Aetna Managed Medicare |
$1,524.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,539.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,722.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,613.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,885.85
|
| Rate for Payer: Cash Price |
$1,633.50
|
| Rate for Payer: Cigna Commercial |
$5,009.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,047.02
|
| Rate for Payer: Health EOS Commercial |
$4,846.05
|
| Rate for Payer: HFN Commercial |
$5,009.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,083.75
|
| Rate for Payer: Multiplan Commercial |
$4,356.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,009.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,668.05
|
| Rate for Payer: Quartz Commercial |
$3,539.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,267.00
|
| Rate for Payer: The Alliance Commercial |
$21,780.00
|
| Rate for Payer: WEA Trust Commercial |
$2,994.75
|
| Rate for Payer: WPS Commercial |
$4,033.11
|
|
|
SMARTWIRE II XT (VOLCANO) 300cm #6613
|
Facility
|
IP
|
$5,035.00
|
|
| Hospital Charge Code |
2973639
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,467.15 |
| Max. Negotiated Rate |
$4,632.20 |
| Rate for Payer: Aetna Commercial |
$4,531.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,330.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,668.55
|
| Rate for Payer: Cash Price |
$1,510.50
|
| Rate for Payer: Cigna Commercial |
$4,632.20
|
| Rate for Payer: Health EOS Commercial |
$4,481.15
|
| Rate for Payer: HFN Commercial |
$4,632.20
|
| Rate for Payer: Multiplan Commercial |
$4,028.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,021.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,632.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,467.15
|
| Rate for Payer: Quartz Commercial |
$3,021.00
|
| Rate for Payer: WEA Trust Commercial |
$2,769.25
|
| Rate for Payer: WPS Commercial |
$3,729.42
|
|
|
SMARTWIRE II XT (VOLCANO) 300cm #6613
|
Facility
|
OP
|
$5,035.00
|
|
| Hospital Charge Code |
2973639
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,409.80 |
| Max. Negotiated Rate |
$20,140.00 |
| Rate for Payer: Aetna Commercial |
$4,531.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,330.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,409.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,272.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,517.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,416.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,668.55
|
| Rate for Payer: Cash Price |
$1,510.50
|
| Rate for Payer: Cigna Commercial |
$4,632.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,817.59
|
| Rate for Payer: Health EOS Commercial |
$4,481.15
|
| Rate for Payer: HFN Commercial |
$4,632.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,776.25
|
| Rate for Payer: Multiplan Commercial |
$4,028.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,021.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,632.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,467.15
|
| Rate for Payer: Quartz Commercial |
$3,272.75
|
| Rate for Payer: Quartz Medicare Advantage |
$3,021.00
|
| Rate for Payer: The Alliance Commercial |
$20,140.00
|
| Rate for Payer: WEA Trust Commercial |
$2,769.25
|
| Rate for Payer: WPS Commercial |
$3,729.42
|
|
|
SMARTWIRE (VOLCANO) J-TIP 185cm 79034
|
Facility
|
OP
|
$6,407.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2973709
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,793.96 |
| Max. Negotiated Rate |
$25,628.00 |
| Rate for Payer: Aetna Commercial |
$5,766.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,510.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,793.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,164.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,203.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,075.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,395.71
|
| Rate for Payer: Cash Price |
$1,922.10
|
| Rate for Payer: Cigna Commercial |
$5,894.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,585.36
|
| Rate for Payer: Health EOS Commercial |
$5,702.23
|
| Rate for Payer: HFN Commercial |
$5,894.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,805.25
|
| Rate for Payer: Multiplan Commercial |
$5,125.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,844.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,894.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,139.43
|
| Rate for Payer: Quartz Commercial |
$4,164.55
|
| Rate for Payer: Quartz Medicare Advantage |
$3,844.20
|
| Rate for Payer: The Alliance Commercial |
$25,628.00
|
| Rate for Payer: WEA Trust Commercial |
$3,523.85
|
| Rate for Payer: WPS Commercial |
$4,745.66
|
|
|
SMARTWIRE (VOLCANO) J-TIP 185cm 79034
|
Facility
|
IP
|
$6,407.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2973709
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,139.43 |
| Max. Negotiated Rate |
$5,894.44 |
| Rate for Payer: Aetna Commercial |
$5,766.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,510.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,395.71
|
| Rate for Payer: Cash Price |
$1,922.10
|
| Rate for Payer: Cigna Commercial |
$5,894.44
|
| Rate for Payer: Health EOS Commercial |
$5,702.23
|
| Rate for Payer: HFN Commercial |
$5,894.44
|
| Rate for Payer: Multiplan Commercial |
$5,125.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,844.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,894.44
|
| Rate for Payer: Quartz Beloit One Network |
$3,139.43
|
| Rate for Payer: Quartz Commercial |
$3,844.20
|
| Rate for Payer: WEA Trust Commercial |
$3,523.85
|
| Rate for Payer: WPS Commercial |
$4,745.66
|
|
|
SMARTWIRE (VOLCANO) J-TIP 300cm #7913J
|
Facility
|
IP
|
$5,445.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2973657
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,668.05 |
| Max. Negotiated Rate |
$5,009.40 |
| Rate for Payer: Aetna Commercial |
$4,900.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,682.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,885.85
|
| Rate for Payer: Cash Price |
$1,633.50
|
| Rate for Payer: Cigna Commercial |
$5,009.40
|
| Rate for Payer: Health EOS Commercial |
$4,846.05
|
| Rate for Payer: HFN Commercial |
$5,009.40
|
| Rate for Payer: Multiplan Commercial |
$4,356.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,009.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,668.05
|
| Rate for Payer: Quartz Commercial |
$3,267.00
|
| Rate for Payer: WEA Trust Commercial |
$2,994.75
|
| Rate for Payer: WPS Commercial |
$4,033.11
|
|
|
SMARTWIRE (VOLCANO) J-TIP 300cm #7913J
|
Facility
|
OP
|
$5,445.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2973657
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,524.60 |
| Max. Negotiated Rate |
$21,780.00 |
| Rate for Payer: Aetna Commercial |
$4,900.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,682.70
|
| Rate for Payer: Aetna Managed Medicare |
$1,524.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,539.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,722.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,613.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,885.85
|
| Rate for Payer: Cash Price |
$1,633.50
|
| Rate for Payer: Cigna Commercial |
$5,009.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,047.02
|
| Rate for Payer: Health EOS Commercial |
$4,846.05
|
| Rate for Payer: HFN Commercial |
$5,009.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,083.75
|
| Rate for Payer: Multiplan Commercial |
$4,356.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,009.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,668.05
|
| Rate for Payer: Quartz Commercial |
$3,539.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,267.00
|
| Rate for Payer: The Alliance Commercial |
$21,780.00
|
| Rate for Payer: WEA Trust Commercial |
$2,994.75
|
| Rate for Payer: WPS Commercial |
$4,033.11
|
|
|
SMIC-101
|
Professional
|
Both
|
$137.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5313490
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.53 |
| Max. Negotiated Rate |
$130.15 |
| Rate for Payer: Aetna Commercial |
$130.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$117.82
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$130.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$68.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.20
|
| Rate for Payer: Health EOS Commercial |
$124.67
|
| Rate for Payer: HFN Commercial |
$130.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.53
|
| Rate for Payer: Multiplan Commercial |
$109.60
|
| Rate for Payer: Preferred Network Access Commercial |
$130.15
|
| Rate for Payer: Quartz Beloit One Network |
$60.28
|
| Rate for Payer: Quartz Commercial |
$78.09
|
| Rate for Payer: The Alliance Commercial |
$68.50
|
| Rate for Payer: WEA Trust Commercial |
$75.35
|
| Rate for Payer: WPS Commercial |
$101.48
|
|
|
SMIC-101
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5313490
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$67.13 |
| Max. Negotiated Rate |
$126.04 |
| Rate for Payer: Aetna Commercial |
$123.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$117.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$72.61
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$126.04
|
| Rate for Payer: Health EOS Commercial |
$121.93
|
| Rate for Payer: HFN Commercial |
$126.04
|
| Rate for Payer: Multiplan Commercial |
$109.60
|
| Rate for Payer: NAPHCARE Commercial |
$82.20
|
| Rate for Payer: Preferred Network Access Commercial |
$126.04
|
| Rate for Payer: Quartz Beloit One Network |
$67.13
|
| Rate for Payer: Quartz Commercial |
$82.20
|
| Rate for Payer: WEA Trust Commercial |
$75.35
|
| Rate for Payer: WPS Commercial |
$101.48
|
|
|
SMIC-101
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5313490
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$126.04 |
| Rate for Payer: Aetna Commercial |
$123.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$117.82
|
| Rate for Payer: Aetna Managed Medicare |
$8.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.36
|
| Rate for Payer: Anthem Medicaid |
$8.94
|
| Rate for Payer: Anthem Medicare Advantage |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$72.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.65
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$126.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$76.67
|
| Rate for Payer: Dean Health Medicaid |
$8.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.65
|
| Rate for Payer: Health EOS Commercial |
$121.93
|
| Rate for Payer: HFN Commercial |
$126.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.65
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.65
|
| Rate for Payer: Managed Health Services Medicaid |
$9.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.65
|
| Rate for Payer: Multiplan Commercial |
$109.60
|
| Rate for Payer: NAPHCARE Commercial |
$12.98
|
| Rate for Payer: Preferred Network Access Commercial |
$126.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.94
|
| Rate for Payer: Quartz Beloit One Network |
$67.13
|
| Rate for Payer: Quartz Commercial |
$89.05
|
| Rate for Payer: Quartz Medicare Advantage |
$8.65
|
| Rate for Payer: The Alliance Commercial |
$34.60
|
| Rate for Payer: United Healthcare Medicaid |
$8.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.65
|
| Rate for Payer: United Healthcare PPO |
$102.75
|
| Rate for Payer: WEA Trust Commercial |
$75.35
|
| Rate for Payer: Wellcare Medicare |
$8.65
|
| Rate for Payer: WMAP Medicaid |
$8.94
|
| Rate for Payer: WPS Commercial |
$101.48
|
|
|
SMOKE EVAC SLEEVE 125MM FOR 4 IN ELECTRODE 0703-005-125
|
Facility
|
IP
|
$158.00
|
|
| Hospital Charge Code |
4520035
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$77.42 |
| Max. Negotiated Rate |
$145.36 |
| Rate for Payer: Aetna Commercial |
$142.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.74
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$145.36
|
| Rate for Payer: Health EOS Commercial |
$140.62
|
| Rate for Payer: HFN Commercial |
$145.36
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: NAPHCARE Commercial |
$94.80
|
| Rate for Payer: Preferred Network Access Commercial |
$145.36
|
| Rate for Payer: Quartz Beloit One Network |
$77.42
|
| Rate for Payer: Quartz Commercial |
$94.80
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
