|
Small white foam
|
Facility
|
OP
|
$191.00
|
|
| Hospital Charge Code |
3006896
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$55.62 |
| Max. Negotiated Rate |
$182.75 |
| Rate for Payer: Aetna Commercial |
$178.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$170.83
|
| Rate for Payer: Aetna Managed Medicare |
$55.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$129.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$95.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.28
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$182.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.16
|
| Rate for Payer: Health EOS Commercial |
$176.79
|
| Rate for Payer: HFN Commercial |
$182.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$148.98
|
| Rate for Payer: Multiplan Commercial |
$158.91
|
| Rate for Payer: NAPHCARE Commercial |
$119.18
|
| Rate for Payer: Preferred Network Access Commercial |
$182.75
|
| Rate for Payer: Quartz Beloit One Network |
$97.33
|
| Rate for Payer: Quartz Commercial |
$129.12
|
| Rate for Payer: Quartz Medicare Advantage |
$119.18
|
| Rate for Payer: The Alliance Commercial |
$99.32
|
| Rate for Payer: WEA Trust Commercial |
$109.25
|
| Rate for Payer: WPS Commercial |
$147.13
|
|
|
SM Antibody
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942855
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$124.34 |
| Max. Negotiated Rate |
$233.46 |
| Rate for Payer: Aetna Commercial |
$228.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.49
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$233.46
|
| Rate for Payer: Health EOS Commercial |
$225.85
|
| Rate for Payer: HFN Commercial |
$233.46
|
| Rate for Payer: Multiplan Commercial |
$203.01
|
| Rate for Payer: Preferred Network Access Commercial |
$233.46
|
| Rate for Payer: Quartz Beloit One Network |
$124.34
|
| Rate for Payer: Quartz Commercial |
$152.26
|
| Rate for Payer: WEA Trust Commercial |
$139.57
|
| Rate for Payer: WPS Commercial |
$187.95
|
|
|
SM Antibody
|
Professional
|
Both
|
$244.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942855
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.65 |
| Max. Negotiated Rate |
$241.07 |
| Rate for Payer: Aetna Commercial |
$241.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.23
|
| 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 |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$241.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$126.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.65
|
| Rate for Payer: Health EOS Commercial |
$230.92
|
| Rate for Payer: HFN Commercial |
$241.07
|
| 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 |
$203.01
|
| Rate for Payer: NAPHCARE Commercial |
$27.97
|
| Rate for Payer: Preferred Network Access Commercial |
$241.07
|
| Rate for Payer: Quartz Beloit One Network |
$111.65
|
| Rate for Payer: Quartz Commercial |
$144.64
|
| 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 |
$139.57
|
| Rate for Payer: WPS Commercial |
$82.05
|
|
|
SM Antibody
|
Facility
|
OP
|
$244.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
2942855
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.65 |
| Max. Negotiated Rate |
$233.46 |
| Rate for Payer: Aetna Commercial |
$228.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.23
|
| 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 |
$134.49
|
| 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 |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$233.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.65
|
| Rate for Payer: Health EOS Commercial |
$225.85
|
| Rate for Payer: HFN Commercial |
$233.46
|
| 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 |
$203.01
|
| Rate for Payer: NAPHCARE Commercial |
$27.97
|
| Rate for Payer: Preferred Network Access Commercial |
$233.46
|
| Rate for Payer: Quartz Beloit One Network |
$124.34
|
| Rate for Payer: Quartz Commercial |
$164.94
|
| 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 |
$190.32
|
| Rate for Payer: WEA Trust Commercial |
$139.57
|
| Rate for Payer: Wellcare Medicare |
$18.65
|
| Rate for Payer: WPS Commercial |
$187.95
|
|
|
SMART NAIL 1.5x16MM
|
Facility
|
OP
|
$2,518.00
|
|
| Hospital Charge Code |
2964954
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$733.24 |
| Max. Negotiated Rate |
$2,409.22 |
| Rate for Payer: Aetna Commercial |
$2,356.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,252.10
|
| Rate for Payer: Aetna Managed Medicare |
$733.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,702.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,309.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,256.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,387.92
|
| Rate for Payer: Cash Price |
$755.40
|
| Rate for Payer: Cigna Commercial |
$2,409.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,465.48
|
| Rate for Payer: Health EOS Commercial |
$2,330.66
|
| Rate for Payer: HFN Commercial |
$2,409.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,964.04
|
| Rate for Payer: Multiplan Commercial |
$2,094.98
|
| Rate for Payer: NAPHCARE Commercial |
$1,571.23
|
| Rate for Payer: Preferred Network Access Commercial |
$2,409.22
|
| Rate for Payer: Quartz Beloit One Network |
$1,283.17
|
| Rate for Payer: Quartz Commercial |
$1,702.17
|
| Rate for Payer: Quartz Medicare Advantage |
$1,571.23
|
| Rate for Payer: The Alliance Commercial |
$1,309.36
|
| Rate for Payer: WEA Trust Commercial |
$1,440.30
|
| Rate for Payer: WPS Commercial |
$1,939.62
|
|
|
SMART NAIL 1.5x16MM
|
Facility
|
IP
|
$2,518.00
|
|
| Hospital Charge Code |
2964954
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,283.17 |
| Max. Negotiated Rate |
$2,409.22 |
| Rate for Payer: Aetna Commercial |
$2,356.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,252.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,387.92
|
| Rate for Payer: Cash Price |
$755.40
|
| Rate for Payer: Cigna Commercial |
$2,409.22
|
| Rate for Payer: Health EOS Commercial |
$2,330.66
|
| Rate for Payer: HFN Commercial |
$2,409.22
|
| Rate for Payer: Multiplan Commercial |
$2,094.98
|
| Rate for Payer: Preferred Network Access Commercial |
$2,409.22
|
| Rate for Payer: Quartz Beloit One Network |
$1,283.17
|
| Rate for Payer: Quartz Commercial |
$1,571.23
|
| Rate for Payer: WEA Trust Commercial |
$1,440.30
|
| Rate for Payer: WPS Commercial |
$1,939.62
|
|
|
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 |
$3,242.08 |
| Max. Negotiated Rate |
$6,087.16 |
| Rate for Payer: Aetna Commercial |
$5,954.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,690.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,506.73
|
| Rate for Payer: Cash Price |
$1,908.60
|
| Rate for Payer: Cigna Commercial |
$6,087.16
|
| Rate for Payer: Health EOS Commercial |
$5,888.67
|
| Rate for Payer: HFN Commercial |
$6,087.16
|
| Rate for Payer: Multiplan Commercial |
$5,293.18
|
| Rate for Payer: Preferred Network Access Commercial |
$6,087.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,242.08
|
| Rate for Payer: Quartz Commercial |
$3,969.89
|
| Rate for Payer: WEA Trust Commercial |
$3,639.06
|
| Rate for Payer: WPS Commercial |
$4,900.65
|
|
|
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 |
$1,852.61 |
| Max. Negotiated Rate |
$6,087.16 |
| Rate for Payer: Aetna Commercial |
$5,954.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,690.17
|
| Rate for Payer: Aetna Managed Medicare |
$1,852.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,300.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,308.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,175.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,506.73
|
| Rate for Payer: Cash Price |
$1,908.60
|
| Rate for Payer: Cigna Commercial |
$6,087.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,702.68
|
| Rate for Payer: Health EOS Commercial |
$5,888.67
|
| Rate for Payer: HFN Commercial |
$6,087.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,962.36
|
| Rate for Payer: Multiplan Commercial |
$5,293.18
|
| Rate for Payer: NAPHCARE Commercial |
$3,969.89
|
| Rate for Payer: Preferred Network Access Commercial |
$6,087.16
|
| Rate for Payer: Quartz Beloit One Network |
$3,242.08
|
| Rate for Payer: Quartz Commercial |
$4,300.71
|
| Rate for Payer: Quartz Medicare Advantage |
$3,969.89
|
| Rate for Payer: The Alliance Commercial |
$3,308.24
|
| Rate for Payer: WEA Trust Commercial |
$3,639.06
|
| Rate for Payer: WPS Commercial |
$4,900.65
|
|
|
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 |
$2,774.77 |
| Max. Negotiated Rate |
$5,209.78 |
| Rate for Payer: Aetna Commercial |
$5,096.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,870.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,001.28
|
| Rate for Payer: Cash Price |
$1,633.50
|
| Rate for Payer: Cigna Commercial |
$5,209.78
|
| Rate for Payer: Health EOS Commercial |
$5,039.89
|
| Rate for Payer: HFN Commercial |
$5,209.78
|
| Rate for Payer: Multiplan Commercial |
$4,530.24
|
| Rate for Payer: Preferred Network Access Commercial |
$5,209.78
|
| Rate for Payer: Quartz Beloit One Network |
$2,774.77
|
| Rate for Payer: Quartz Commercial |
$3,397.68
|
| Rate for Payer: WEA Trust Commercial |
$3,114.54
|
| Rate for Payer: WPS Commercial |
$4,194.28
|
|
|
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 |
$1,585.58 |
| Max. Negotiated Rate |
$5,209.78 |
| Rate for Payer: Aetna Commercial |
$5,096.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,870.01
|
| Rate for Payer: Aetna Managed Medicare |
$1,585.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,680.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,831.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,718.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,001.28
|
| Rate for Payer: Cash Price |
$1,633.50
|
| Rate for Payer: Cigna Commercial |
$5,209.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,168.99
|
| Rate for Payer: Health EOS Commercial |
$5,039.89
|
| Rate for Payer: HFN Commercial |
$5,209.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,247.10
|
| Rate for Payer: Multiplan Commercial |
$4,530.24
|
| Rate for Payer: NAPHCARE Commercial |
$3,397.68
|
| Rate for Payer: Preferred Network Access Commercial |
$5,209.78
|
| Rate for Payer: Quartz Beloit One Network |
$2,774.77
|
| Rate for Payer: Quartz Commercial |
$3,680.82
|
| Rate for Payer: Quartz Medicare Advantage |
$3,397.68
|
| Rate for Payer: The Alliance Commercial |
$2,831.40
|
| Rate for Payer: WEA Trust Commercial |
$3,114.54
|
| Rate for Payer: WPS Commercial |
$4,194.28
|
|
|
SMARTWIRE II XT (VOLCANO) 300cm #6613
|
Facility
|
IP
|
$5,035.00
|
|
| Hospital Charge Code |
2973639
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,565.84 |
| Max. Negotiated Rate |
$4,817.49 |
| Rate for Payer: Aetna Commercial |
$4,712.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,503.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,775.29
|
| Rate for Payer: Cash Price |
$1,510.50
|
| Rate for Payer: Cigna Commercial |
$4,817.49
|
| Rate for Payer: Health EOS Commercial |
$4,660.40
|
| Rate for Payer: HFN Commercial |
$4,817.49
|
| Rate for Payer: Multiplan Commercial |
$4,189.12
|
| Rate for Payer: Preferred Network Access Commercial |
$4,817.49
|
| Rate for Payer: Quartz Beloit One Network |
$2,565.84
|
| Rate for Payer: Quartz Commercial |
$3,141.84
|
| Rate for Payer: WEA Trust Commercial |
$2,880.02
|
| Rate for Payer: WPS Commercial |
$3,878.46
|
|
|
SMARTWIRE II XT (VOLCANO) 300cm #6613
|
Facility
|
OP
|
$5,035.00
|
|
| Hospital Charge Code |
2973639
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,466.19 |
| Max. Negotiated Rate |
$4,817.49 |
| Rate for Payer: Aetna Commercial |
$4,712.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,503.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,466.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,403.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,618.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,513.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,775.29
|
| Rate for Payer: Cash Price |
$1,510.50
|
| Rate for Payer: Cigna Commercial |
$4,817.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,930.37
|
| Rate for Payer: Health EOS Commercial |
$4,660.40
|
| Rate for Payer: HFN Commercial |
$4,817.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,927.30
|
| Rate for Payer: Multiplan Commercial |
$4,189.12
|
| Rate for Payer: NAPHCARE Commercial |
$3,141.84
|
| Rate for Payer: Preferred Network Access Commercial |
$4,817.49
|
| Rate for Payer: Quartz Beloit One Network |
$2,565.84
|
| Rate for Payer: Quartz Commercial |
$3,403.66
|
| Rate for Payer: Quartz Medicare Advantage |
$3,141.84
|
| Rate for Payer: The Alliance Commercial |
$2,618.20
|
| Rate for Payer: WEA Trust Commercial |
$2,880.02
|
| Rate for Payer: WPS Commercial |
$3,878.46
|
|
|
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 |
$3,265.01 |
| Max. Negotiated Rate |
$6,130.22 |
| Rate for Payer: Aetna Commercial |
$5,996.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,730.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,531.54
|
| Rate for Payer: Cash Price |
$1,922.10
|
| Rate for Payer: Cigna Commercial |
$6,130.22
|
| Rate for Payer: Health EOS Commercial |
$5,930.32
|
| Rate for Payer: HFN Commercial |
$6,130.22
|
| Rate for Payer: Multiplan Commercial |
$5,330.62
|
| Rate for Payer: Preferred Network Access Commercial |
$6,130.22
|
| Rate for Payer: Quartz Beloit One Network |
$3,265.01
|
| Rate for Payer: Quartz Commercial |
$3,997.97
|
| Rate for Payer: WEA Trust Commercial |
$3,664.80
|
| Rate for Payer: WPS Commercial |
$4,935.31
|
|
|
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 |
$1,865.72 |
| Max. Negotiated Rate |
$6,130.22 |
| Rate for Payer: Aetna Commercial |
$5,996.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,730.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,865.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,331.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,331.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,198.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,531.54
|
| Rate for Payer: Cash Price |
$1,922.10
|
| Rate for Payer: Cigna Commercial |
$6,130.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,728.87
|
| Rate for Payer: Health EOS Commercial |
$5,930.32
|
| Rate for Payer: HFN Commercial |
$6,130.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,997.46
|
| Rate for Payer: Multiplan Commercial |
$5,330.62
|
| Rate for Payer: NAPHCARE Commercial |
$3,997.97
|
| Rate for Payer: Preferred Network Access Commercial |
$6,130.22
|
| Rate for Payer: Quartz Beloit One Network |
$3,265.01
|
| Rate for Payer: Quartz Commercial |
$4,331.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,997.97
|
| Rate for Payer: The Alliance Commercial |
$3,331.64
|
| Rate for Payer: WEA Trust Commercial |
$3,664.80
|
| Rate for Payer: WPS Commercial |
$4,935.31
|
|
|
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 |
$2,774.77 |
| Max. Negotiated Rate |
$5,209.78 |
| Rate for Payer: Aetna Commercial |
$5,096.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,870.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,001.28
|
| Rate for Payer: Cash Price |
$1,633.50
|
| Rate for Payer: Cigna Commercial |
$5,209.78
|
| Rate for Payer: Health EOS Commercial |
$5,039.89
|
| Rate for Payer: HFN Commercial |
$5,209.78
|
| Rate for Payer: Multiplan Commercial |
$4,530.24
|
| Rate for Payer: Preferred Network Access Commercial |
$5,209.78
|
| Rate for Payer: Quartz Beloit One Network |
$2,774.77
|
| Rate for Payer: Quartz Commercial |
$3,397.68
|
| Rate for Payer: WEA Trust Commercial |
$3,114.54
|
| Rate for Payer: WPS Commercial |
$4,194.28
|
|
|
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 |
$1,585.58 |
| Max. Negotiated Rate |
$5,209.78 |
| Rate for Payer: Aetna Commercial |
$5,096.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,870.01
|
| Rate for Payer: Aetna Managed Medicare |
$1,585.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,680.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,831.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,718.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,001.28
|
| Rate for Payer: Cash Price |
$1,633.50
|
| Rate for Payer: Cigna Commercial |
$5,209.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,168.99
|
| Rate for Payer: Health EOS Commercial |
$5,039.89
|
| Rate for Payer: HFN Commercial |
$5,209.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,247.10
|
| Rate for Payer: Multiplan Commercial |
$4,530.24
|
| Rate for Payer: NAPHCARE Commercial |
$3,397.68
|
| Rate for Payer: Preferred Network Access Commercial |
$5,209.78
|
| Rate for Payer: Quartz Beloit One Network |
$2,774.77
|
| Rate for Payer: Quartz Commercial |
$3,680.82
|
| Rate for Payer: Quartz Medicare Advantage |
$3,397.68
|
| Rate for Payer: The Alliance Commercial |
$2,831.40
|
| Rate for Payer: WEA Trust Commercial |
$3,114.54
|
| Rate for Payer: WPS Commercial |
$4,194.28
|
|
|
Smear, primary source with interpretation; fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types
|
Facility
|
OP
|
$22.42
|
|
|
Service Code
|
CPT 87206
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$22.42 |
| Rate for Payer: Aetna Managed Medicare |
$5.61
|
| Rate for Payer: Anthem Medicare Advantage |
$5.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.61
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.61
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.61
|
| Rate for Payer: NAPHCARE Commercial |
$8.41
|
| Rate for Payer: Quartz Medicare Advantage |
$5.61
|
| Rate for Payer: The Alliance Commercial |
$22.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.61
|
| Rate for Payer: Wellcare Medicare |
$5.61
|
|
|
Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types
|
Facility
|
OP
|
$17.76
|
|
|
Service Code
|
CPT 87205
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$17.76 |
| Rate for Payer: Aetna Managed Medicare |
$4.44
|
| Rate for Payer: Anthem Medicare Advantage |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.44
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.44
|
| Rate for Payer: NAPHCARE Commercial |
$6.66
|
| Rate for Payer: Quartz Medicare Advantage |
$4.44
|
| Rate for Payer: The Alliance Commercial |
$17.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.44
|
| Rate for Payer: Wellcare Medicare |
$4.44
|
|
|
SMIC-101
|
Professional
|
Both
|
$137.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5313490
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$135.36 |
| Rate for Payer: Aetna Commercial |
$135.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$122.53
|
| Rate for Payer: Aetna Managed Medicare |
$9.00
|
| Rate for Payer: Anthem Medicare Advantage |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.00
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$135.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$71.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.00
|
| Rate for Payer: Health EOS Commercial |
$129.66
|
| Rate for Payer: HFN Commercial |
$135.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$113.98
|
| Rate for Payer: NAPHCARE Commercial |
$13.49
|
| Rate for Payer: Preferred Network Access Commercial |
$135.36
|
| Rate for Payer: Quartz Beloit One Network |
$62.69
|
| Rate for Payer: Quartz Commercial |
$81.21
|
| Rate for Payer: Quartz Medicare Advantage |
$9.00
|
| Rate for Payer: The Alliance Commercial |
$35.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.00
|
| Rate for Payer: WEA Trust Commercial |
$78.36
|
| Rate for Payer: WPS Commercial |
$39.58
|
|
|
SMIC-101
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5313490
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$69.82 |
| Max. Negotiated Rate |
$131.08 |
| Rate for Payer: Aetna Commercial |
$128.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$122.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$75.51
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$131.08
|
| Rate for Payer: Health EOS Commercial |
$126.81
|
| Rate for Payer: HFN Commercial |
$131.08
|
| Rate for Payer: Multiplan Commercial |
$113.98
|
| Rate for Payer: Preferred Network Access Commercial |
$131.08
|
| Rate for Payer: Quartz Beloit One Network |
$69.82
|
| Rate for Payer: Quartz Commercial |
$85.49
|
| Rate for Payer: WEA Trust Commercial |
$78.36
|
| Rate for Payer: WPS Commercial |
$105.53
|
|
|
SMIC-101
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5313490
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$131.08 |
| Rate for Payer: Aetna Commercial |
$128.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$122.53
|
| Rate for Payer: Aetna Managed Medicare |
$9.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.93
|
| Rate for Payer: Anthem Medicare Advantage |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$75.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.00
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$131.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$79.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9.00
|
| Rate for Payer: Health EOS Commercial |
$126.81
|
| Rate for Payer: HFN Commercial |
$131.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.00
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$113.98
|
| Rate for Payer: NAPHCARE Commercial |
$13.49
|
| Rate for Payer: Preferred Network Access Commercial |
$131.08
|
| Rate for Payer: Quartz Beloit One Network |
$69.82
|
| Rate for Payer: Quartz Commercial |
$92.61
|
| Rate for Payer: Quartz Medicare Advantage |
$9.00
|
| Rate for Payer: The Alliance Commercial |
$35.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.00
|
| Rate for Payer: United Healthcare PPO |
$106.86
|
| Rate for Payer: WEA Trust Commercial |
$78.36
|
| Rate for Payer: Wellcare Medicare |
$9.00
|
| Rate for Payer: WPS Commercial |
$105.53
|
|
|
SMOKE EVAC SLEEVE 125MM FOR 4 IN ELECTRODE 0703-005-125
|
Facility
|
OP
|
$158.00
|
|
| Hospital Charge Code |
4520035
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.01 |
| Max. Negotiated Rate |
$151.17 |
| Rate for Payer: Aetna Commercial |
$147.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.32
|
| Rate for Payer: Aetna Managed Medicare |
$46.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$106.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$82.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$78.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.09
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$151.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.96
|
| Rate for Payer: Health EOS Commercial |
$146.24
|
| Rate for Payer: HFN Commercial |
$151.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.24
|
| Rate for Payer: Multiplan Commercial |
$131.46
|
| Rate for Payer: NAPHCARE Commercial |
$98.59
|
| Rate for Payer: Preferred Network Access Commercial |
$151.17
|
| Rate for Payer: Quartz Beloit One Network |
$80.52
|
| Rate for Payer: Quartz Commercial |
$106.81
|
| Rate for Payer: Quartz Medicare Advantage |
$98.59
|
| Rate for Payer: The Alliance Commercial |
$82.16
|
| Rate for Payer: WEA Trust Commercial |
$90.38
|
| Rate for Payer: WPS Commercial |
$121.71
|
|
|
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 |
$80.52 |
| Max. Negotiated Rate |
$151.17 |
| Rate for Payer: Aetna Commercial |
$147.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.09
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$151.17
|
| Rate for Payer: Health EOS Commercial |
$146.24
|
| Rate for Payer: HFN Commercial |
$151.17
|
| Rate for Payer: Multiplan Commercial |
$131.46
|
| Rate for Payer: Preferred Network Access Commercial |
$151.17
|
| Rate for Payer: Quartz Beloit One Network |
$80.52
|
| Rate for Payer: Quartz Commercial |
$98.59
|
| Rate for Payer: WEA Trust Commercial |
$90.38
|
| Rate for Payer: WPS Commercial |
$121.71
|
|
|
SMOKE EVAC SLEEVE 165MM FOR 6 IN ELECTRODE 0703-005-165
|
Facility
|
OP
|
$106.00
|
|
| Hospital Charge Code |
5685687
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.87 |
| Max. Negotiated Rate |
$101.42 |
| Rate for Payer: Aetna Commercial |
$99.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.81
|
| Rate for Payer: Aetna Managed Medicare |
$30.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$55.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.43
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$101.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.69
|
| Rate for Payer: Health EOS Commercial |
$98.11
|
| Rate for Payer: HFN Commercial |
$101.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.68
|
| Rate for Payer: Multiplan Commercial |
$88.19
|
| Rate for Payer: NAPHCARE Commercial |
$66.14
|
| Rate for Payer: Preferred Network Access Commercial |
$101.42
|
| Rate for Payer: Quartz Beloit One Network |
$54.02
|
| Rate for Payer: Quartz Commercial |
$71.66
|
| Rate for Payer: Quartz Medicare Advantage |
$66.14
|
| Rate for Payer: The Alliance Commercial |
$55.12
|
| Rate for Payer: WEA Trust Commercial |
$60.63
|
| Rate for Payer: WPS Commercial |
$81.65
|
|
|
SMOKE EVAC SLEEVE 165MM FOR 6 IN ELECTRODE 0703-005-165
|
Facility
|
IP
|
$106.00
|
|
| Hospital Charge Code |
5685687
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.02 |
| Max. Negotiated Rate |
$101.42 |
| Rate for Payer: Aetna Commercial |
$99.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.43
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$101.42
|
| Rate for Payer: Health EOS Commercial |
$98.11
|
| Rate for Payer: HFN Commercial |
$101.42
|
| Rate for Payer: Multiplan Commercial |
$88.19
|
| Rate for Payer: Preferred Network Access Commercial |
$101.42
|
| Rate for Payer: Quartz Beloit One Network |
$54.02
|
| Rate for Payer: Quartz Commercial |
$66.14
|
| Rate for Payer: WEA Trust Commercial |
$60.63
|
| Rate for Payer: WPS Commercial |
$81.65
|
|
