|
S. pneumoniae Antigen
|
Professional
|
Both
|
$88.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
5096643
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$86.94 |
| Rate for Payer: Aetna Commercial |
$86.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$78.71
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$86.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$83.28
|
| Rate for Payer: HFN Commercial |
$86.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$73.22
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$86.94
|
| Rate for Payer: Quartz Beloit One Network |
$40.27
|
| Rate for Payer: Quartz Commercial |
$52.17
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$47.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$50.34
|
| Rate for Payer: WPS Commercial |
$52.81
|
|
|
S. pneumoniae Antigen
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
5096643
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$84.20 |
| Rate for Payer: Aetna Commercial |
$82.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$78.71
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.92
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$84.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$81.45
|
| Rate for Payer: HFN Commercial |
$84.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$73.22
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$84.20
|
| Rate for Payer: Quartz Beloit One Network |
$44.84
|
| Rate for Payer: Quartz Commercial |
$59.49
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$48.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: United Healthcare PPO |
$68.64
|
| Rate for Payer: WEA Trust Commercial |
$50.34
|
| Rate for Payer: Wellcare Medicare |
$12.00
|
| Rate for Payer: WPS Commercial |
$67.79
|
|
|
S. pneumoniae Antigen
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
5096643
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$44.84 |
| Max. Negotiated Rate |
$84.20 |
| Rate for Payer: Aetna Commercial |
$82.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$78.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.51
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$84.20
|
| Rate for Payer: Health EOS Commercial |
$81.45
|
| Rate for Payer: HFN Commercial |
$84.20
|
| Rate for Payer: Multiplan Commercial |
$73.22
|
| Rate for Payer: Preferred Network Access Commercial |
$84.20
|
| Rate for Payer: Quartz Beloit One Network |
$44.84
|
| Rate for Payer: Quartz Commercial |
$54.91
|
| Rate for Payer: WEA Trust Commercial |
$50.34
|
| Rate for Payer: WPS Commercial |
$67.79
|
|
|
S Pneumoniae Antigen
|
Facility
|
IP
|
$254.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
983400
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$129.44 |
| Max. Negotiated Rate |
$243.03 |
| Rate for Payer: Aetna Commercial |
$237.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.00
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$243.03
|
| Rate for Payer: Health EOS Commercial |
$235.10
|
| Rate for Payer: HFN Commercial |
$243.03
|
| Rate for Payer: Multiplan Commercial |
$211.33
|
| Rate for Payer: Preferred Network Access Commercial |
$243.03
|
| Rate for Payer: Quartz Beloit One Network |
$129.44
|
| Rate for Payer: Quartz Commercial |
$158.50
|
| Rate for Payer: WEA Trust Commercial |
$145.29
|
| Rate for Payer: WPS Commercial |
$195.66
|
|
|
S Pneumoniae Antigen
|
Professional
|
Both
|
$254.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
983400
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$250.95 |
| Rate for Payer: Aetna Commercial |
$250.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.18
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$250.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$132.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$240.39
|
| Rate for Payer: HFN Commercial |
$250.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$211.33
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$250.95
|
| Rate for Payer: Quartz Beloit One Network |
$116.23
|
| Rate for Payer: Quartz Commercial |
$150.57
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$47.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$145.29
|
| Rate for Payer: WPS Commercial |
$52.81
|
|
|
S Pneumoniae Antigen
|
Facility
|
OP
|
$254.00
|
|
|
Service Code
|
CPT 86403
|
| Hospital Charge Code |
983400
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$243.03 |
| Rate for Payer: Aetna Commercial |
$237.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.18
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.92
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$243.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$147.83
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$235.10
|
| Rate for Payer: HFN Commercial |
$243.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$211.33
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$243.03
|
| Rate for Payer: Quartz Beloit One Network |
$129.44
|
| Rate for Payer: Quartz Commercial |
$171.70
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$48.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: United Healthcare PPO |
$198.12
|
| Rate for Payer: WEA Trust Commercial |
$145.29
|
| Rate for Payer: Wellcare Medicare |
$12.00
|
| Rate for Payer: WPS Commercial |
$195.66
|
|
|
SPONGE 18 X 18 LAP MDS231318LF
|
Facility
|
OP
|
$87.00
|
|
| Hospital Charge Code |
2963614
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.33 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Aetna Managed Medicare |
$25.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.63
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.86
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: NAPHCARE Commercial |
$54.29
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$58.81
|
| Rate for Payer: Quartz Medicare Advantage |
$54.29
|
| Rate for Payer: The Alliance Commercial |
$45.24
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
SPONGE 18 X 18 LAP MDS231318LF
|
Facility
|
IP
|
$87.00
|
|
| Hospital Charge Code |
2963614
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$54.29
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
SPONGE EYE SPEAR 1 1/4 7301
|
Facility
|
IP
|
$1,838.00
|
|
| Hospital Charge Code |
2969029
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$936.64 |
| Max. Negotiated Rate |
$1,758.60 |
| Rate for Payer: Aetna Commercial |
$1,720.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,643.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,013.11
|
| Rate for Payer: Cash Price |
$551.40
|
| Rate for Payer: Cigna Commercial |
$1,758.60
|
| Rate for Payer: Health EOS Commercial |
$1,701.25
|
| Rate for Payer: HFN Commercial |
$1,758.60
|
| Rate for Payer: Multiplan Commercial |
$1,529.22
|
| Rate for Payer: Preferred Network Access Commercial |
$1,758.60
|
| Rate for Payer: Quartz Beloit One Network |
$936.64
|
| Rate for Payer: Quartz Commercial |
$1,146.91
|
| Rate for Payer: WEA Trust Commercial |
$1,051.34
|
| Rate for Payer: WPS Commercial |
$1,415.81
|
|
|
SPONGE EYE SPEAR 1 1/4 7301
|
Facility
|
OP
|
$1,838.00
|
|
| Hospital Charge Code |
2969029
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$535.23 |
| Max. Negotiated Rate |
$1,758.60 |
| Rate for Payer: Aetna Commercial |
$1,720.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,643.91
|
| Rate for Payer: Aetna Managed Medicare |
$535.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,242.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$955.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$917.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,013.11
|
| Rate for Payer: Cash Price |
$551.40
|
| Rate for Payer: Cigna Commercial |
$1,758.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,069.72
|
| Rate for Payer: Health EOS Commercial |
$1,701.25
|
| Rate for Payer: HFN Commercial |
$1,758.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,433.64
|
| Rate for Payer: Multiplan Commercial |
$1,529.22
|
| Rate for Payer: NAPHCARE Commercial |
$1,146.91
|
| Rate for Payer: Preferred Network Access Commercial |
$1,758.60
|
| Rate for Payer: Quartz Beloit One Network |
$936.64
|
| Rate for Payer: Quartz Commercial |
$1,242.49
|
| Rate for Payer: Quartz Medicare Advantage |
$1,146.91
|
| Rate for Payer: The Alliance Commercial |
$955.76
|
| Rate for Payer: WEA Trust Commercial |
$1,051.34
|
| Rate for Payer: WPS Commercial |
$1,415.81
|
|
|
SPONGE GAUZE BULK NON-STRL 4x4
|
Facility
|
OP
|
$181.00
|
|
| Hospital Charge Code |
2963400
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$52.71 |
| Max. Negotiated Rate |
$173.18 |
| Rate for Payer: Aetna Commercial |
$169.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$161.89
|
| Rate for Payer: Aetna Managed Medicare |
$52.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$122.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$94.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$90.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.77
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cigna Commercial |
$173.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$105.34
|
| Rate for Payer: Health EOS Commercial |
$167.53
|
| Rate for Payer: HFN Commercial |
$173.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$141.18
|
| Rate for Payer: Multiplan Commercial |
$150.59
|
| Rate for Payer: NAPHCARE Commercial |
$112.94
|
| Rate for Payer: Preferred Network Access Commercial |
$173.18
|
| Rate for Payer: Quartz Beloit One Network |
$92.24
|
| Rate for Payer: Quartz Commercial |
$122.36
|
| Rate for Payer: Quartz Medicare Advantage |
$112.94
|
| Rate for Payer: The Alliance Commercial |
$94.12
|
| Rate for Payer: WEA Trust Commercial |
$103.53
|
| Rate for Payer: WPS Commercial |
$139.42
|
|
|
SPONGE GAUZE BULK NON-STRL 4x4
|
Facility
|
IP
|
$181.00
|
|
| Hospital Charge Code |
2963400
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$92.24 |
| Max. Negotiated Rate |
$173.18 |
| Rate for Payer: Aetna Commercial |
$169.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$161.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.77
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cigna Commercial |
$173.18
|
| Rate for Payer: Health EOS Commercial |
$167.53
|
| Rate for Payer: HFN Commercial |
$173.18
|
| Rate for Payer: Multiplan Commercial |
$150.59
|
| Rate for Payer: Preferred Network Access Commercial |
$173.18
|
| Rate for Payer: Quartz Beloit One Network |
$92.24
|
| Rate for Payer: Quartz Commercial |
$112.94
|
| Rate for Payer: WEA Trust Commercial |
$103.53
|
| Rate for Payer: WPS Commercial |
$139.42
|
|
|
SPONGE LAP 4x18 407
|
Facility
|
OP
|
$30.00
|
|
| Hospital Charge Code |
2963536
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna Commercial |
$28.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Aetna Managed Medicare |
$8.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.54
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$28.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.46
|
| Rate for Payer: Health EOS Commercial |
$27.77
|
| Rate for Payer: HFN Commercial |
$28.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.40
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$28.70
|
| Rate for Payer: Quartz Beloit One Network |
$15.29
|
| Rate for Payer: Quartz Commercial |
$20.28
|
| Rate for Payer: Quartz Medicare Advantage |
$18.72
|
| Rate for Payer: The Alliance Commercial |
$15.60
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: WPS Commercial |
$23.11
|
|
|
SPONGE LAP 4x18 407
|
Facility
|
IP
|
$30.00
|
|
| Hospital Charge Code |
2963536
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna Commercial |
$28.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.54
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$28.70
|
| Rate for Payer: Health EOS Commercial |
$27.77
|
| Rate for Payer: HFN Commercial |
$28.70
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: Preferred Network Access Commercial |
$28.70
|
| Rate for Payer: Quartz Beloit One Network |
$15.29
|
| Rate for Payer: Quartz Commercial |
$18.72
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: WPS Commercial |
$23.11
|
|
|
SPONGE NEURO 1/2x 1-1/2 200103"
|
Facility
|
IP
|
$105.00
|
|
| Hospital Charge Code |
2963455
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.51 |
| Max. Negotiated Rate |
$100.46 |
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.88
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$100.46
|
| Rate for Payer: Health EOS Commercial |
$97.19
|
| Rate for Payer: HFN Commercial |
$100.46
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: Preferred Network Access Commercial |
$100.46
|
| Rate for Payer: Quartz Beloit One Network |
$53.51
|
| Rate for Payer: Quartz Commercial |
$65.52
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$80.88
|
|
|
SPONGE NEURO 1/2x 1-1/2 200103"
|
Facility
|
OP
|
$105.00
|
|
| Hospital Charge Code |
2963455
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.58 |
| Max. Negotiated Rate |
$100.46 |
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Aetna Managed Medicare |
$30.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.88
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$100.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.11
|
| Rate for Payer: Health EOS Commercial |
$97.19
|
| Rate for Payer: HFN Commercial |
$100.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.90
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: NAPHCARE Commercial |
$65.52
|
| Rate for Payer: Preferred Network Access Commercial |
$100.46
|
| Rate for Payer: Quartz Beloit One Network |
$53.51
|
| Rate for Payer: Quartz Commercial |
$70.98
|
| Rate for Payer: Quartz Medicare Advantage |
$65.52
|
| Rate for Payer: The Alliance Commercial |
$54.60
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$80.88
|
|
|
SPONGE NEURO 1/2 X 1/2 XRAY DETEC NEUROSPNG05"
|
Facility
|
IP
|
$54.00
|
|
| Hospital Charge Code |
2963947
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.52 |
| Max. Negotiated Rate |
$51.67 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$33.70
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
SPONGE NEURO 1/2 X 1/2 XRAY DETEC NEUROSPNG05"
|
Facility
|
OP
|
$54.00
|
|
| Hospital Charge Code |
2963947
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.72 |
| Max. Negotiated Rate |
$51.67 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.43
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.12
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$33.70
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$36.50
|
| Rate for Payer: Quartz Medicare Advantage |
$33.70
|
| Rate for Payer: The Alliance Commercial |
$28.08
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
SPONGE NEURO 1/2 X 3 XRAY DETEC NEUROSPNG09"
|
Facility
|
IP
|
$185.00
|
|
| Hospital Charge Code |
2963126
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$94.28 |
| Max. Negotiated Rate |
$177.01 |
| Rate for Payer: Aetna Commercial |
$173.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.97
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cigna Commercial |
$177.01
|
| Rate for Payer: Health EOS Commercial |
$171.24
|
| Rate for Payer: HFN Commercial |
$177.01
|
| Rate for Payer: Multiplan Commercial |
$153.92
|
| Rate for Payer: Preferred Network Access Commercial |
$177.01
|
| Rate for Payer: Quartz Beloit One Network |
$94.28
|
| Rate for Payer: Quartz Commercial |
$115.44
|
| Rate for Payer: WEA Trust Commercial |
$105.82
|
| Rate for Payer: WPS Commercial |
$142.51
|
|
|
SPONGE NEURO 1/2 X 3 XRAY DETEC NEUROSPNG09"
|
Facility
|
OP
|
$185.00
|
|
| Hospital Charge Code |
2963126
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.87 |
| Max. Negotiated Rate |
$177.01 |
| Rate for Payer: Aetna Commercial |
$173.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.46
|
| Rate for Payer: Aetna Managed Medicare |
$53.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$125.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$96.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$92.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.97
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cigna Commercial |
$177.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$107.67
|
| Rate for Payer: Health EOS Commercial |
$171.24
|
| Rate for Payer: HFN Commercial |
$177.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$144.30
|
| Rate for Payer: Multiplan Commercial |
$153.92
|
| Rate for Payer: NAPHCARE Commercial |
$115.44
|
| Rate for Payer: Preferred Network Access Commercial |
$177.01
|
| Rate for Payer: Quartz Beloit One Network |
$94.28
|
| Rate for Payer: Quartz Commercial |
$125.06
|
| Rate for Payer: Quartz Medicare Advantage |
$115.44
|
| Rate for Payer: The Alliance Commercial |
$96.20
|
| Rate for Payer: WEA Trust Commercial |
$105.82
|
| Rate for Payer: WPS Commercial |
$142.51
|
|
|
SPONGE NEURO 1 X 3 XRAY DETEC NEUROSPNG14"
|
Facility
|
IP
|
$178.00
|
|
| Hospital Charge Code |
2963136
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$90.71 |
| Max. Negotiated Rate |
$170.31 |
| Rate for Payer: Aetna Commercial |
$166.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.11
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$170.31
|
| Rate for Payer: Health EOS Commercial |
$164.76
|
| Rate for Payer: HFN Commercial |
$170.31
|
| Rate for Payer: Multiplan Commercial |
$148.10
|
| Rate for Payer: Preferred Network Access Commercial |
$170.31
|
| Rate for Payer: Quartz Beloit One Network |
$90.71
|
| Rate for Payer: Quartz Commercial |
$111.07
|
| Rate for Payer: WEA Trust Commercial |
$101.82
|
| Rate for Payer: WPS Commercial |
$137.11
|
|
|
SPONGE NEURO 1 X 3 XRAY DETEC NEUROSPNG14"
|
Facility
|
OP
|
$178.00
|
|
| Hospital Charge Code |
2963136
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.83 |
| Max. Negotiated Rate |
$170.31 |
| Rate for Payer: Aetna Commercial |
$166.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.20
|
| Rate for Payer: Aetna Managed Medicare |
$51.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$120.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$92.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.11
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$170.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$103.60
|
| Rate for Payer: Health EOS Commercial |
$164.76
|
| Rate for Payer: HFN Commercial |
$170.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$138.84
|
| Rate for Payer: Multiplan Commercial |
$148.10
|
| Rate for Payer: NAPHCARE Commercial |
$111.07
|
| Rate for Payer: Preferred Network Access Commercial |
$170.31
|
| Rate for Payer: Quartz Beloit One Network |
$90.71
|
| Rate for Payer: Quartz Commercial |
$120.33
|
| Rate for Payer: Quartz Medicare Advantage |
$111.07
|
| Rate for Payer: The Alliance Commercial |
$92.56
|
| Rate for Payer: WEA Trust Commercial |
$101.82
|
| Rate for Payer: WPS Commercial |
$137.11
|
|
|
SPONGE PEANUT w/SPONGE HOLDER 7103
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
2963252
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.97 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$30.58
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
SPONGE PEANUT w/SPONGE HOLDER 7103
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
2963252
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.27 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Aetna Managed Medicare |
$14.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.52
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.22
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: NAPHCARE Commercial |
$30.58
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$33.12
|
| Rate for Payer: Quartz Medicare Advantage |
$30.58
|
| Rate for Payer: The Alliance Commercial |
$25.48
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
SPONGE RAYTEX 4 X 4 16 PLY 7317
|
Facility
|
OP
|
$33.00
|
|
| Hospital Charge Code |
2962819
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.61 |
| Max. Negotiated Rate |
$31.57 |
| Rate for Payer: Aetna Commercial |
$30.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.52
|
| Rate for Payer: Aetna Managed Medicare |
$9.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.19
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$31.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.21
|
| Rate for Payer: Health EOS Commercial |
$30.54
|
| Rate for Payer: HFN Commercial |
$31.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.74
|
| Rate for Payer: Multiplan Commercial |
$27.46
|
| Rate for Payer: NAPHCARE Commercial |
$20.59
|
| Rate for Payer: Preferred Network Access Commercial |
$31.57
|
| Rate for Payer: Quartz Beloit One Network |
$16.82
|
| Rate for Payer: Quartz Commercial |
$22.31
|
| Rate for Payer: Quartz Medicare Advantage |
$20.59
|
| Rate for Payer: The Alliance Commercial |
$17.16
|
| Rate for Payer: WEA Trust Commercial |
$18.88
|
| Rate for Payer: WPS Commercial |
$25.42
|
|
