|
SUPRAFOIL 0.1MM NYLON F-SS-01
|
Facility
|
IP
|
$205.00
|
|
| Hospital Charge Code |
2969361
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$100.45 |
| Max. Negotiated Rate |
$188.60 |
| Rate for Payer: Aetna Commercial |
$184.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.65
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$188.60
|
| Rate for Payer: Health EOS Commercial |
$182.45
|
| Rate for Payer: HFN Commercial |
$188.60
|
| Rate for Payer: Multiplan Commercial |
$164.00
|
| Rate for Payer: NAPHCARE Commercial |
$123.00
|
| Rate for Payer: Preferred Network Access Commercial |
$188.60
|
| Rate for Payer: Quartz Beloit One Network |
$100.45
|
| Rate for Payer: Quartz Commercial |
$123.00
|
| Rate for Payer: WEA Trust Commercial |
$112.75
|
| Rate for Payer: WPS Commercial |
$151.84
|
|
|
SUPRAFOIL 0.2MM NYLON F-SS-02
|
Facility
|
OP
|
$205.00
|
|
| Hospital Charge Code |
2969362
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$820.00 |
| Rate for Payer: Aetna Commercial |
$184.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.30
|
| Rate for Payer: Aetna Managed Medicare |
$57.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$133.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$102.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$98.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.65
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$188.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.72
|
| Rate for Payer: Health EOS Commercial |
$182.45
|
| Rate for Payer: HFN Commercial |
$188.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$153.75
|
| Rate for Payer: Multiplan Commercial |
$164.00
|
| Rate for Payer: NAPHCARE Commercial |
$123.00
|
| Rate for Payer: Preferred Network Access Commercial |
$188.60
|
| Rate for Payer: Quartz Beloit One Network |
$100.45
|
| Rate for Payer: Quartz Commercial |
$133.25
|
| Rate for Payer: Quartz Medicare Advantage |
$123.00
|
| Rate for Payer: The Alliance Commercial |
$820.00
|
| Rate for Payer: WEA Trust Commercial |
$112.75
|
| Rate for Payer: WPS Commercial |
$151.84
|
|
|
SUPRAFOIL 0.2MM NYLON F-SS-02
|
Facility
|
IP
|
$205.00
|
|
| Hospital Charge Code |
2969362
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$100.45 |
| Max. Negotiated Rate |
$188.60 |
| Rate for Payer: Aetna Commercial |
$184.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.65
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$188.60
|
| Rate for Payer: Health EOS Commercial |
$182.45
|
| Rate for Payer: HFN Commercial |
$188.60
|
| Rate for Payer: Multiplan Commercial |
$164.00
|
| Rate for Payer: NAPHCARE Commercial |
$123.00
|
| Rate for Payer: Preferred Network Access Commercial |
$188.60
|
| Rate for Payer: Quartz Beloit One Network |
$100.45
|
| Rate for Payer: Quartz Commercial |
$123.00
|
| Rate for Payer: WEA Trust Commercial |
$112.75
|
| Rate for Payer: WPS Commercial |
$151.84
|
|
|
SUPRAFOIL 0.3MM NYLON F-SS-03
|
Facility
|
OP
|
$205.00
|
|
| Hospital Charge Code |
2969363
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$820.00 |
| Rate for Payer: Aetna Commercial |
$184.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.30
|
| Rate for Payer: Aetna Managed Medicare |
$57.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$133.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$102.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$98.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.65
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$188.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.72
|
| Rate for Payer: Health EOS Commercial |
$182.45
|
| Rate for Payer: HFN Commercial |
$188.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$153.75
|
| Rate for Payer: Multiplan Commercial |
$164.00
|
| Rate for Payer: NAPHCARE Commercial |
$123.00
|
| Rate for Payer: Preferred Network Access Commercial |
$188.60
|
| Rate for Payer: Quartz Beloit One Network |
$100.45
|
| Rate for Payer: Quartz Commercial |
$133.25
|
| Rate for Payer: Quartz Medicare Advantage |
$123.00
|
| Rate for Payer: The Alliance Commercial |
$820.00
|
| Rate for Payer: WEA Trust Commercial |
$112.75
|
| Rate for Payer: WPS Commercial |
$151.84
|
|
|
SUPRAFOIL 0.3MM NYLON F-SS-03
|
Facility
|
IP
|
$205.00
|
|
| Hospital Charge Code |
2969363
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$100.45 |
| Max. Negotiated Rate |
$188.60 |
| Rate for Payer: Aetna Commercial |
$184.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.65
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$188.60
|
| Rate for Payer: Health EOS Commercial |
$182.45
|
| Rate for Payer: HFN Commercial |
$188.60
|
| Rate for Payer: Multiplan Commercial |
$164.00
|
| Rate for Payer: NAPHCARE Commercial |
$123.00
|
| Rate for Payer: Preferred Network Access Commercial |
$188.60
|
| Rate for Payer: Quartz Beloit One Network |
$100.45
|
| Rate for Payer: Quartz Commercial |
$123.00
|
| Rate for Payer: WEA Trust Commercial |
$112.75
|
| Rate for Payer: WPS Commercial |
$151.84
|
|
|
SUPRAFOIL 0.4MM NYLON F-SS-04
|
Facility
|
OP
|
$205.00
|
|
| Hospital Charge Code |
2969364
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$820.00 |
| Rate for Payer: Aetna Commercial |
$184.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.30
|
| Rate for Payer: Aetna Managed Medicare |
$57.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$133.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$102.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$98.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.65
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$188.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.72
|
| Rate for Payer: Health EOS Commercial |
$182.45
|
| Rate for Payer: HFN Commercial |
$188.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$153.75
|
| Rate for Payer: Multiplan Commercial |
$164.00
|
| Rate for Payer: NAPHCARE Commercial |
$123.00
|
| Rate for Payer: Preferred Network Access Commercial |
$188.60
|
| Rate for Payer: Quartz Beloit One Network |
$100.45
|
| Rate for Payer: Quartz Commercial |
$133.25
|
| Rate for Payer: Quartz Medicare Advantage |
$123.00
|
| Rate for Payer: The Alliance Commercial |
$820.00
|
| Rate for Payer: WEA Trust Commercial |
$112.75
|
| Rate for Payer: WPS Commercial |
$151.84
|
|
|
SUPRAFOIL 0.4MM NYLON F-SS-04
|
Facility
|
IP
|
$205.00
|
|
| Hospital Charge Code |
2969364
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$100.45 |
| Max. Negotiated Rate |
$188.60 |
| Rate for Payer: Aetna Commercial |
$184.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.65
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$188.60
|
| Rate for Payer: Health EOS Commercial |
$182.45
|
| Rate for Payer: HFN Commercial |
$188.60
|
| Rate for Payer: Multiplan Commercial |
$164.00
|
| Rate for Payer: NAPHCARE Commercial |
$123.00
|
| Rate for Payer: Preferred Network Access Commercial |
$188.60
|
| Rate for Payer: Quartz Beloit One Network |
$100.45
|
| Rate for Payer: Quartz Commercial |
$123.00
|
| Rate for Payer: WEA Trust Commercial |
$112.75
|
| Rate for Payer: WPS Commercial |
$151.84
|
|
|
SUPRAFOIL 0.6MM NYLON F-SS-06
|
Facility
|
IP
|
$205.00
|
|
| Hospital Charge Code |
2969365
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$100.45 |
| Max. Negotiated Rate |
$188.60 |
| Rate for Payer: Aetna Commercial |
$184.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.65
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$188.60
|
| Rate for Payer: Health EOS Commercial |
$182.45
|
| Rate for Payer: HFN Commercial |
$188.60
|
| Rate for Payer: Multiplan Commercial |
$164.00
|
| Rate for Payer: NAPHCARE Commercial |
$123.00
|
| Rate for Payer: Preferred Network Access Commercial |
$188.60
|
| Rate for Payer: Quartz Beloit One Network |
$100.45
|
| Rate for Payer: Quartz Commercial |
$123.00
|
| Rate for Payer: WEA Trust Commercial |
$112.75
|
| Rate for Payer: WPS Commercial |
$151.84
|
|
|
SUPRAFOIL 0.6MM NYLON F-SS-06
|
Facility
|
OP
|
$205.00
|
|
| Hospital Charge Code |
2969365
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$820.00 |
| Rate for Payer: Aetna Commercial |
$184.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.30
|
| Rate for Payer: Aetna Managed Medicare |
$57.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$133.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$102.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$98.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.65
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$188.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.72
|
| Rate for Payer: Health EOS Commercial |
$182.45
|
| Rate for Payer: HFN Commercial |
$188.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$153.75
|
| Rate for Payer: Multiplan Commercial |
$164.00
|
| Rate for Payer: NAPHCARE Commercial |
$123.00
|
| Rate for Payer: Preferred Network Access Commercial |
$188.60
|
| Rate for Payer: Quartz Beloit One Network |
$100.45
|
| Rate for Payer: Quartz Commercial |
$133.25
|
| Rate for Payer: Quartz Medicare Advantage |
$123.00
|
| Rate for Payer: The Alliance Commercial |
$820.00
|
| Rate for Payer: WEA Trust Commercial |
$112.75
|
| Rate for Payer: WPS Commercial |
$151.84
|
|
|
SUPRAPUBIC TUBE PLACEMENT, OPEN
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960254
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
SUPRAPUBIC TUBE PLACEMENT, OPEN
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960254
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
SUPRA PUBIC TUBE PLACEMENT, PUNCH
|
Facility
|
OP
|
$291.00
|
|
| Hospital Charge Code |
2960396
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$81.48 |
| Max. Negotiated Rate |
$1,164.00 |
| Rate for Payer: Aetna Commercial |
$261.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.26
|
| Rate for Payer: Aetna Managed Medicare |
$81.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$189.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.23
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$267.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.84
|
| Rate for Payer: Health EOS Commercial |
$258.99
|
| Rate for Payer: HFN Commercial |
$267.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$218.25
|
| Rate for Payer: Multiplan Commercial |
$232.80
|
| Rate for Payer: NAPHCARE Commercial |
$174.60
|
| Rate for Payer: Preferred Network Access Commercial |
$267.72
|
| Rate for Payer: Quartz Beloit One Network |
$142.59
|
| Rate for Payer: Quartz Commercial |
$189.15
|
| Rate for Payer: Quartz Medicare Advantage |
$174.60
|
| Rate for Payer: The Alliance Commercial |
$1,164.00
|
| Rate for Payer: WEA Trust Commercial |
$160.05
|
| Rate for Payer: WPS Commercial |
$215.54
|
|
|
SUPRA PUBIC TUBE PLACEMENT, PUNCH
|
Facility
|
IP
|
$291.00
|
|
| Hospital Charge Code |
2960396
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$142.59 |
| Max. Negotiated Rate |
$267.72 |
| Rate for Payer: Aetna Commercial |
$261.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.23
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$267.72
|
| Rate for Payer: Health EOS Commercial |
$258.99
|
| Rate for Payer: HFN Commercial |
$267.72
|
| Rate for Payer: Multiplan Commercial |
$232.80
|
| Rate for Payer: NAPHCARE Commercial |
$174.60
|
| Rate for Payer: Preferred Network Access Commercial |
$267.72
|
| Rate for Payer: Quartz Beloit One Network |
$142.59
|
| Rate for Payer: Quartz Commercial |
$174.60
|
| Rate for Payer: WEA Trust Commercial |
$160.05
|
| Rate for Payer: WPS Commercial |
$215.54
|
|
|
Supravalvular Aortography 9356726
|
Professional
|
Both
|
$1,763.00
|
|
|
Service Code
|
CPT 93567 26
|
| Hospital Charge Code |
5170623
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$1,674.85 |
| Rate for Payer: Aetna Commercial |
$1,674.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,516.18
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cash Price |
$528.90
|
| Rate for Payer: Cigna Commercial |
$1,674.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,057.80
|
| Rate for Payer: Health EOS Commercial |
$1,604.33
|
| Rate for Payer: HFN Commercial |
$1,674.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$166.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$166.58
|
| Rate for Payer: Multiplan Commercial |
$1,410.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,674.85
|
| Rate for Payer: Quartz Beloit One Network |
$775.72
|
| Rate for Payer: Quartz Commercial |
$1,004.91
|
| Rate for Payer: The Alliance Commercial |
$881.50
|
| Rate for Payer: United Healthcare Medicaid |
$34.80
|
| Rate for Payer: WEA Trust Commercial |
$969.65
|
| Rate for Payer: WPS Commercial |
$1,305.85
|
|
|
SurePath Pap and HPV DNA
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
CPT 87624
|
| Hospital Charge Code |
4253292
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$78.40 |
| Max. Negotiated Rate |
$147.20 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
SurePath Pap and HPV DNA
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
CPT 87624
|
| Hospital Charge Code |
4253292
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna Commercial |
$152.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$152.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$80.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.00
|
| Rate for Payer: Health EOS Commercial |
$145.60
|
| Rate for Payer: HFN Commercial |
$152.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$123.87
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: Preferred Network Access Commercial |
$152.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.40
|
| Rate for Payer: Quartz Commercial |
$91.20
|
| Rate for Payer: The Alliance Commercial |
$80.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
SurePath Pap and HPV DNA
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
CPT 87624
|
| Hospital Charge Code |
4253292
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$147.20 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Aetna Managed Medicare |
$35.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.25
|
| Rate for Payer: Anthem Medicaid |
$36.26
|
| Rate for Payer: Anthem Medicare Advantage |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.09
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$35.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.54
|
| Rate for Payer: Dean Health Medicaid |
$36.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$35.09
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$35.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$36.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.09
|
| Rate for Payer: Managed Health Services Medicaid |
$37.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$35.09
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$52.64
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$36.26
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$104.00
|
| Rate for Payer: Quartz Medicare Advantage |
$35.09
|
| Rate for Payer: The Alliance Commercial |
$140.36
|
| Rate for Payer: United Healthcare Medicaid |
$36.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare PPO |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: Wellcare Medicare |
$35.09
|
| Rate for Payer: WMAP Medicaid |
$36.26
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
SURESOUND 92300-01
|
Facility
|
OP
|
$1,212.00
|
|
| Hospital Charge Code |
2965140
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$339.36 |
| Max. Negotiated Rate |
$4,848.00 |
| Rate for Payer: Aetna Commercial |
$1,090.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,042.32
|
| Rate for Payer: Aetna Managed Medicare |
$339.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$787.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$606.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$581.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$642.36
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,115.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$678.24
|
| Rate for Payer: Health EOS Commercial |
$1,078.68
|
| Rate for Payer: HFN Commercial |
$1,115.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$909.00
|
| Rate for Payer: Multiplan Commercial |
$969.60
|
| Rate for Payer: NAPHCARE Commercial |
$727.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,115.04
|
| Rate for Payer: Quartz Beloit One Network |
$593.88
|
| Rate for Payer: Quartz Commercial |
$787.80
|
| Rate for Payer: Quartz Medicare Advantage |
$727.20
|
| Rate for Payer: The Alliance Commercial |
$4,848.00
|
| Rate for Payer: WEA Trust Commercial |
$666.60
|
| Rate for Payer: WPS Commercial |
$897.73
|
|
|
SURESOUND 92300-01
|
Facility
|
IP
|
$1,212.00
|
|
| Hospital Charge Code |
2965140
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$593.88 |
| Max. Negotiated Rate |
$1,115.04 |
| Rate for Payer: Aetna Commercial |
$1,090.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,042.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$642.36
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna Commercial |
$1,115.04
|
| Rate for Payer: Health EOS Commercial |
$1,078.68
|
| Rate for Payer: HFN Commercial |
$1,115.04
|
| Rate for Payer: Multiplan Commercial |
$969.60
|
| Rate for Payer: NAPHCARE Commercial |
$727.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,115.04
|
| Rate for Payer: Quartz Beloit One Network |
$593.88
|
| Rate for Payer: Quartz Commercial |
$727.20
|
| Rate for Payer: WEA Trust Commercial |
$666.60
|
| Rate for Payer: WPS Commercial |
$897.73
|
|
|
SUR-FIT NATURA DRAINABLE POUCH
|
Facility
|
OP
|
$86.00
|
|
| Hospital Charge Code |
2971127
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.08 |
| Max. Negotiated Rate |
$344.00 |
| Rate for Payer: Aetna Commercial |
$77.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.96
|
| Rate for Payer: Aetna Managed Medicare |
$24.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.58
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$79.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.13
|
| Rate for Payer: Health EOS Commercial |
$76.54
|
| Rate for Payer: HFN Commercial |
$79.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.50
|
| Rate for Payer: Multiplan Commercial |
$68.80
|
| Rate for Payer: NAPHCARE Commercial |
$51.60
|
| Rate for Payer: Preferred Network Access Commercial |
$79.12
|
| Rate for Payer: Quartz Beloit One Network |
$42.14
|
| Rate for Payer: Quartz Commercial |
$55.90
|
| Rate for Payer: Quartz Medicare Advantage |
$51.60
|
| Rate for Payer: The Alliance Commercial |
$344.00
|
| Rate for Payer: WEA Trust Commercial |
$47.30
|
| Rate for Payer: WPS Commercial |
$63.70
|
|
|
SUR-FIT NATURA DRAINABLE POUCH
|
Facility
|
IP
|
$86.00
|
|
| Hospital Charge Code |
2971127
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$42.14 |
| Max. Negotiated Rate |
$79.12 |
| Rate for Payer: Aetna Commercial |
$77.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.58
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$79.12
|
| Rate for Payer: Health EOS Commercial |
$76.54
|
| Rate for Payer: HFN Commercial |
$79.12
|
| Rate for Payer: Multiplan Commercial |
$68.80
|
| Rate for Payer: NAPHCARE Commercial |
$51.60
|
| Rate for Payer: Preferred Network Access Commercial |
$79.12
|
| Rate for Payer: Quartz Beloit One Network |
$42.14
|
| Rate for Payer: Quartz Commercial |
$51.60
|
| Rate for Payer: WEA Trust Commercial |
$47.30
|
| Rate for Payer: WPS Commercial |
$63.70
|
|
|
SUR-FIT NATURA STOMAHESIVE
|
Facility
|
OP
|
$123.00
|
|
| Hospital Charge Code |
2971231
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$34.44 |
| Max. Negotiated Rate |
$492.00 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Aetna Managed Medicare |
$34.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$79.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$59.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.83
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.25
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$79.95
|
| Rate for Payer: Quartz Medicare Advantage |
$73.80
|
| Rate for Payer: The Alliance Commercial |
$492.00
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
SUR-FIT NATURA STOMAHESIVE
|
Facility
|
IP
|
$123.00
|
|
| Hospital Charge Code |
2971231
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$60.27 |
| Max. Negotiated Rate |
$113.16 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$73.80
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
Surgical Dress Holder Reuse A4463
|
Professional
|
Both
|
$49.00
|
|
|
Service Code
|
HCPCS A4463
|
| Hospital Charge Code |
4954606
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$54.68 |
| Rate for Payer: Aetna Commercial |
$46.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.40
|
| Rate for Payer: Health EOS Commercial |
$44.59
|
| Rate for Payer: HFN Commercial |
$46.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$54.68
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: Preferred Network Access Commercial |
$46.55
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$27.93
|
| Rate for Payer: The Alliance Commercial |
$24.50
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Surgical Dress Holder Reuse A4463
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
HCPCS A4463
|
| Hospital Charge Code |
4954606
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: Aetna Commercial |
$44.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Aetna Managed Medicare |
$13.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.97
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$45.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.42
|
| Rate for Payer: Health EOS Commercial |
$43.61
|
| Rate for Payer: HFN Commercial |
$45.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.75
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: NAPHCARE Commercial |
$29.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.08
|
| Rate for Payer: Quartz Beloit One Network |
$24.01
|
| Rate for Payer: Quartz Commercial |
$31.85
|
| Rate for Payer: Quartz Medicare Advantage |
$29.40
|
| Rate for Payer: The Alliance Commercial |
$196.00
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
