|
STER-DRAPE SMALL 24 X 14 DYNJSD1040
|
Facility
|
OP
|
$102.00
|
|
| Hospital Charge Code |
2963304
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$28.56 |
| Max. Negotiated Rate |
$408.00 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Aetna Managed Medicare |
$28.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.06
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$93.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.08
|
| Rate for Payer: Health EOS Commercial |
$90.78
|
| Rate for Payer: HFN Commercial |
$93.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.50
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: NAPHCARE Commercial |
$61.20
|
| Rate for Payer: Preferred Network Access Commercial |
$93.84
|
| Rate for Payer: Quartz Beloit One Network |
$49.98
|
| Rate for Payer: Quartz Commercial |
$66.30
|
| Rate for Payer: Quartz Medicare Advantage |
$61.20
|
| Rate for Payer: The Alliance Commercial |
$408.00
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
Stereotactic Body Radiation Delivery 77373
|
Professional
|
Both
|
$6,691.00
|
|
|
Service Code
|
CPT 77373
|
| Hospital Charge Code |
5430723
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2,944.04 |
| Max. Negotiated Rate |
$6,356.45 |
| Rate for Payer: Aetna Commercial |
$6,356.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,754.26
|
| Rate for Payer: Cash Price |
$2,007.30
|
| Rate for Payer: Cash Price |
$2,007.30
|
| Rate for Payer: Cigna Commercial |
$6,356.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,345.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,014.60
|
| Rate for Payer: Health EOS Commercial |
$6,088.81
|
| Rate for Payer: HFN Commercial |
$6,356.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,880.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,880.71
|
| Rate for Payer: Multiplan Commercial |
$5,352.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,356.45
|
| Rate for Payer: Quartz Beloit One Network |
$2,944.04
|
| Rate for Payer: Quartz Commercial |
$3,813.87
|
| Rate for Payer: The Alliance Commercial |
$3,345.50
|
| Rate for Payer: WEA Trust Commercial |
$3,680.05
|
| Rate for Payer: WPS Commercial |
$4,956.02
|
|
|
Stereotactic Body Radiation Management 77435
|
Professional
|
Both
|
$8,637.00
|
|
|
Service Code
|
CPT 77435
|
| Hospital Charge Code |
5432657
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2,167.53 |
| Max. Negotiated Rate |
$8,205.15 |
| Rate for Payer: Aetna Commercial |
$8,205.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,427.82
|
| Rate for Payer: Cash Price |
$2,591.10
|
| Rate for Payer: Cash Price |
$2,591.10
|
| Rate for Payer: Cigna Commercial |
$8,205.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,318.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,182.20
|
| Rate for Payer: Health EOS Commercial |
$7,859.67
|
| Rate for Payer: HFN Commercial |
$8,205.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,167.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,167.53
|
| Rate for Payer: Multiplan Commercial |
$6,909.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,205.15
|
| Rate for Payer: Quartz Beloit One Network |
$3,800.28
|
| Rate for Payer: Quartz Commercial |
$4,923.09
|
| Rate for Payer: The Alliance Commercial |
$4,318.50
|
| Rate for Payer: WEA Trust Commercial |
$4,750.35
|
| Rate for Payer: WPS Commercial |
$6,397.43
|
|
|
Stereotactic Body Radiation Therapy
|
Facility
|
IP
|
$12,381.00
|
|
|
Service Code
|
CPT 77373
|
| Hospital Charge Code |
3970755
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$6,066.69 |
| Max. Negotiated Rate |
$11,390.52 |
| Rate for Payer: Aetna Commercial |
$11,142.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,647.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,561.93
|
| Rate for Payer: Cash Price |
$3,714.30
|
| Rate for Payer: Cigna Commercial |
$11,390.52
|
| Rate for Payer: Health EOS Commercial |
$11,019.09
|
| Rate for Payer: HFN Commercial |
$11,390.52
|
| Rate for Payer: Multiplan Commercial |
$9,904.80
|
| Rate for Payer: NAPHCARE Commercial |
$7,428.60
|
| Rate for Payer: Preferred Network Access Commercial |
$11,390.52
|
| Rate for Payer: Quartz Beloit One Network |
$6,066.69
|
| Rate for Payer: Quartz Commercial |
$7,428.60
|
| Rate for Payer: WEA Trust Commercial |
$6,809.55
|
| Rate for Payer: WPS Commercial |
$9,170.61
|
|
|
Stereotactic Body Radiation Therapy
|
Facility
|
OP
|
$12,381.00
|
|
|
Service Code
|
CPT 77373
|
| Hospital Charge Code |
3970755
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,763.67 |
| Max. Negotiated Rate |
$11,390.52 |
| Rate for Payer: Aetna Commercial |
$11,142.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,647.66
|
| Rate for Payer: Aetna Managed Medicare |
$1,763.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,613.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,291.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,026.46
|
| Rate for Payer: Anthem Medicare Advantage |
$1,763.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,561.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,763.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,763.67
|
| Rate for Payer: Cash Price |
$3,714.30
|
| Rate for Payer: Cash Price |
$3,714.30
|
| Rate for Payer: Cigna Commercial |
$11,390.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,763.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,928.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,763.67
|
| Rate for Payer: Health EOS Commercial |
$11,019.09
|
| Rate for Payer: HFN Commercial |
$11,390.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,560.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,763.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,763.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,763.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,763.67
|
| Rate for Payer: Multiplan Commercial |
$9,904.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,645.50
|
| Rate for Payer: Preferred Network Access Commercial |
$11,390.52
|
| Rate for Payer: Quartz Beloit One Network |
$6,066.69
|
| Rate for Payer: Quartz Commercial |
$8,047.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,763.67
|
| Rate for Payer: The Alliance Commercial |
$7,054.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,763.67
|
| Rate for Payer: United Healthcare PPO |
$7,428.60
|
| Rate for Payer: WEA Trust Commercial |
$6,809.55
|
| Rate for Payer: Wellcare Medicare |
$1,763.67
|
| Rate for Payer: WPS Commercial |
$9,170.61
|
|
|
Stereotactic Cranial Linear Radiation Therapy
|
Facility
|
IP
|
$18,484.00
|
|
|
Service Code
|
CPT 77372
|
| Hospital Charge Code |
5586206
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$9,057.16 |
| Max. Negotiated Rate |
$17,005.28 |
| Rate for Payer: Aetna Commercial |
$16,635.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,896.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,796.52
|
| Rate for Payer: Cash Price |
$5,545.20
|
| Rate for Payer: Cigna Commercial |
$17,005.28
|
| Rate for Payer: Health EOS Commercial |
$16,450.76
|
| Rate for Payer: HFN Commercial |
$17,005.28
|
| Rate for Payer: Multiplan Commercial |
$14,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$11,090.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17,005.28
|
| Rate for Payer: Quartz Beloit One Network |
$9,057.16
|
| Rate for Payer: Quartz Commercial |
$11,090.40
|
| Rate for Payer: WEA Trust Commercial |
$10,166.20
|
| Rate for Payer: WPS Commercial |
$13,691.10
|
|
|
Stereotactic Cranial Linear Radiation Therapy
|
Facility
|
OP
|
$18,484.00
|
|
|
Service Code
|
CPT 77372
|
| Hospital Charge Code |
5586206
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$7,696.99 |
| Max. Negotiated Rate |
$30,787.96 |
| Rate for Payer: Aetna Commercial |
$16,635.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,896.24
|
| Rate for Payer: Aetna Managed Medicare |
$7,696.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28,863.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23,090.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21,936.42
|
| Rate for Payer: Anthem Medicare Advantage |
$7,696.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,796.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,696.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,696.99
|
| Rate for Payer: Cash Price |
$5,545.20
|
| Rate for Payer: Cash Price |
$5,545.20
|
| Rate for Payer: Cigna Commercial |
$17,005.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,696.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,343.65
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,696.99
|
| Rate for Payer: Health EOS Commercial |
$16,450.76
|
| Rate for Payer: HFN Commercial |
$17,005.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,632.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,696.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,696.99
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,696.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,696.99
|
| Rate for Payer: Multiplan Commercial |
$14,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$11,545.48
|
| Rate for Payer: Preferred Network Access Commercial |
$17,005.28
|
| Rate for Payer: Quartz Beloit One Network |
$9,057.16
|
| Rate for Payer: Quartz Commercial |
$12,014.60
|
| Rate for Payer: Quartz Medicare Advantage |
$7,696.99
|
| Rate for Payer: The Alliance Commercial |
$30,787.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,696.99
|
| Rate for Payer: United Healthcare PPO |
$11,090.40
|
| Rate for Payer: WEA Trust Commercial |
$10,166.20
|
| Rate for Payer: Wellcare Medicare |
$7,696.99
|
| Rate for Payer: WPS Commercial |
$13,691.10
|
|
|
STEREOTACTIC RADIATION CRANIAL LESION TX MANAGEMENT 77432
|
Professional
|
Both
|
$5,762.00
|
|
|
Service Code
|
CPT 77432
|
| Hospital Charge Code |
5586200
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,436.43 |
| Max. Negotiated Rate |
$5,473.90 |
| Rate for Payer: Aetna Commercial |
$5,473.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,955.32
|
| Rate for Payer: Cash Price |
$1,728.60
|
| Rate for Payer: Cash Price |
$1,728.60
|
| Rate for Payer: Cigna Commercial |
$5,473.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,881.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,457.20
|
| Rate for Payer: Health EOS Commercial |
$5,243.42
|
| Rate for Payer: HFN Commercial |
$5,473.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,436.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,436.43
|
| Rate for Payer: Multiplan Commercial |
$4,609.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,473.90
|
| Rate for Payer: Quartz Beloit One Network |
$2,535.28
|
| Rate for Payer: Quartz Commercial |
$3,284.34
|
| Rate for Payer: The Alliance Commercial |
$2,881.00
|
| Rate for Payer: WEA Trust Commercial |
$3,169.10
|
| Rate for Payer: WPS Commercial |
$4,267.91
|
|
|
STERI-DRAPE INCISE IOBAN 2 LG ISOLATION 27 X 12IN WITH POUCH 6619
|
Facility
|
OP
|
$991.00
|
|
| Hospital Charge Code |
2963200
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$277.48 |
| Max. Negotiated Rate |
$3,964.00 |
| Rate for Payer: Aetna Commercial |
$891.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$852.26
|
| Rate for Payer: Aetna Managed Medicare |
$277.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$644.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$495.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$475.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$525.23
|
| Rate for Payer: Cash Price |
$297.30
|
| Rate for Payer: Cigna Commercial |
$911.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$554.56
|
| Rate for Payer: Health EOS Commercial |
$881.99
|
| Rate for Payer: HFN Commercial |
$911.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$743.25
|
| Rate for Payer: Multiplan Commercial |
$792.80
|
| Rate for Payer: NAPHCARE Commercial |
$594.60
|
| Rate for Payer: Preferred Network Access Commercial |
$911.72
|
| Rate for Payer: Quartz Beloit One Network |
$485.59
|
| Rate for Payer: Quartz Commercial |
$644.15
|
| Rate for Payer: Quartz Medicare Advantage |
$594.60
|
| Rate for Payer: The Alliance Commercial |
$3,964.00
|
| Rate for Payer: WEA Trust Commercial |
$545.05
|
| Rate for Payer: WPS Commercial |
$734.03
|
|
|
STERI-DRAPE INCISE IOBAN 2 LG ISOLATION 27 X 12IN WITH POUCH 6619
|
Facility
|
IP
|
$991.00
|
|
| Hospital Charge Code |
2963200
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$485.59 |
| Max. Negotiated Rate |
$911.72 |
| Rate for Payer: Aetna Commercial |
$891.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$852.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$525.23
|
| Rate for Payer: Cash Price |
$297.30
|
| Rate for Payer: Cigna Commercial |
$911.72
|
| Rate for Payer: Health EOS Commercial |
$881.99
|
| Rate for Payer: HFN Commercial |
$911.72
|
| Rate for Payer: Multiplan Commercial |
$792.80
|
| Rate for Payer: NAPHCARE Commercial |
$594.60
|
| Rate for Payer: Preferred Network Access Commercial |
$911.72
|
| Rate for Payer: Quartz Beloit One Network |
$485.59
|
| Rate for Payer: Quartz Commercial |
$594.60
|
| Rate for Payer: WEA Trust Commercial |
$545.05
|
| Rate for Payer: WPS Commercial |
$734.03
|
|
|
STERI-DRAPE LARGE 23 X 33 1051
|
Facility
|
OP
|
$234.00
|
|
| Hospital Charge Code |
2963417
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$65.52 |
| Max. Negotiated Rate |
$936.00 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$65.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$152.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$117.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$112.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.95
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$175.50
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$140.40
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$140.40
|
| Rate for Payer: The Alliance Commercial |
$936.00
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
STERI-DRAPE LARGE 23 X 33 1051
|
Facility
|
IP
|
$234.00
|
|
| Hospital Charge Code |
2963417
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$140.40
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
STERILE BLANK LATEX FREE #AM897AM
|
Facility
|
IP
|
$83.00
|
|
| Hospital Charge Code |
2971737
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.67 |
| Max. Negotiated Rate |
$76.36 |
| Rate for Payer: Aetna Commercial |
$74.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.99
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: Health EOS Commercial |
$73.87
|
| Rate for Payer: HFN Commercial |
$76.36
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: NAPHCARE Commercial |
$49.80
|
| Rate for Payer: Preferred Network Access Commercial |
$76.36
|
| Rate for Payer: Quartz Beloit One Network |
$40.67
|
| Rate for Payer: Quartz Commercial |
$49.80
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
STERILE BLANK LATEX FREE #AM897AM
|
Facility
|
OP
|
$83.00
|
|
| Hospital Charge Code |
2971737
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.24 |
| Max. Negotiated Rate |
$332.00 |
| Rate for Payer: Aetna Commercial |
$74.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Aetna Managed Medicare |
$23.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.99
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.45
|
| Rate for Payer: Health EOS Commercial |
$73.87
|
| Rate for Payer: HFN Commercial |
$76.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.25
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: NAPHCARE Commercial |
$49.80
|
| Rate for Payer: Preferred Network Access Commercial |
$76.36
|
| Rate for Payer: Quartz Beloit One Network |
$40.67
|
| Rate for Payer: Quartz Commercial |
$53.95
|
| Rate for Payer: Quartz Medicare Advantage |
$49.80
|
| Rate for Payer: The Alliance Commercial |
$332.00
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
STERILE CONTAINER 0.9 SODIUM
|
Facility
|
OP
|
$864.00
|
|
| Hospital Charge Code |
2974006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$241.92 |
| Max. Negotiated Rate |
$3,456.00 |
| Rate for Payer: Aetna Commercial |
$777.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$743.04
|
| Rate for Payer: Aetna Managed Medicare |
$241.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$561.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$432.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$414.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$457.92
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cigna Commercial |
$794.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$483.49
|
| Rate for Payer: Health EOS Commercial |
$768.96
|
| Rate for Payer: HFN Commercial |
$794.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$648.00
|
| Rate for Payer: Multiplan Commercial |
$691.20
|
| Rate for Payer: NAPHCARE Commercial |
$518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$794.88
|
| Rate for Payer: Quartz Beloit One Network |
$423.36
|
| Rate for Payer: Quartz Commercial |
$561.60
|
| Rate for Payer: Quartz Medicare Advantage |
$518.40
|
| Rate for Payer: The Alliance Commercial |
$3,456.00
|
| Rate for Payer: WEA Trust Commercial |
$475.20
|
| Rate for Payer: WPS Commercial |
$639.96
|
|
|
STERILE CONTAINER 0.9 SODIUM
|
Facility
|
IP
|
$864.00
|
|
| Hospital Charge Code |
2974006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$423.36 |
| Max. Negotiated Rate |
$794.88 |
| Rate for Payer: Aetna Commercial |
$777.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$743.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$457.92
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cigna Commercial |
$794.88
|
| Rate for Payer: Health EOS Commercial |
$768.96
|
| Rate for Payer: HFN Commercial |
$794.88
|
| Rate for Payer: Multiplan Commercial |
$691.20
|
| Rate for Payer: NAPHCARE Commercial |
$518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$794.88
|
| Rate for Payer: Quartz Beloit One Network |
$423.36
|
| Rate for Payer: Quartz Commercial |
$518.40
|
| Rate for Payer: WEA Trust Commercial |
$475.20
|
| Rate for Payer: WPS Commercial |
$639.96
|
|
|
STERILE CUSTOM MED LATEX FREE #132174
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
2971974
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.17
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$42.00
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
STERILE CUSTOM MED LATEX FREE #132174
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2971974
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
STERIPACK SIDEKICK CORETRAK ARTICULATING XPCK1200
|
Facility
|
OP
|
$16,243.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6178282
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,548.04 |
| Max. Negotiated Rate |
$64,972.00 |
| Rate for Payer: Aetna Commercial |
$14,618.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,968.98
|
| Rate for Payer: Aetna Managed Medicare |
$4,548.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,557.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,121.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,796.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,608.79
|
| Rate for Payer: Cash Price |
$4,872.90
|
| Rate for Payer: Cigna Commercial |
$14,943.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,089.58
|
| Rate for Payer: Health EOS Commercial |
$14,456.27
|
| Rate for Payer: HFN Commercial |
$14,943.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,182.25
|
| Rate for Payer: Multiplan Commercial |
$12,994.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,745.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,943.56
|
| Rate for Payer: Quartz Beloit One Network |
$7,959.07
|
| Rate for Payer: Quartz Commercial |
$10,557.95
|
| Rate for Payer: Quartz Medicare Advantage |
$9,745.80
|
| Rate for Payer: The Alliance Commercial |
$64,972.00
|
| Rate for Payer: WEA Trust Commercial |
$8,933.65
|
| Rate for Payer: WPS Commercial |
$12,031.19
|
|
|
STERIPACK SIDEKICK CORETRAK ARTICULATING XPCK1200
|
Facility
|
IP
|
$16,243.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6178282
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,959.07 |
| Max. Negotiated Rate |
$14,943.56 |
| Rate for Payer: Aetna Commercial |
$14,618.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,968.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,608.79
|
| Rate for Payer: Cash Price |
$4,872.90
|
| Rate for Payer: Cigna Commercial |
$14,943.56
|
| Rate for Payer: Health EOS Commercial |
$14,456.27
|
| Rate for Payer: HFN Commercial |
$14,943.56
|
| Rate for Payer: Multiplan Commercial |
$12,994.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,745.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,943.56
|
| Rate for Payer: Quartz Beloit One Network |
$7,959.07
|
| Rate for Payer: Quartz Commercial |
$9,745.80
|
| Rate for Payer: WEA Trust Commercial |
$8,933.65
|
| Rate for Payer: WPS Commercial |
$12,031.19
|
|
|
STERI STRIP 1/2 X 4 R1547
|
Facility
|
IP
|
$54.00
|
|
| Hospital Charge Code |
2963545
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$32.40
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
STERI STRIP 1/2 X 4 R1547
|
Facility
|
OP
|
$54.00
|
|
| Hospital Charge Code |
2963545
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$15.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.22
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.50
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$35.10
|
| Rate for Payer: Quartz Medicare Advantage |
$32.40
|
| Rate for Payer: The Alliance Commercial |
$216.00
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
STERI STRIP 1/4X 1 1/2
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
2974499
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.23 |
| Max. Negotiated Rate |
$24.84 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$16.20
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
STERI STRIP 1/4X 1 1/2
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
2974499
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Aetna Managed Medicare |
$7.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.11
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.25
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$17.55
|
| Rate for Payer: Quartz Medicare Advantage |
$16.20
|
| Rate for Payer: The Alliance Commercial |
$108.00
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
STERI STRIP 1/4 X 3 TAPE R1541"
|
Facility
|
OP
|
$84.00
|
|
| Hospital Charge Code |
2962791
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Aetna Managed Medicare |
$23.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.01
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$54.60
|
| Rate for Payer: Quartz Medicare Advantage |
$50.40
|
| Rate for Payer: The Alliance Commercial |
$336.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
