|
SYRINGE KIT TRAUMACEM (TM) V+ STERILE 03.702.150S
|
Facility
|
IP
|
$2,160.60
|
|
| Hospital Charge Code |
6246253
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,058.69 |
| Max. Negotiated Rate |
$1,987.75 |
| Rate for Payer: Aetna Commercial |
$1,944.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,858.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,145.12
|
| Rate for Payer: Cash Price |
$648.18
|
| Rate for Payer: Cigna Commercial |
$1,987.75
|
| Rate for Payer: Health EOS Commercial |
$1,922.93
|
| Rate for Payer: HFN Commercial |
$1,987.75
|
| Rate for Payer: Multiplan Commercial |
$1,728.48
|
| Rate for Payer: NAPHCARE Commercial |
$1,296.36
|
| Rate for Payer: Preferred Network Access Commercial |
$1,987.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,058.69
|
| Rate for Payer: Quartz Commercial |
$1,296.36
|
| Rate for Payer: WEA Trust Commercial |
$1,188.33
|
| Rate for Payer: WPS Commercial |
$1,600.36
|
|
|
SYRINGE KIT TRAUMACEM (TM) V+ STERILE 03.702.150S
|
Facility
|
OP
|
$2,160.60
|
|
| Hospital Charge Code |
6246253
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$604.97 |
| Max. Negotiated Rate |
$8,642.40 |
| Rate for Payer: Aetna Commercial |
$1,944.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,858.12
|
| Rate for Payer: Aetna Managed Medicare |
$604.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,404.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,080.30
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,037.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,145.12
|
| Rate for Payer: Cash Price |
$648.18
|
| Rate for Payer: Cigna Commercial |
$1,987.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,209.07
|
| Rate for Payer: Health EOS Commercial |
$1,922.93
|
| Rate for Payer: HFN Commercial |
$1,987.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,620.45
|
| Rate for Payer: Multiplan Commercial |
$1,728.48
|
| Rate for Payer: NAPHCARE Commercial |
$1,296.36
|
| Rate for Payer: Preferred Network Access Commercial |
$1,987.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,058.69
|
| Rate for Payer: Quartz Commercial |
$1,404.39
|
| Rate for Payer: Quartz Medicare Advantage |
$1,296.36
|
| Rate for Payer: The Alliance Commercial |
$8,642.40
|
| Rate for Payer: WEA Trust Commercial |
$1,188.33
|
| Rate for Payer: WPS Commercial |
$1,600.36
|
|
|
SYRINGE SLIP 6cc #8881516911
|
Facility
|
IP
|
$3.00
|
|
| Hospital Charge Code |
2974544
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: Health EOS Commercial |
$2.67
|
| Rate for Payer: HFN Commercial |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: NAPHCARE Commercial |
$1.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2.76
|
| Rate for Payer: Quartz Beloit One Network |
$1.47
|
| Rate for Payer: Quartz Commercial |
$1.80
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$2.22
|
|
|
SYRINGE SLIP 6cc #8881516911
|
Facility
|
OP
|
$3.00
|
|
| Hospital Charge Code |
2974544
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.58
|
| Rate for Payer: Aetna Managed Medicare |
$0.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.68
|
| Rate for Payer: Health EOS Commercial |
$2.67
|
| Rate for Payer: HFN Commercial |
$2.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: NAPHCARE Commercial |
$1.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2.76
|
| Rate for Payer: Quartz Beloit One Network |
$1.47
|
| Rate for Payer: Quartz Commercial |
$1.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1.80
|
| Rate for Payer: The Alliance Commercial |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$2.22
|
|
|
SYRINGE W/ 3mL NASAL DRUG MAD100
|
Facility
|
IP
|
$128.00
|
|
| Hospital Charge Code |
2974763
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$62.72 |
| Max. Negotiated Rate |
$117.76 |
| Rate for Payer: Aetna Commercial |
$115.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$117.76
|
| Rate for Payer: Health EOS Commercial |
$113.92
|
| Rate for Payer: HFN Commercial |
$117.76
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: NAPHCARE Commercial |
$76.80
|
| Rate for Payer: Preferred Network Access Commercial |
$117.76
|
| Rate for Payer: Quartz Beloit One Network |
$62.72
|
| Rate for Payer: Quartz Commercial |
$76.80
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
SYRINGE W/ 3mL NASAL DRUG MAD100
|
Facility
|
OP
|
$128.00
|
|
| Hospital Charge Code |
2974763
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.84 |
| Max. Negotiated Rate |
$512.00 |
| Rate for Payer: Aetna Commercial |
$115.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Aetna Managed Medicare |
$35.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$117.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.63
|
| Rate for Payer: Health EOS Commercial |
$113.92
|
| Rate for Payer: HFN Commercial |
$117.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.00
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: NAPHCARE Commercial |
$76.80
|
| Rate for Payer: Preferred Network Access Commercial |
$117.76
|
| Rate for Payer: Quartz Beloit One Network |
$62.72
|
| Rate for Payer: Quartz Commercial |
$83.20
|
| Rate for Payer: Quartz Medicare Advantage |
$76.80
|
| Rate for Payer: The Alliance Commercial |
$512.00
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
SYS REPOSITION PREVALON AIRTAP 7217
|
Facility
|
IP
|
$2,423.00
|
|
| Hospital Charge Code |
5414958
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,187.27 |
| Max. Negotiated Rate |
$2,229.16 |
| Rate for Payer: Aetna Commercial |
$2,180.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,083.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,284.19
|
| Rate for Payer: Cash Price |
$726.90
|
| Rate for Payer: Cigna Commercial |
$2,229.16
|
| Rate for Payer: Health EOS Commercial |
$2,156.47
|
| Rate for Payer: HFN Commercial |
$2,229.16
|
| Rate for Payer: Multiplan Commercial |
$1,938.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,453.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,229.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,187.27
|
| Rate for Payer: Quartz Commercial |
$1,453.80
|
| Rate for Payer: WEA Trust Commercial |
$1,332.65
|
| Rate for Payer: WPS Commercial |
$1,794.72
|
|
|
SYS REPOSITION PREVALON AIRTAP 7217
|
Facility
|
OP
|
$2,423.00
|
|
| Hospital Charge Code |
5414958
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$678.44 |
| Max. Negotiated Rate |
$9,692.00 |
| Rate for Payer: Aetna Commercial |
$2,180.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,083.78
|
| Rate for Payer: Aetna Managed Medicare |
$678.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,574.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,211.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,163.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,284.19
|
| Rate for Payer: Cash Price |
$726.90
|
| Rate for Payer: Cigna Commercial |
$2,229.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,355.91
|
| Rate for Payer: Health EOS Commercial |
$2,156.47
|
| Rate for Payer: HFN Commercial |
$2,229.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,817.25
|
| Rate for Payer: Multiplan Commercial |
$1,938.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,453.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,229.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,187.27
|
| Rate for Payer: Quartz Commercial |
$1,574.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,453.80
|
| Rate for Payer: The Alliance Commercial |
$9,692.00
|
| Rate for Payer: WEA Trust Commercial |
$1,332.65
|
| Rate for Payer: WPS Commercial |
$1,794.72
|
|
|
SYSTEM 1 LAPIPLASTY (4HL CRV PLT X 2, 2.7X12MM LOCK SCREW X 5, 2.7X14MM LOCK SCREW X 4) SK12
|
Facility
|
IP
|
$27,986.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6175181
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13,713.14 |
| Max. Negotiated Rate |
$25,747.12 |
| Rate for Payer: Aetna Commercial |
$25,187.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24,067.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,832.58
|
| Rate for Payer: Cash Price |
$8,395.80
|
| Rate for Payer: Cigna Commercial |
$25,747.12
|
| Rate for Payer: Health EOS Commercial |
$24,907.54
|
| Rate for Payer: HFN Commercial |
$25,747.12
|
| Rate for Payer: Multiplan Commercial |
$22,388.80
|
| Rate for Payer: NAPHCARE Commercial |
$16,791.60
|
| Rate for Payer: Preferred Network Access Commercial |
$25,747.12
|
| Rate for Payer: Quartz Beloit One Network |
$13,713.14
|
| Rate for Payer: Quartz Commercial |
$16,791.60
|
| Rate for Payer: WEA Trust Commercial |
$15,392.30
|
| Rate for Payer: WPS Commercial |
$20,729.23
|
|
|
SYSTEM 1 LAPIPLASTY (4HL CRV PLT X 2, 2.7X12MM LOCK SCREW X 5, 2.7X14MM LOCK SCREW X 4) SK12
|
Facility
|
OP
|
$27,986.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6175181
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,836.08 |
| Max. Negotiated Rate |
$111,944.00 |
| Rate for Payer: Aetna Commercial |
$25,187.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24,067.96
|
| Rate for Payer: Aetna Managed Medicare |
$7,836.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,190.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,993.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,433.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14,832.58
|
| Rate for Payer: Cash Price |
$8,395.80
|
| Rate for Payer: Cigna Commercial |
$25,747.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,660.97
|
| Rate for Payer: Health EOS Commercial |
$24,907.54
|
| Rate for Payer: HFN Commercial |
$25,747.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,989.50
|
| Rate for Payer: Multiplan Commercial |
$22,388.80
|
| Rate for Payer: NAPHCARE Commercial |
$16,791.60
|
| Rate for Payer: Preferred Network Access Commercial |
$25,747.12
|
| Rate for Payer: Quartz Beloit One Network |
$13,713.14
|
| Rate for Payer: Quartz Commercial |
$18,190.90
|
| Rate for Payer: Quartz Medicare Advantage |
$16,791.60
|
| Rate for Payer: The Alliance Commercial |
$111,944.00
|
| Rate for Payer: WEA Trust Commercial |
$15,392.30
|
| Rate for Payer: WPS Commercial |
$20,729.23
|
|
|
SYSTEM 2 LAPIPLASTY (4HL CRV PLT X 2, 2.7X12MM LOCK SCREW X 5, 2.7X14MM LOCK SCREW X 4) SK14
|
Facility
|
IP
|
$35,242.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5599637
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17,268.58 |
| Max. Negotiated Rate |
$32,422.64 |
| Rate for Payer: Aetna Commercial |
$31,717.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30,308.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18,678.26
|
| Rate for Payer: Cash Price |
$10,572.60
|
| Rate for Payer: Cigna Commercial |
$32,422.64
|
| Rate for Payer: Health EOS Commercial |
$31,365.38
|
| Rate for Payer: HFN Commercial |
$32,422.64
|
| Rate for Payer: Multiplan Commercial |
$28,193.60
|
| Rate for Payer: NAPHCARE Commercial |
$21,145.20
|
| Rate for Payer: Preferred Network Access Commercial |
$32,422.64
|
| Rate for Payer: Quartz Beloit One Network |
$17,268.58
|
| Rate for Payer: Quartz Commercial |
$21,145.20
|
| Rate for Payer: WEA Trust Commercial |
$19,383.10
|
| Rate for Payer: WPS Commercial |
$26,103.75
|
|
|
SYSTEM 2 LAPIPLASTY (4HL CRV PLT X 2, 2.7X12MM LOCK SCREW X 5, 2.7X14MM LOCK SCREW X 4) SK14
|
Facility
|
OP
|
$35,242.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5599637
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,867.76 |
| Max. Negotiated Rate |
$140,968.00 |
| Rate for Payer: Aetna Commercial |
$31,717.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30,308.12
|
| Rate for Payer: Aetna Managed Medicare |
$9,867.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22,907.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,621.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,916.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18,678.26
|
| Rate for Payer: Cash Price |
$10,572.60
|
| Rate for Payer: Cigna Commercial |
$32,422.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,721.42
|
| Rate for Payer: Health EOS Commercial |
$31,365.38
|
| Rate for Payer: HFN Commercial |
$32,422.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,431.50
|
| Rate for Payer: Multiplan Commercial |
$28,193.60
|
| Rate for Payer: NAPHCARE Commercial |
$21,145.20
|
| Rate for Payer: Preferred Network Access Commercial |
$32,422.64
|
| Rate for Payer: Quartz Beloit One Network |
$17,268.58
|
| Rate for Payer: Quartz Commercial |
$22,907.30
|
| Rate for Payer: Quartz Medicare Advantage |
$21,145.20
|
| Rate for Payer: The Alliance Commercial |
$140,968.00
|
| Rate for Payer: WEA Trust Commercial |
$19,383.10
|
| Rate for Payer: WPS Commercial |
$26,103.75
|
|
|
SYSTEM ABTHERA SENSA T.R.A.C. OPEN ABDOMINAL DRESSING M8275026/5
|
Facility
|
IP
|
$11,204.00
|
|
| Hospital Charge Code |
4640619
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,489.96 |
| Max. Negotiated Rate |
$10,307.68 |
| Rate for Payer: Aetna Commercial |
$10,083.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,635.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,938.12
|
| Rate for Payer: Cash Price |
$3,361.20
|
| Rate for Payer: Cigna Commercial |
$10,307.68
|
| Rate for Payer: Health EOS Commercial |
$9,971.56
|
| Rate for Payer: HFN Commercial |
$10,307.68
|
| Rate for Payer: Multiplan Commercial |
$8,963.20
|
| Rate for Payer: NAPHCARE Commercial |
$6,722.40
|
| Rate for Payer: Preferred Network Access Commercial |
$10,307.68
|
| Rate for Payer: Quartz Beloit One Network |
$5,489.96
|
| Rate for Payer: Quartz Commercial |
$6,722.40
|
| Rate for Payer: WEA Trust Commercial |
$6,162.20
|
| Rate for Payer: WPS Commercial |
$8,298.80
|
|
|
SYSTEM ABTHERA SENSA T.R.A.C. OPEN ABDOMINAL DRESSING M8275026/5
|
Facility
|
OP
|
$11,204.00
|
|
| Hospital Charge Code |
4640619
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,137.12 |
| Max. Negotiated Rate |
$44,816.00 |
| Rate for Payer: Aetna Commercial |
$10,083.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,635.44
|
| Rate for Payer: Aetna Managed Medicare |
$3,137.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,282.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,602.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,377.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,938.12
|
| Rate for Payer: Cash Price |
$3,361.20
|
| Rate for Payer: Cigna Commercial |
$10,307.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,269.76
|
| Rate for Payer: Health EOS Commercial |
$9,971.56
|
| Rate for Payer: HFN Commercial |
$10,307.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,403.00
|
| Rate for Payer: Multiplan Commercial |
$8,963.20
|
| Rate for Payer: NAPHCARE Commercial |
$6,722.40
|
| Rate for Payer: Preferred Network Access Commercial |
$10,307.68
|
| Rate for Payer: Quartz Beloit One Network |
$5,489.96
|
| Rate for Payer: Quartz Commercial |
$7,282.60
|
| Rate for Payer: Quartz Medicare Advantage |
$6,722.40
|
| Rate for Payer: The Alliance Commercial |
$44,816.00
|
| Rate for Payer: WEA Trust Commercial |
$6,162.20
|
| Rate for Payer: WPS Commercial |
$8,298.80
|
|
|
SYSTEM COPE CATHETER INTRODUCTION G03407
|
Facility
|
OP
|
$1,291.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5306823
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$361.48 |
| Max. Negotiated Rate |
$5,164.00 |
| Rate for Payer: Aetna Commercial |
$1,161.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,110.26
|
| Rate for Payer: Aetna Managed Medicare |
$361.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$839.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$645.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$619.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$684.23
|
| Rate for Payer: Cash Price |
$387.30
|
| Rate for Payer: Cigna Commercial |
$1,187.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$722.44
|
| Rate for Payer: Health EOS Commercial |
$1,148.99
|
| Rate for Payer: HFN Commercial |
$1,187.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$968.25
|
| Rate for Payer: Multiplan Commercial |
$1,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$774.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,187.72
|
| Rate for Payer: Quartz Beloit One Network |
$632.59
|
| Rate for Payer: Quartz Commercial |
$839.15
|
| Rate for Payer: Quartz Medicare Advantage |
$774.60
|
| Rate for Payer: The Alliance Commercial |
$5,164.00
|
| Rate for Payer: WEA Trust Commercial |
$710.05
|
| Rate for Payer: WPS Commercial |
$956.24
|
|
|
SYSTEM COPE CATHETER INTRODUCTION G03407
|
Facility
|
IP
|
$1,291.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5306823
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$632.59 |
| Max. Negotiated Rate |
$1,187.72 |
| Rate for Payer: Aetna Commercial |
$1,161.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,110.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$684.23
|
| Rate for Payer: Cash Price |
$387.30
|
| Rate for Payer: Cigna Commercial |
$1,187.72
|
| Rate for Payer: Health EOS Commercial |
$1,148.99
|
| Rate for Payer: HFN Commercial |
$1,187.72
|
| Rate for Payer: Multiplan Commercial |
$1,032.80
|
| Rate for Payer: NAPHCARE Commercial |
$774.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,187.72
|
| Rate for Payer: Quartz Beloit One Network |
$632.59
|
| Rate for Payer: Quartz Commercial |
$774.60
|
| Rate for Payer: WEA Trust Commercial |
$710.05
|
| Rate for Payer: WPS Commercial |
$956.24
|
|
|
SYSTEM CUSTOM PERFUSION VACUUM 0Y35R
|
Facility
|
IP
|
$598.00
|
|
| Hospital Charge Code |
3792827
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$293.02 |
| Max. Negotiated Rate |
$550.16 |
| Rate for Payer: Aetna Commercial |
$538.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$514.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$316.94
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cigna Commercial |
$550.16
|
| Rate for Payer: Health EOS Commercial |
$532.22
|
| Rate for Payer: HFN Commercial |
$550.16
|
| Rate for Payer: Multiplan Commercial |
$478.40
|
| Rate for Payer: NAPHCARE Commercial |
$358.80
|
| Rate for Payer: Preferred Network Access Commercial |
$550.16
|
| Rate for Payer: Quartz Beloit One Network |
$293.02
|
| Rate for Payer: Quartz Commercial |
$358.80
|
| Rate for Payer: WEA Trust Commercial |
$328.90
|
| Rate for Payer: WPS Commercial |
$442.94
|
|
|
SYSTEM CUSTOM PERFUSION VACUUM 0Y35R
|
Facility
|
OP
|
$598.00
|
|
| Hospital Charge Code |
3792827
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$167.44 |
| Max. Negotiated Rate |
$2,392.00 |
| Rate for Payer: Aetna Commercial |
$538.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$514.28
|
| Rate for Payer: Aetna Managed Medicare |
$167.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$388.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$299.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$287.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$316.94
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cigna Commercial |
$550.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$334.64
|
| Rate for Payer: Health EOS Commercial |
$532.22
|
| Rate for Payer: HFN Commercial |
$550.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$448.50
|
| Rate for Payer: Multiplan Commercial |
$478.40
|
| Rate for Payer: NAPHCARE Commercial |
$358.80
|
| Rate for Payer: Preferred Network Access Commercial |
$550.16
|
| Rate for Payer: Quartz Beloit One Network |
$293.02
|
| Rate for Payer: Quartz Commercial |
$388.70
|
| Rate for Payer: Quartz Medicare Advantage |
$358.80
|
| Rate for Payer: The Alliance Commercial |
$2,392.00
|
| Rate for Payer: WEA Trust Commercial |
$328.90
|
| Rate for Payer: WPS Commercial |
$442.94
|
|
|
Systemic Lupus (SLE) Comprehensive Diagnostics Panel
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
CPT 86038
|
| Hospital Charge Code |
3398191
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$85.26 |
| Max. Negotiated Rate |
$160.08 |
| Rate for Payer: Aetna Commercial |
$156.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.22
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$160.08
|
| Rate for Payer: Health EOS Commercial |
$154.86
|
| Rate for Payer: HFN Commercial |
$160.08
|
| Rate for Payer: Multiplan Commercial |
$139.20
|
| Rate for Payer: NAPHCARE Commercial |
$104.40
|
| Rate for Payer: Preferred Network Access Commercial |
$160.08
|
| Rate for Payer: Quartz Beloit One Network |
$85.26
|
| Rate for Payer: Quartz Commercial |
$104.40
|
| Rate for Payer: WEA Trust Commercial |
$95.70
|
| Rate for Payer: WPS Commercial |
$128.88
|
|
|
Systemic Lupus (SLE) Comprehensive Diagnostics Panel
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
CPT 86038
|
| Hospital Charge Code |
3398191
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.09 |
| Max. Negotiated Rate |
$160.08 |
| Rate for Payer: Aetna Commercial |
$156.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.64
|
| Rate for Payer: Aetna Managed Medicare |
$12.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.07
|
| Rate for Payer: Anthem Medicaid |
$12.49
|
| Rate for Payer: Anthem Medicare Advantage |
$12.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.09
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$160.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.37
|
| Rate for Payer: Dean Health Medicaid |
$12.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.09
|
| Rate for Payer: Health EOS Commercial |
$154.86
|
| Rate for Payer: HFN Commercial |
$160.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.09
|
| Rate for Payer: Managed Health Services Medicaid |
$12.99
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.09
|
| Rate for Payer: Multiplan Commercial |
$139.20
|
| Rate for Payer: NAPHCARE Commercial |
$18.14
|
| Rate for Payer: Preferred Network Access Commercial |
$160.08
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.49
|
| Rate for Payer: Quartz Beloit One Network |
$85.26
|
| Rate for Payer: Quartz Commercial |
$113.10
|
| Rate for Payer: Quartz Medicare Advantage |
$12.09
|
| Rate for Payer: The Alliance Commercial |
$48.36
|
| Rate for Payer: United Healthcare Medicaid |
$12.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.09
|
| Rate for Payer: United Healthcare PPO |
$130.50
|
| Rate for Payer: WEA Trust Commercial |
$95.70
|
| Rate for Payer: Wellcare Medicare |
$12.09
|
| Rate for Payer: WMAP Medicaid |
$12.49
|
| Rate for Payer: WPS Commercial |
$128.88
|
|
|
Systemic Lupus (SLE) Comprehensive Diagnostics Panel
|
Professional
|
Both
|
$174.00
|
|
|
Service Code
|
CPT 86038
|
| Hospital Charge Code |
3398191
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.68 |
| Max. Negotiated Rate |
$165.30 |
| Rate for Payer: Aetna Commercial |
$165.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.64
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$165.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$87.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104.40
|
| Rate for Payer: Health EOS Commercial |
$158.34
|
| Rate for Payer: HFN Commercial |
$165.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.68
|
| Rate for Payer: Multiplan Commercial |
$139.20
|
| Rate for Payer: Preferred Network Access Commercial |
$165.30
|
| Rate for Payer: Quartz Beloit One Network |
$76.56
|
| Rate for Payer: Quartz Commercial |
$99.18
|
| Rate for Payer: The Alliance Commercial |
$87.00
|
| Rate for Payer: WEA Trust Commercial |
$95.70
|
| Rate for Payer: WPS Commercial |
$128.88
|
|
|
SYSTEM IRRIGATION IRRISEPT IRRISEPT
|
Facility
|
OP
|
$1,129.00
|
|
| Hospital Charge Code |
5349335
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$316.12 |
| Max. Negotiated Rate |
$4,516.00 |
| Rate for Payer: Aetna Commercial |
$1,016.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$970.94
|
| Rate for Payer: Aetna Managed Medicare |
$316.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$733.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$564.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$598.37
|
| Rate for Payer: Cash Price |
$338.70
|
| Rate for Payer: Cigna Commercial |
$1,038.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$631.79
|
| Rate for Payer: Health EOS Commercial |
$1,004.81
|
| Rate for Payer: HFN Commercial |
$1,038.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$846.75
|
| Rate for Payer: Multiplan Commercial |
$903.20
|
| Rate for Payer: NAPHCARE Commercial |
$677.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,038.68
|
| Rate for Payer: Quartz Beloit One Network |
$553.21
|
| Rate for Payer: Quartz Commercial |
$733.85
|
| Rate for Payer: Quartz Medicare Advantage |
$677.40
|
| Rate for Payer: The Alliance Commercial |
$4,516.00
|
| Rate for Payer: WEA Trust Commercial |
$620.95
|
| Rate for Payer: WPS Commercial |
$836.25
|
|
|
SYSTEM IRRIGATION IRRISEPT IRRISEPT
|
Facility
|
IP
|
$1,129.00
|
|
| Hospital Charge Code |
5349335
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$553.21 |
| Max. Negotiated Rate |
$1,038.68 |
| Rate for Payer: Aetna Commercial |
$1,016.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$970.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$598.37
|
| Rate for Payer: Cash Price |
$338.70
|
| Rate for Payer: Cigna Commercial |
$1,038.68
|
| Rate for Payer: Health EOS Commercial |
$1,004.81
|
| Rate for Payer: HFN Commercial |
$1,038.68
|
| Rate for Payer: Multiplan Commercial |
$903.20
|
| Rate for Payer: NAPHCARE Commercial |
$677.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,038.68
|
| Rate for Payer: Quartz Beloit One Network |
$553.21
|
| Rate for Payer: Quartz Commercial |
$677.40
|
| Rate for Payer: WEA Trust Commercial |
$620.95
|
| Rate for Payer: WPS Commercial |
$836.25
|
|
|
SYSTEM MAX CORE BIOPSY 18 X 20CM (GENERAL) MC1820
|
Facility
|
OP
|
$861.00
|
|
| Hospital Charge Code |
2969353
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$241.08 |
| Max. Negotiated Rate |
$3,444.00 |
| Rate for Payer: Aetna Commercial |
$774.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$740.46
|
| Rate for Payer: Aetna Managed Medicare |
$241.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$559.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$430.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$413.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$456.33
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$792.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$481.82
|
| Rate for Payer: Health EOS Commercial |
$766.29
|
| Rate for Payer: HFN Commercial |
$792.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$645.75
|
| Rate for Payer: Multiplan Commercial |
$688.80
|
| Rate for Payer: NAPHCARE Commercial |
$516.60
|
| Rate for Payer: Preferred Network Access Commercial |
$792.12
|
| Rate for Payer: Quartz Beloit One Network |
$421.89
|
| Rate for Payer: Quartz Commercial |
$559.65
|
| Rate for Payer: Quartz Medicare Advantage |
$516.60
|
| Rate for Payer: The Alliance Commercial |
$3,444.00
|
| Rate for Payer: WEA Trust Commercial |
$473.55
|
| Rate for Payer: WPS Commercial |
$637.74
|
|
|
SYSTEM MAX CORE BIOPSY 18 X 20CM (GENERAL) MC1820
|
Facility
|
IP
|
$861.00
|
|
| Hospital Charge Code |
2969353
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$421.89 |
| Max. Negotiated Rate |
$792.12 |
| Rate for Payer: Aetna Commercial |
$774.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$740.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$456.33
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$792.12
|
| Rate for Payer: Health EOS Commercial |
$766.29
|
| Rate for Payer: HFN Commercial |
$792.12
|
| Rate for Payer: Multiplan Commercial |
$688.80
|
| Rate for Payer: NAPHCARE Commercial |
$516.60
|
| Rate for Payer: Preferred Network Access Commercial |
$792.12
|
| Rate for Payer: Quartz Beloit One Network |
$421.89
|
| Rate for Payer: Quartz Commercial |
$516.60
|
| Rate for Payer: WEA Trust Commercial |
$473.55
|
| Rate for Payer: WPS Commercial |
$637.74
|
|
