|
T4 Free, Direct Dialysis
|
Facility
|
OP
|
$752.00
|
|
|
Service Code
|
CPT 84439
|
| Hospital Charge Code |
983417
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.02 |
| Max. Negotiated Rate |
$691.84 |
| Rate for Payer: Aetna Commercial |
$676.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$646.72
|
| Rate for Payer: Aetna Managed Medicare |
$9.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.78
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.97
|
| Rate for Payer: Anthem Medicaid |
$9.32
|
| Rate for Payer: Anthem Medicare Advantage |
$9.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$398.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.02
|
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Cigna Commercial |
$691.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$420.82
|
| Rate for Payer: Dean Health Medicaid |
$9.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9.02
|
| Rate for Payer: Health EOS Commercial |
$669.28
|
| Rate for Payer: HFN Commercial |
$691.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.02
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.02
|
| Rate for Payer: Managed Health Services Medicaid |
$9.69
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9.02
|
| Rate for Payer: Multiplan Commercial |
$601.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.53
|
| Rate for Payer: Preferred Network Access Commercial |
$691.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9.32
|
| Rate for Payer: Quartz Beloit One Network |
$368.48
|
| Rate for Payer: Quartz Commercial |
$488.80
|
| Rate for Payer: Quartz Medicare Advantage |
$9.02
|
| Rate for Payer: The Alliance Commercial |
$36.08
|
| Rate for Payer: United Healthcare Medicaid |
$9.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.02
|
| Rate for Payer: United Healthcare PPO |
$564.00
|
| Rate for Payer: WEA Trust Commercial |
$413.60
|
| Rate for Payer: Wellcare Medicare |
$9.02
|
| Rate for Payer: WMAP Medicaid |
$9.32
|
| Rate for Payer: WPS Commercial |
$557.01
|
|
|
TACKER ABSORBATACK 5MM ABSORBABLE FIXATION DEVICE ABSTACK30X
|
Facility
|
OP
|
$6,187.00
|
|
| Hospital Charge Code |
3825401
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,732.36 |
| Max. Negotiated Rate |
$24,748.00 |
| Rate for Payer: Aetna Commercial |
$5,568.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,320.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,732.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,021.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,093.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,969.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,279.11
|
| Rate for Payer: Cash Price |
$1,856.10
|
| Rate for Payer: Cigna Commercial |
$5,692.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,462.25
|
| Rate for Payer: Health EOS Commercial |
$5,506.43
|
| Rate for Payer: HFN Commercial |
$5,692.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,640.25
|
| Rate for Payer: Multiplan Commercial |
$4,949.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,712.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,692.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,031.63
|
| Rate for Payer: Quartz Commercial |
$4,021.55
|
| Rate for Payer: Quartz Medicare Advantage |
$3,712.20
|
| Rate for Payer: The Alliance Commercial |
$24,748.00
|
| Rate for Payer: WEA Trust Commercial |
$3,402.85
|
| Rate for Payer: WPS Commercial |
$4,582.71
|
|
|
TACKER ABSORBATACK 5MM ABSORBABLE FIXATION DEVICE ABSTACK30X
|
Facility
|
IP
|
$6,187.00
|
|
| Hospital Charge Code |
3825401
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,031.63 |
| Max. Negotiated Rate |
$5,692.04 |
| Rate for Payer: Aetna Commercial |
$5,568.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,320.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,279.11
|
| Rate for Payer: Cash Price |
$1,856.10
|
| Rate for Payer: Cigna Commercial |
$5,692.04
|
| Rate for Payer: Health EOS Commercial |
$5,506.43
|
| Rate for Payer: HFN Commercial |
$5,692.04
|
| Rate for Payer: Multiplan Commercial |
$4,949.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,712.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,692.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,031.63
|
| Rate for Payer: Quartz Commercial |
$3,712.20
|
| Rate for Payer: WEA Trust Commercial |
$3,402.85
|
| Rate for Payer: WPS Commercial |
$4,582.71
|
|
|
TACKER OPTIFIX AT ABSORBABLE ARTICULATING 15 0113315
|
Facility
|
OP
|
$3,766.00
|
|
| Hospital Charge Code |
5563427
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,054.48 |
| Max. Negotiated Rate |
$15,064.00 |
| Rate for Payer: Aetna Commercial |
$3,389.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,238.76
|
| Rate for Payer: Aetna Managed Medicare |
$1,054.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,447.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,883.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,807.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,995.98
|
| Rate for Payer: Cash Price |
$1,129.80
|
| Rate for Payer: Cigna Commercial |
$3,464.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,107.45
|
| Rate for Payer: Health EOS Commercial |
$3,351.74
|
| Rate for Payer: HFN Commercial |
$3,464.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,824.50
|
| Rate for Payer: Multiplan Commercial |
$3,012.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,259.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,464.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,845.34
|
| Rate for Payer: Quartz Commercial |
$2,447.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,259.60
|
| Rate for Payer: The Alliance Commercial |
$15,064.00
|
| Rate for Payer: WEA Trust Commercial |
$2,071.30
|
| Rate for Payer: WPS Commercial |
$2,789.48
|
|
|
TACKER OPTIFIX AT ABSORBABLE ARTICULATING 15 0113315
|
Facility
|
IP
|
$3,766.00
|
|
| Hospital Charge Code |
5563427
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,845.34 |
| Max. Negotiated Rate |
$3,464.72 |
| Rate for Payer: Aetna Commercial |
$3,389.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,238.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,995.98
|
| Rate for Payer: Cash Price |
$1,129.80
|
| Rate for Payer: Cigna Commercial |
$3,464.72
|
| Rate for Payer: Health EOS Commercial |
$3,351.74
|
| Rate for Payer: HFN Commercial |
$3,464.72
|
| Rate for Payer: Multiplan Commercial |
$3,012.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,259.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,464.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,845.34
|
| Rate for Payer: Quartz Commercial |
$2,259.60
|
| Rate for Payer: WEA Trust Commercial |
$2,071.30
|
| Rate for Payer: WPS Commercial |
$2,789.48
|
|
|
TACKER OPTIFIX AT ABSORBABLE ARTICULATING 30 0113330
|
Facility
|
OP
|
$4,308.00
|
|
| Hospital Charge Code |
5497124
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,206.24 |
| Max. Negotiated Rate |
$17,232.00 |
| Rate for Payer: Aetna Commercial |
$3,877.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,704.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,206.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,800.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,154.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,067.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,283.24
|
| Rate for Payer: Cash Price |
$1,292.40
|
| Rate for Payer: Cigna Commercial |
$3,963.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,410.76
|
| Rate for Payer: Health EOS Commercial |
$3,834.12
|
| Rate for Payer: HFN Commercial |
$3,963.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,231.00
|
| Rate for Payer: Multiplan Commercial |
$3,446.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,584.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,963.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,110.92
|
| Rate for Payer: Quartz Commercial |
$2,800.20
|
| Rate for Payer: Quartz Medicare Advantage |
$2,584.80
|
| Rate for Payer: The Alliance Commercial |
$17,232.00
|
| Rate for Payer: WEA Trust Commercial |
$2,369.40
|
| Rate for Payer: WPS Commercial |
$3,190.94
|
|
|
TACKER OPTIFIX AT ABSORBABLE ARTICULATING 30 0113330
|
Facility
|
IP
|
$4,308.00
|
|
| Hospital Charge Code |
5497124
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,110.92 |
| Max. Negotiated Rate |
$3,963.36 |
| Rate for Payer: Aetna Commercial |
$3,877.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,704.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,283.24
|
| Rate for Payer: Cash Price |
$1,292.40
|
| Rate for Payer: Cigna Commercial |
$3,963.36
|
| Rate for Payer: Health EOS Commercial |
$3,834.12
|
| Rate for Payer: HFN Commercial |
$3,963.36
|
| Rate for Payer: Multiplan Commercial |
$3,446.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,584.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,963.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,110.92
|
| Rate for Payer: Quartz Commercial |
$2,584.80
|
| Rate for Payer: WEA Trust Commercial |
$2,369.40
|
| Rate for Payer: WPS Commercial |
$3,190.94
|
|
|
TACKER RELIATACK 5MM ARTICULATING RELOADABLE FIXATION DEVICE RELTACK4XDPTSW
|
Facility
|
IP
|
$6,267.00
|
|
| Hospital Charge Code |
4640732
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,070.83 |
| Max. Negotiated Rate |
$5,765.64 |
| Rate for Payer: Aetna Commercial |
$5,640.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,389.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,321.51
|
| Rate for Payer: Cash Price |
$1,880.10
|
| Rate for Payer: Cigna Commercial |
$5,765.64
|
| Rate for Payer: Health EOS Commercial |
$5,577.63
|
| Rate for Payer: HFN Commercial |
$5,765.64
|
| Rate for Payer: Multiplan Commercial |
$5,013.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,760.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,765.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,070.83
|
| Rate for Payer: Quartz Commercial |
$3,760.20
|
| Rate for Payer: WEA Trust Commercial |
$3,446.85
|
| Rate for Payer: WPS Commercial |
$4,641.97
|
|
|
TACKER RELIATACK 5MM ARTICULATING RELOADABLE FIXATION DEVICE RELTACK4XDPTSW
|
Facility
|
OP
|
$6,267.00
|
|
| Hospital Charge Code |
4640732
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,754.76 |
| Max. Negotiated Rate |
$25,068.00 |
| Rate for Payer: Aetna Commercial |
$5,640.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,389.62
|
| Rate for Payer: Aetna Managed Medicare |
$1,754.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,073.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,133.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,008.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,321.51
|
| Rate for Payer: Cash Price |
$1,880.10
|
| Rate for Payer: Cigna Commercial |
$5,765.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,507.01
|
| Rate for Payer: Health EOS Commercial |
$5,577.63
|
| Rate for Payer: HFN Commercial |
$5,765.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,700.25
|
| Rate for Payer: Multiplan Commercial |
$5,013.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,760.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,765.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,070.83
|
| Rate for Payer: Quartz Commercial |
$4,073.55
|
| Rate for Payer: Quartz Medicare Advantage |
$3,760.20
|
| Rate for Payer: The Alliance Commercial |
$25,068.00
|
| Rate for Payer: WEA Trust Commercial |
$3,446.85
|
| Rate for Payer: WPS Commercial |
$4,641.97
|
|
|
TACKER SYSTEM SORBAFIX 30 ABSORBABLE FIXATION 36CM FASTENER 0113116
|
Facility
|
OP
|
$5,590.00
|
|
| Hospital Charge Code |
4594890
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,565.20 |
| Max. Negotiated Rate |
$22,360.00 |
| Rate for Payer: Aetna Commercial |
$5,031.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,807.40
|
| Rate for Payer: Aetna Managed Medicare |
$1,565.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,633.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,795.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,683.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,962.70
|
| Rate for Payer: Cash Price |
$1,677.00
|
| Rate for Payer: Cigna Commercial |
$5,142.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,128.16
|
| Rate for Payer: Health EOS Commercial |
$4,975.10
|
| Rate for Payer: HFN Commercial |
$5,142.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,192.50
|
| Rate for Payer: Multiplan Commercial |
$4,472.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,354.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,142.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,739.10
|
| Rate for Payer: Quartz Commercial |
$3,633.50
|
| Rate for Payer: Quartz Medicare Advantage |
$3,354.00
|
| Rate for Payer: The Alliance Commercial |
$22,360.00
|
| Rate for Payer: WEA Trust Commercial |
$3,074.50
|
| Rate for Payer: WPS Commercial |
$4,140.51
|
|
|
TACKER SYSTEM SORBAFIX 30 ABSORBABLE FIXATION 36CM FASTENER 0113116
|
Facility
|
IP
|
$5,590.00
|
|
| Hospital Charge Code |
4594890
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,739.10 |
| Max. Negotiated Rate |
$5,142.80 |
| Rate for Payer: Aetna Commercial |
$5,031.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,807.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,962.70
|
| Rate for Payer: Cash Price |
$1,677.00
|
| Rate for Payer: Cigna Commercial |
$5,142.80
|
| Rate for Payer: Health EOS Commercial |
$4,975.10
|
| Rate for Payer: HFN Commercial |
$5,142.80
|
| Rate for Payer: Multiplan Commercial |
$4,472.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,354.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,142.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,739.10
|
| Rate for Payer: Quartz Commercial |
$3,354.00
|
| Rate for Payer: WEA Trust Commercial |
$3,074.50
|
| Rate for Payer: WPS Commercial |
$4,140.51
|
|
|
TACK SMALL PLATE 80-0248
|
Facility
|
OP
|
$1,244.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5611756
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$348.32 |
| Max. Negotiated Rate |
$4,976.00 |
| Rate for Payer: Aetna Commercial |
$1,119.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,069.84
|
| Rate for Payer: Aetna Managed Medicare |
$348.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$808.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$622.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$597.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$659.32
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cigna Commercial |
$1,144.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$696.14
|
| Rate for Payer: Health EOS Commercial |
$1,107.16
|
| Rate for Payer: HFN Commercial |
$1,144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$933.00
|
| Rate for Payer: Multiplan Commercial |
$995.20
|
| Rate for Payer: NAPHCARE Commercial |
$746.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,144.48
|
| Rate for Payer: Quartz Beloit One Network |
$609.56
|
| Rate for Payer: Quartz Commercial |
$808.60
|
| Rate for Payer: Quartz Medicare Advantage |
$746.40
|
| Rate for Payer: The Alliance Commercial |
$4,976.00
|
| Rate for Payer: WEA Trust Commercial |
$684.20
|
| Rate for Payer: WPS Commercial |
$921.43
|
|
|
TACK SMALL PLATE 80-0248
|
Facility
|
IP
|
$1,244.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5611756
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$609.56 |
| Max. Negotiated Rate |
$1,144.48 |
| Rate for Payer: Aetna Commercial |
$1,119.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,069.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$659.32
|
| Rate for Payer: Cash Price |
$373.20
|
| Rate for Payer: Cigna Commercial |
$1,144.48
|
| Rate for Payer: Health EOS Commercial |
$1,107.16
|
| Rate for Payer: HFN Commercial |
$1,144.48
|
| Rate for Payer: Multiplan Commercial |
$995.20
|
| Rate for Payer: NAPHCARE Commercial |
$746.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,144.48
|
| Rate for Payer: Quartz Beloit One Network |
$609.56
|
| Rate for Payer: Quartz Commercial |
$746.40
|
| Rate for Payer: WEA Trust Commercial |
$684.20
|
| Rate for Payer: WPS Commercial |
$921.43
|
|
|
Tacrolimus Level
|
Facility
|
IP
|
$453.00
|
|
|
Service Code
|
CPT 80197
|
| Hospital Charge Code |
978075
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$221.97 |
| Max. Negotiated Rate |
$416.76 |
| Rate for Payer: Aetna Commercial |
$407.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$389.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$240.09
|
| Rate for Payer: Cash Price |
$135.90
|
| Rate for Payer: Cigna Commercial |
$416.76
|
| Rate for Payer: Health EOS Commercial |
$403.17
|
| Rate for Payer: HFN Commercial |
$416.76
|
| Rate for Payer: Multiplan Commercial |
$362.40
|
| Rate for Payer: NAPHCARE Commercial |
$271.80
|
| Rate for Payer: Preferred Network Access Commercial |
$416.76
|
| Rate for Payer: Quartz Beloit One Network |
$221.97
|
| Rate for Payer: Quartz Commercial |
$271.80
|
| Rate for Payer: WEA Trust Commercial |
$249.15
|
| Rate for Payer: WPS Commercial |
$335.54
|
|
|
Tacrolimus Level
|
Facility
|
OP
|
$453.00
|
|
|
Service Code
|
CPT 80197
|
| Hospital Charge Code |
978075
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.73 |
| Max. Negotiated Rate |
$416.76 |
| Rate for Payer: Aetna Commercial |
$407.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$389.58
|
| Rate for Payer: Aetna Managed Medicare |
$13.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.79
|
| Rate for Payer: Anthem Medicaid |
$14.19
|
| Rate for Payer: Anthem Medicare Advantage |
$13.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$240.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.73
|
| Rate for Payer: Cash Price |
$135.90
|
| Rate for Payer: Cash Price |
$135.90
|
| Rate for Payer: Cigna Commercial |
$416.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$253.50
|
| Rate for Payer: Dean Health Medicaid |
$14.19
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.73
|
| Rate for Payer: Health EOS Commercial |
$403.17
|
| Rate for Payer: HFN Commercial |
$416.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.73
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.19
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.73
|
| Rate for Payer: Managed Health Services Medicaid |
$14.76
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.73
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.73
|
| Rate for Payer: Multiplan Commercial |
$362.40
|
| Rate for Payer: NAPHCARE Commercial |
$20.60
|
| Rate for Payer: Preferred Network Access Commercial |
$416.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.19
|
| Rate for Payer: Quartz Beloit One Network |
$221.97
|
| Rate for Payer: Quartz Commercial |
$294.45
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$54.92
|
| Rate for Payer: United Healthcare Medicaid |
$14.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.73
|
| Rate for Payer: United Healthcare PPO |
$339.75
|
| Rate for Payer: WEA Trust Commercial |
$249.15
|
| Rate for Payer: Wellcare Medicare |
$13.73
|
| Rate for Payer: WMAP Medicaid |
$14.19
|
| Rate for Payer: WPS Commercial |
$335.54
|
|
|
Tacrolimus Level
|
Professional
|
Both
|
$453.00
|
|
|
Service Code
|
CPT 80197
|
| Hospital Charge Code |
978075
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.47 |
| Max. Negotiated Rate |
$430.35 |
| Rate for Payer: Aetna Commercial |
$430.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$389.58
|
| Rate for Payer: Cash Price |
$135.90
|
| Rate for Payer: Cash Price |
$135.90
|
| Rate for Payer: Cigna Commercial |
$430.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$226.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$271.80
|
| Rate for Payer: Health EOS Commercial |
$412.23
|
| Rate for Payer: HFN Commercial |
$430.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.47
|
| Rate for Payer: Multiplan Commercial |
$362.40
|
| Rate for Payer: Preferred Network Access Commercial |
$430.35
|
| Rate for Payer: Quartz Beloit One Network |
$199.32
|
| Rate for Payer: Quartz Commercial |
$258.21
|
| Rate for Payer: The Alliance Commercial |
$226.50
|
| Rate for Payer: WEA Trust Commercial |
$249.15
|
| Rate for Payer: WPS Commercial |
$335.54
|
|
|
Tacrolimus to Mayo
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT 80197
|
| Hospital Charge Code |
5038606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.90 |
| Max. Negotiated Rate |
$101.20 |
| Rate for Payer: Aetna Commercial |
$99.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.30
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$101.20
|
| Rate for Payer: Health EOS Commercial |
$97.90
|
| Rate for Payer: HFN Commercial |
$101.20
|
| Rate for Payer: Multiplan Commercial |
$88.00
|
| Rate for Payer: NAPHCARE Commercial |
$66.00
|
| Rate for Payer: Preferred Network Access Commercial |
$101.20
|
| Rate for Payer: Quartz Beloit One Network |
$53.90
|
| Rate for Payer: Quartz Commercial |
$66.00
|
| Rate for Payer: WEA Trust Commercial |
$60.50
|
| Rate for Payer: WPS Commercial |
$81.48
|
|
|
Tacrolimus to Mayo
|
Professional
|
Both
|
$110.00
|
|
|
Service Code
|
CPT 80197
|
| Hospital Charge Code |
5038606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.40 |
| Max. Negotiated Rate |
$104.50 |
| Rate for Payer: Aetna Commercial |
$104.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.60
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$104.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$55.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.00
|
| Rate for Payer: Health EOS Commercial |
$100.10
|
| Rate for Payer: HFN Commercial |
$104.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.47
|
| Rate for Payer: Multiplan Commercial |
$88.00
|
| Rate for Payer: Preferred Network Access Commercial |
$104.50
|
| Rate for Payer: Quartz Beloit One Network |
$48.40
|
| Rate for Payer: Quartz Commercial |
$62.70
|
| Rate for Payer: The Alliance Commercial |
$55.00
|
| Rate for Payer: WEA Trust Commercial |
$60.50
|
| Rate for Payer: WPS Commercial |
$81.48
|
|
|
Tacrolimus to Mayo
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
CPT 80197
|
| Hospital Charge Code |
5038606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.73 |
| Max. Negotiated Rate |
$101.20 |
| Rate for Payer: Aetna Commercial |
$99.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.60
|
| Rate for Payer: Aetna Managed Medicare |
$13.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.79
|
| Rate for Payer: Anthem Medicaid |
$14.19
|
| Rate for Payer: Anthem Medicare Advantage |
$13.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.73
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$101.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.56
|
| Rate for Payer: Dean Health Medicaid |
$14.19
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.73
|
| Rate for Payer: Health EOS Commercial |
$97.90
|
| Rate for Payer: HFN Commercial |
$101.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.73
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.19
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.73
|
| Rate for Payer: Managed Health Services Medicaid |
$14.76
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.73
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.73
|
| Rate for Payer: Multiplan Commercial |
$88.00
|
| Rate for Payer: NAPHCARE Commercial |
$20.60
|
| Rate for Payer: Preferred Network Access Commercial |
$101.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.19
|
| Rate for Payer: Quartz Beloit One Network |
$53.90
|
| Rate for Payer: Quartz Commercial |
$71.50
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$54.92
|
| Rate for Payer: United Healthcare Medicaid |
$14.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.73
|
| Rate for Payer: United Healthcare PPO |
$82.50
|
| Rate for Payer: WEA Trust Commercial |
$60.50
|
| Rate for Payer: Wellcare Medicare |
$13.73
|
| Rate for Payer: WMAP Medicaid |
$14.19
|
| Rate for Payer: WPS Commercial |
$81.48
|
|
|
TALAR DOME FLAT CUT INFINITY ADAPTIS SZ 1 33680031
|
Facility
|
OP
|
$41,883.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6175038
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,727.24 |
| Max. Negotiated Rate |
$167,532.00 |
| Rate for Payer: Aetna Commercial |
$37,694.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36,019.38
|
| Rate for Payer: Aetna Managed Medicare |
$11,727.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,223.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20,941.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,103.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22,197.99
|
| Rate for Payer: Cash Price |
$12,564.90
|
| Rate for Payer: Cigna Commercial |
$38,532.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23,437.73
|
| Rate for Payer: Health EOS Commercial |
$37,275.87
|
| Rate for Payer: HFN Commercial |
$38,532.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31,412.25
|
| Rate for Payer: Multiplan Commercial |
$33,506.40
|
| Rate for Payer: NAPHCARE Commercial |
$25,129.80
|
| Rate for Payer: Preferred Network Access Commercial |
$38,532.36
|
| Rate for Payer: Quartz Beloit One Network |
$20,522.67
|
| Rate for Payer: Quartz Commercial |
$27,223.95
|
| Rate for Payer: Quartz Medicare Advantage |
$25,129.80
|
| Rate for Payer: The Alliance Commercial |
$167,532.00
|
| Rate for Payer: WEA Trust Commercial |
$23,035.65
|
| Rate for Payer: WPS Commercial |
$31,022.74
|
|
|
TALAR DOME FLAT CUT INFINITY ADAPTIS SZ 1 33680031
|
Facility
|
IP
|
$41,883.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6175038
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20,522.67 |
| Max. Negotiated Rate |
$38,532.36 |
| Rate for Payer: Aetna Commercial |
$37,694.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36,019.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22,197.99
|
| Rate for Payer: Cash Price |
$12,564.90
|
| Rate for Payer: Cigna Commercial |
$38,532.36
|
| Rate for Payer: Health EOS Commercial |
$37,275.87
|
| Rate for Payer: HFN Commercial |
$38,532.36
|
| Rate for Payer: Multiplan Commercial |
$33,506.40
|
| Rate for Payer: NAPHCARE Commercial |
$25,129.80
|
| Rate for Payer: Preferred Network Access Commercial |
$38,532.36
|
| Rate for Payer: Quartz Beloit One Network |
$20,522.67
|
| Rate for Payer: Quartz Commercial |
$25,129.80
|
| Rate for Payer: WEA Trust Commercial |
$23,035.65
|
| Rate for Payer: WPS Commercial |
$31,022.74
|
|
|
TALAR DOME FLAT CUT INFINITY ADAPTIS SZ 2 33680032
|
Facility
|
IP
|
$42,292.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20,723.08 |
| Max. Negotiated Rate |
$38,908.64 |
| Rate for Payer: Aetna Commercial |
$38,062.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36,371.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22,414.76
|
| Rate for Payer: Cash Price |
$12,687.60
|
| Rate for Payer: Cigna Commercial |
$38,908.64
|
| Rate for Payer: Health EOS Commercial |
$37,639.88
|
| Rate for Payer: HFN Commercial |
$38,908.64
|
| Rate for Payer: Multiplan Commercial |
$33,833.60
|
| Rate for Payer: NAPHCARE Commercial |
$25,375.20
|
| Rate for Payer: Preferred Network Access Commercial |
$38,908.64
|
| Rate for Payer: Quartz Beloit One Network |
$20,723.08
|
| Rate for Payer: Quartz Commercial |
$25,375.20
|
| Rate for Payer: WEA Trust Commercial |
$23,260.60
|
| Rate for Payer: WPS Commercial |
$31,325.68
|
|
|
TALAR DOME FLAT CUT INFINITY ADAPTIS SZ 2 33680032
|
Facility
|
OP
|
$42,292.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831725
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,841.76 |
| Max. Negotiated Rate |
$169,168.00 |
| Rate for Payer: Aetna Commercial |
$38,062.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36,371.12
|
| Rate for Payer: Aetna Managed Medicare |
$11,841.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27,489.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21,146.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,300.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22,414.76
|
| Rate for Payer: Cash Price |
$12,687.60
|
| Rate for Payer: Cigna Commercial |
$38,908.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23,666.60
|
| Rate for Payer: Health EOS Commercial |
$37,639.88
|
| Rate for Payer: HFN Commercial |
$38,908.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31,719.00
|
| Rate for Payer: Multiplan Commercial |
$33,833.60
|
| Rate for Payer: NAPHCARE Commercial |
$25,375.20
|
| Rate for Payer: Preferred Network Access Commercial |
$38,908.64
|
| Rate for Payer: Quartz Beloit One Network |
$20,723.08
|
| Rate for Payer: Quartz Commercial |
$27,489.80
|
| Rate for Payer: Quartz Medicare Advantage |
$25,375.20
|
| Rate for Payer: The Alliance Commercial |
$169,168.00
|
| Rate for Payer: WEA Trust Commercial |
$23,260.60
|
| Rate for Payer: WPS Commercial |
$31,325.68
|
|
|
TALC POWDER STERILE (MED)
|
Facility
|
OP
|
$564.00
|
|
| Hospital Charge Code |
4519278
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$157.92 |
| Max. Negotiated Rate |
$2,256.00 |
| Rate for Payer: Aetna Commercial |
$507.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$485.04
|
| Rate for Payer: Aetna Managed Medicare |
$157.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$366.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$282.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$270.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$298.92
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cigna Commercial |
$518.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$315.61
|
| Rate for Payer: Health EOS Commercial |
$501.96
|
| Rate for Payer: HFN Commercial |
$518.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$423.00
|
| Rate for Payer: Multiplan Commercial |
$451.20
|
| Rate for Payer: NAPHCARE Commercial |
$338.40
|
| Rate for Payer: Preferred Network Access Commercial |
$518.88
|
| Rate for Payer: Quartz Beloit One Network |
$276.36
|
| Rate for Payer: Quartz Commercial |
$366.60
|
| Rate for Payer: Quartz Medicare Advantage |
$338.40
|
| Rate for Payer: The Alliance Commercial |
$2,256.00
|
| Rate for Payer: WEA Trust Commercial |
$310.20
|
| Rate for Payer: WPS Commercial |
$417.75
|
|
|
TALC POWDER STERILE (MED)
|
Facility
|
IP
|
$564.00
|
|
| Hospital Charge Code |
4519278
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$276.36 |
| Max. Negotiated Rate |
$518.88 |
| Rate for Payer: Aetna Commercial |
$507.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$485.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$298.92
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cigna Commercial |
$518.88
|
| Rate for Payer: Health EOS Commercial |
$501.96
|
| Rate for Payer: HFN Commercial |
$518.88
|
| Rate for Payer: Multiplan Commercial |
$451.20
|
| Rate for Payer: NAPHCARE Commercial |
$338.40
|
| Rate for Payer: Preferred Network Access Commercial |
$518.88
|
| Rate for Payer: Quartz Beloit One Network |
$276.36
|
| Rate for Payer: Quartz Commercial |
$338.40
|
| Rate for Payer: WEA Trust Commercial |
$310.20
|
| Rate for Payer: WPS Commercial |
$417.75
|
|
