|
SUPPORT WRIST PROFLEX LFT/XLRG #9497-11
|
Facility
|
OP
|
$469.00
|
|
| Hospital Charge Code |
2969727
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$136.57 |
| Max. Negotiated Rate |
$448.74 |
| Rate for Payer: Aetna Commercial |
$438.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$419.47
|
| Rate for Payer: Aetna Managed Medicare |
$136.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$317.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$243.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$234.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$258.51
|
| Rate for Payer: Cash Price |
$140.70
|
| Rate for Payer: Cigna Commercial |
$448.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$272.96
|
| Rate for Payer: Health EOS Commercial |
$434.11
|
| Rate for Payer: HFN Commercial |
$448.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$365.82
|
| Rate for Payer: Multiplan Commercial |
$390.21
|
| Rate for Payer: NAPHCARE Commercial |
$292.66
|
| Rate for Payer: Preferred Network Access Commercial |
$448.74
|
| Rate for Payer: Quartz Beloit One Network |
$239.00
|
| Rate for Payer: Quartz Commercial |
$317.04
|
| Rate for Payer: Quartz Medicare Advantage |
$292.66
|
| Rate for Payer: The Alliance Commercial |
$243.88
|
| Rate for Payer: WEA Trust Commercial |
$268.27
|
| Rate for Payer: WPS Commercial |
$361.27
|
|
|
SUPPORT WRIST PROFLEX LFT/XLRG #9497-11
|
Facility
|
IP
|
$469.00
|
|
| Hospital Charge Code |
2969727
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$239.00 |
| Max. Negotiated Rate |
$448.74 |
| Rate for Payer: Aetna Commercial |
$438.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$419.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$258.51
|
| Rate for Payer: Cash Price |
$140.70
|
| Rate for Payer: Cigna Commercial |
$448.74
|
| Rate for Payer: Health EOS Commercial |
$434.11
|
| Rate for Payer: HFN Commercial |
$448.74
|
| Rate for Payer: Multiplan Commercial |
$390.21
|
| Rate for Payer: Preferred Network Access Commercial |
$448.74
|
| Rate for Payer: Quartz Beloit One Network |
$239.00
|
| Rate for Payer: Quartz Commercial |
$292.66
|
| Rate for Payer: WEA Trust Commercial |
$268.27
|
| Rate for Payer: WPS Commercial |
$361.27
|
|
|
SUPPORT WRIST PROFLEX RT/LRG #9497-04
|
Facility
|
IP
|
$348.00
|
|
| Hospital Charge Code |
2969723
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$177.34 |
| Max. Negotiated Rate |
$332.97 |
| Rate for Payer: Aetna Commercial |
$325.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$311.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$191.82
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$332.97
|
| Rate for Payer: Health EOS Commercial |
$322.11
|
| Rate for Payer: HFN Commercial |
$332.97
|
| Rate for Payer: Multiplan Commercial |
$289.54
|
| Rate for Payer: Preferred Network Access Commercial |
$332.97
|
| Rate for Payer: Quartz Beloit One Network |
$177.34
|
| Rate for Payer: Quartz Commercial |
$217.15
|
| Rate for Payer: WEA Trust Commercial |
$199.06
|
| Rate for Payer: WPS Commercial |
$268.06
|
|
|
SUPPORT WRIST PROFLEX RT/LRG #9497-04
|
Facility
|
OP
|
$348.00
|
|
| Hospital Charge Code |
2969723
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$101.34 |
| Max. Negotiated Rate |
$332.97 |
| Rate for Payer: Aetna Commercial |
$325.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$311.25
|
| Rate for Payer: Aetna Managed Medicare |
$101.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$235.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$180.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$173.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$191.82
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$332.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$202.54
|
| Rate for Payer: Health EOS Commercial |
$322.11
|
| Rate for Payer: HFN Commercial |
$332.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$271.44
|
| Rate for Payer: Multiplan Commercial |
$289.54
|
| Rate for Payer: NAPHCARE Commercial |
$217.15
|
| Rate for Payer: Preferred Network Access Commercial |
$332.97
|
| Rate for Payer: Quartz Beloit One Network |
$177.34
|
| Rate for Payer: Quartz Commercial |
$235.25
|
| Rate for Payer: Quartz Medicare Advantage |
$217.15
|
| Rate for Payer: The Alliance Commercial |
$180.96
|
| Rate for Payer: WEA Trust Commercial |
$199.06
|
| Rate for Payer: WPS Commercial |
$268.06
|
|
|
SUPPORT WRIST PROFLEX RT/MED #9497-03
|
Facility
|
OP
|
$348.00
|
|
| Hospital Charge Code |
2970982
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$101.34 |
| Max. Negotiated Rate |
$332.97 |
| Rate for Payer: Aetna Commercial |
$325.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$311.25
|
| Rate for Payer: Aetna Managed Medicare |
$101.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$235.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$180.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$173.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$191.82
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$332.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$202.54
|
| Rate for Payer: Health EOS Commercial |
$322.11
|
| Rate for Payer: HFN Commercial |
$332.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$271.44
|
| Rate for Payer: Multiplan Commercial |
$289.54
|
| Rate for Payer: NAPHCARE Commercial |
$217.15
|
| Rate for Payer: Preferred Network Access Commercial |
$332.97
|
| Rate for Payer: Quartz Beloit One Network |
$177.34
|
| Rate for Payer: Quartz Commercial |
$235.25
|
| Rate for Payer: Quartz Medicare Advantage |
$217.15
|
| Rate for Payer: The Alliance Commercial |
$180.96
|
| Rate for Payer: WEA Trust Commercial |
$199.06
|
| Rate for Payer: WPS Commercial |
$268.06
|
|
|
SUPPORT WRIST PROFLEX RT/MED #9497-03
|
Facility
|
IP
|
$348.00
|
|
| Hospital Charge Code |
2970982
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$177.34 |
| Max. Negotiated Rate |
$332.97 |
| Rate for Payer: Aetna Commercial |
$325.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$311.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$191.82
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$332.97
|
| Rate for Payer: Health EOS Commercial |
$322.11
|
| Rate for Payer: HFN Commercial |
$332.97
|
| Rate for Payer: Multiplan Commercial |
$289.54
|
| Rate for Payer: Preferred Network Access Commercial |
$332.97
|
| Rate for Payer: Quartz Beloit One Network |
$177.34
|
| Rate for Payer: Quartz Commercial |
$217.15
|
| Rate for Payer: WEA Trust Commercial |
$199.06
|
| Rate for Payer: WPS Commercial |
$268.06
|
|
|
SUPPORT WRIST PROFLEX RT/SM #9497-02
|
Facility
|
OP
|
$348.00
|
|
| Hospital Charge Code |
2969724
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$101.34 |
| Max. Negotiated Rate |
$332.97 |
| Rate for Payer: Aetna Commercial |
$325.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$311.25
|
| Rate for Payer: Aetna Managed Medicare |
$101.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$235.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$180.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$173.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$191.82
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$332.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$202.54
|
| Rate for Payer: Health EOS Commercial |
$322.11
|
| Rate for Payer: HFN Commercial |
$332.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$271.44
|
| Rate for Payer: Multiplan Commercial |
$289.54
|
| Rate for Payer: NAPHCARE Commercial |
$217.15
|
| Rate for Payer: Preferred Network Access Commercial |
$332.97
|
| Rate for Payer: Quartz Beloit One Network |
$177.34
|
| Rate for Payer: Quartz Commercial |
$235.25
|
| Rate for Payer: Quartz Medicare Advantage |
$217.15
|
| Rate for Payer: The Alliance Commercial |
$180.96
|
| Rate for Payer: WEA Trust Commercial |
$199.06
|
| Rate for Payer: WPS Commercial |
$268.06
|
|
|
SUPPORT WRIST PROFLEX RT/SM #9497-02
|
Facility
|
IP
|
$348.00
|
|
| Hospital Charge Code |
2969724
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$177.34 |
| Max. Negotiated Rate |
$332.97 |
| Rate for Payer: Aetna Commercial |
$325.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$311.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$191.82
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$332.97
|
| Rate for Payer: Health EOS Commercial |
$322.11
|
| Rate for Payer: HFN Commercial |
$332.97
|
| Rate for Payer: Multiplan Commercial |
$289.54
|
| Rate for Payer: Preferred Network Access Commercial |
$332.97
|
| Rate for Payer: Quartz Beloit One Network |
$177.34
|
| Rate for Payer: Quartz Commercial |
$217.15
|
| Rate for Payer: WEA Trust Commercial |
$199.06
|
| Rate for Payer: WPS Commercial |
$268.06
|
|
|
SUPPORT WRIST PROFLEX RT/XL #9497-10
|
Facility
|
IP
|
$469.00
|
|
| Hospital Charge Code |
2969725
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$239.00 |
| Max. Negotiated Rate |
$448.74 |
| Rate for Payer: Aetna Commercial |
$438.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$419.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$258.51
|
| Rate for Payer: Cash Price |
$140.70
|
| Rate for Payer: Cigna Commercial |
$448.74
|
| Rate for Payer: Health EOS Commercial |
$434.11
|
| Rate for Payer: HFN Commercial |
$448.74
|
| Rate for Payer: Multiplan Commercial |
$390.21
|
| Rate for Payer: Preferred Network Access Commercial |
$448.74
|
| Rate for Payer: Quartz Beloit One Network |
$239.00
|
| Rate for Payer: Quartz Commercial |
$292.66
|
| Rate for Payer: WEA Trust Commercial |
$268.27
|
| Rate for Payer: WPS Commercial |
$361.27
|
|
|
SUPPORT WRIST PROFLEX RT/XL #9497-10
|
Facility
|
OP
|
$469.00
|
|
| Hospital Charge Code |
2969725
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$136.57 |
| Max. Negotiated Rate |
$448.74 |
| Rate for Payer: Aetna Commercial |
$438.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$419.47
|
| Rate for Payer: Aetna Managed Medicare |
$136.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$317.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$243.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$234.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$258.51
|
| Rate for Payer: Cash Price |
$140.70
|
| Rate for Payer: Cigna Commercial |
$448.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$272.96
|
| Rate for Payer: Health EOS Commercial |
$434.11
|
| Rate for Payer: HFN Commercial |
$448.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$365.82
|
| Rate for Payer: Multiplan Commercial |
$390.21
|
| Rate for Payer: NAPHCARE Commercial |
$292.66
|
| Rate for Payer: Preferred Network Access Commercial |
$448.74
|
| Rate for Payer: Quartz Beloit One Network |
$239.00
|
| Rate for Payer: Quartz Commercial |
$317.04
|
| Rate for Payer: Quartz Medicare Advantage |
$292.66
|
| Rate for Payer: The Alliance Commercial |
$243.88
|
| Rate for Payer: WEA Trust Commercial |
$268.27
|
| Rate for Payer: WPS Commercial |
$361.27
|
|
|
SUPRACLAVICULAR BLOCK - SET-UP CHARGE
|
Facility
|
OP
|
$229.00
|
|
| Hospital Charge Code |
4519591
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$66.68 |
| Max. Negotiated Rate |
$219.11 |
| Rate for Payer: Aetna Commercial |
$214.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.82
|
| Rate for Payer: Aetna Managed Medicare |
$66.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$154.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$119.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$114.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.22
|
| Rate for Payer: Cash Price |
$68.70
|
| Rate for Payer: Cigna Commercial |
$219.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$133.28
|
| Rate for Payer: Health EOS Commercial |
$211.96
|
| Rate for Payer: HFN Commercial |
$219.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$178.62
|
| Rate for Payer: Multiplan Commercial |
$190.53
|
| Rate for Payer: NAPHCARE Commercial |
$142.90
|
| Rate for Payer: Preferred Network Access Commercial |
$219.11
|
| Rate for Payer: Quartz Beloit One Network |
$116.70
|
| Rate for Payer: Quartz Commercial |
$154.80
|
| Rate for Payer: Quartz Medicare Advantage |
$142.90
|
| Rate for Payer: The Alliance Commercial |
$119.08
|
| Rate for Payer: WEA Trust Commercial |
$130.99
|
| Rate for Payer: WPS Commercial |
$176.40
|
|
|
SUPRACLAVICULAR BLOCK - SET-UP CHARGE
|
Facility
|
IP
|
$229.00
|
|
| Hospital Charge Code |
4519591
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$116.70 |
| Max. Negotiated Rate |
$219.11 |
| Rate for Payer: Aetna Commercial |
$214.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.22
|
| Rate for Payer: Cash Price |
$68.70
|
| Rate for Payer: Cigna Commercial |
$219.11
|
| Rate for Payer: Health EOS Commercial |
$211.96
|
| Rate for Payer: HFN Commercial |
$219.11
|
| Rate for Payer: Multiplan Commercial |
$190.53
|
| Rate for Payer: Preferred Network Access Commercial |
$219.11
|
| Rate for Payer: Quartz Beloit One Network |
$116.70
|
| Rate for Payer: Quartz Commercial |
$142.90
|
| Rate for Payer: WEA Trust Commercial |
$130.99
|
| Rate for Payer: WPS Commercial |
$176.40
|
|
|
SUPRAFOIL 0.1MM NYLON F-SS-01
|
Facility
|
OP
|
$205.00
|
|
| Hospital Charge Code |
2969361
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$59.70 |
| Max. Negotiated Rate |
$196.14 |
| Rate for Payer: Aetna Commercial |
$191.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.35
|
| Rate for Payer: Aetna Managed Medicare |
$59.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$138.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$106.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$102.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.00
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$196.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.31
|
| Rate for Payer: Health EOS Commercial |
$189.75
|
| Rate for Payer: HFN Commercial |
$196.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$159.90
|
| Rate for Payer: Multiplan Commercial |
$170.56
|
| Rate for Payer: NAPHCARE Commercial |
$127.92
|
| Rate for Payer: Preferred Network Access Commercial |
$196.14
|
| Rate for Payer: Quartz Beloit One Network |
$104.47
|
| Rate for Payer: Quartz Commercial |
$138.58
|
| Rate for Payer: Quartz Medicare Advantage |
$127.92
|
| Rate for Payer: The Alliance Commercial |
$106.60
|
| Rate for Payer: WEA Trust Commercial |
$117.26
|
| Rate for Payer: WPS Commercial |
$157.91
|
|
|
SUPRAFOIL 0.1MM NYLON F-SS-01
|
Facility
|
IP
|
$205.00
|
|
| Hospital Charge Code |
2969361
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$104.47 |
| Max. Negotiated Rate |
$196.14 |
| Rate for Payer: Aetna Commercial |
$191.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.00
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$196.14
|
| Rate for Payer: Health EOS Commercial |
$189.75
|
| Rate for Payer: HFN Commercial |
$196.14
|
| Rate for Payer: Multiplan Commercial |
$170.56
|
| Rate for Payer: Preferred Network Access Commercial |
$196.14
|
| Rate for Payer: Quartz Beloit One Network |
$104.47
|
| Rate for Payer: Quartz Commercial |
$127.92
|
| Rate for Payer: WEA Trust Commercial |
$117.26
|
| Rate for Payer: WPS Commercial |
$157.91
|
|
|
SUPRAFOIL 0.2MM NYLON F-SS-02
|
Facility
|
OP
|
$205.00
|
|
| Hospital Charge Code |
2969362
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$59.70 |
| Max. Negotiated Rate |
$196.14 |
| Rate for Payer: Aetna Commercial |
$191.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.35
|
| Rate for Payer: Aetna Managed Medicare |
$59.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$138.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$106.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$102.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.00
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$196.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.31
|
| Rate for Payer: Health EOS Commercial |
$189.75
|
| Rate for Payer: HFN Commercial |
$196.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$159.90
|
| Rate for Payer: Multiplan Commercial |
$170.56
|
| Rate for Payer: NAPHCARE Commercial |
$127.92
|
| Rate for Payer: Preferred Network Access Commercial |
$196.14
|
| Rate for Payer: Quartz Beloit One Network |
$104.47
|
| Rate for Payer: Quartz Commercial |
$138.58
|
| Rate for Payer: Quartz Medicare Advantage |
$127.92
|
| Rate for Payer: The Alliance Commercial |
$106.60
|
| Rate for Payer: WEA Trust Commercial |
$117.26
|
| Rate for Payer: WPS Commercial |
$157.91
|
|
|
SUPRAFOIL 0.2MM NYLON F-SS-02
|
Facility
|
IP
|
$205.00
|
|
| Hospital Charge Code |
2969362
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$104.47 |
| Max. Negotiated Rate |
$196.14 |
| Rate for Payer: Aetna Commercial |
$191.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.00
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$196.14
|
| Rate for Payer: Health EOS Commercial |
$189.75
|
| Rate for Payer: HFN Commercial |
$196.14
|
| Rate for Payer: Multiplan Commercial |
$170.56
|
| Rate for Payer: Preferred Network Access Commercial |
$196.14
|
| Rate for Payer: Quartz Beloit One Network |
$104.47
|
| Rate for Payer: Quartz Commercial |
$127.92
|
| Rate for Payer: WEA Trust Commercial |
$117.26
|
| Rate for Payer: WPS Commercial |
$157.91
|
|
|
SUPRAFOIL 0.3MM NYLON F-SS-03
|
Facility
|
OP
|
$205.00
|
|
| Hospital Charge Code |
2969363
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$59.70 |
| Max. Negotiated Rate |
$196.14 |
| Rate for Payer: Aetna Commercial |
$191.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.35
|
| Rate for Payer: Aetna Managed Medicare |
$59.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$138.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$106.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$102.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.00
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$196.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.31
|
| Rate for Payer: Health EOS Commercial |
$189.75
|
| Rate for Payer: HFN Commercial |
$196.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$159.90
|
| Rate for Payer: Multiplan Commercial |
$170.56
|
| Rate for Payer: NAPHCARE Commercial |
$127.92
|
| Rate for Payer: Preferred Network Access Commercial |
$196.14
|
| Rate for Payer: Quartz Beloit One Network |
$104.47
|
| Rate for Payer: Quartz Commercial |
$138.58
|
| Rate for Payer: Quartz Medicare Advantage |
$127.92
|
| Rate for Payer: The Alliance Commercial |
$106.60
|
| Rate for Payer: WEA Trust Commercial |
$117.26
|
| Rate for Payer: WPS Commercial |
$157.91
|
|
|
SUPRAFOIL 0.3MM NYLON F-SS-03
|
Facility
|
IP
|
$205.00
|
|
| Hospital Charge Code |
2969363
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$104.47 |
| Max. Negotiated Rate |
$196.14 |
| Rate for Payer: Aetna Commercial |
$191.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.00
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$196.14
|
| Rate for Payer: Health EOS Commercial |
$189.75
|
| Rate for Payer: HFN Commercial |
$196.14
|
| Rate for Payer: Multiplan Commercial |
$170.56
|
| Rate for Payer: Preferred Network Access Commercial |
$196.14
|
| Rate for Payer: Quartz Beloit One Network |
$104.47
|
| Rate for Payer: Quartz Commercial |
$127.92
|
| Rate for Payer: WEA Trust Commercial |
$117.26
|
| Rate for Payer: WPS Commercial |
$157.91
|
|
|
SUPRAFOIL 0.4MM NYLON F-SS-04
|
Facility
|
IP
|
$205.00
|
|
| Hospital Charge Code |
2969364
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$104.47 |
| Max. Negotiated Rate |
$196.14 |
| Rate for Payer: Aetna Commercial |
$191.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.00
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$196.14
|
| Rate for Payer: Health EOS Commercial |
$189.75
|
| Rate for Payer: HFN Commercial |
$196.14
|
| Rate for Payer: Multiplan Commercial |
$170.56
|
| Rate for Payer: Preferred Network Access Commercial |
$196.14
|
| Rate for Payer: Quartz Beloit One Network |
$104.47
|
| Rate for Payer: Quartz Commercial |
$127.92
|
| Rate for Payer: WEA Trust Commercial |
$117.26
|
| Rate for Payer: WPS Commercial |
$157.91
|
|
|
SUPRAFOIL 0.4MM NYLON F-SS-04
|
Facility
|
OP
|
$205.00
|
|
| Hospital Charge Code |
2969364
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$59.70 |
| Max. Negotiated Rate |
$196.14 |
| Rate for Payer: Aetna Commercial |
$191.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.35
|
| Rate for Payer: Aetna Managed Medicare |
$59.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$138.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$106.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$102.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.00
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$196.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.31
|
| Rate for Payer: Health EOS Commercial |
$189.75
|
| Rate for Payer: HFN Commercial |
$196.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$159.90
|
| Rate for Payer: Multiplan Commercial |
$170.56
|
| Rate for Payer: NAPHCARE Commercial |
$127.92
|
| Rate for Payer: Preferred Network Access Commercial |
$196.14
|
| Rate for Payer: Quartz Beloit One Network |
$104.47
|
| Rate for Payer: Quartz Commercial |
$138.58
|
| Rate for Payer: Quartz Medicare Advantage |
$127.92
|
| Rate for Payer: The Alliance Commercial |
$106.60
|
| Rate for Payer: WEA Trust Commercial |
$117.26
|
| Rate for Payer: WPS Commercial |
$157.91
|
|
|
SUPRAFOIL 0.6MM NYLON F-SS-06
|
Facility
|
IP
|
$205.00
|
|
| Hospital Charge Code |
2969365
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$104.47 |
| Max. Negotiated Rate |
$196.14 |
| Rate for Payer: Aetna Commercial |
$191.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.00
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$196.14
|
| Rate for Payer: Health EOS Commercial |
$189.75
|
| Rate for Payer: HFN Commercial |
$196.14
|
| Rate for Payer: Multiplan Commercial |
$170.56
|
| Rate for Payer: Preferred Network Access Commercial |
$196.14
|
| Rate for Payer: Quartz Beloit One Network |
$104.47
|
| Rate for Payer: Quartz Commercial |
$127.92
|
| Rate for Payer: WEA Trust Commercial |
$117.26
|
| Rate for Payer: WPS Commercial |
$157.91
|
|
|
SUPRAFOIL 0.6MM NYLON F-SS-06
|
Facility
|
OP
|
$205.00
|
|
| Hospital Charge Code |
2969365
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$59.70 |
| Max. Negotiated Rate |
$196.14 |
| Rate for Payer: Aetna Commercial |
$191.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$183.35
|
| Rate for Payer: Aetna Managed Medicare |
$59.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$138.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$106.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$102.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.00
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$196.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.31
|
| Rate for Payer: Health EOS Commercial |
$189.75
|
| Rate for Payer: HFN Commercial |
$196.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$159.90
|
| Rate for Payer: Multiplan Commercial |
$170.56
|
| Rate for Payer: NAPHCARE Commercial |
$127.92
|
| Rate for Payer: Preferred Network Access Commercial |
$196.14
|
| Rate for Payer: Quartz Beloit One Network |
$104.47
|
| Rate for Payer: Quartz Commercial |
$138.58
|
| Rate for Payer: Quartz Medicare Advantage |
$127.92
|
| Rate for Payer: The Alliance Commercial |
$106.60
|
| Rate for Payer: WEA Trust Commercial |
$117.26
|
| Rate for Payer: WPS Commercial |
$157.91
|
|
|
SUPRAPUBIC TUBE PLACEMENT, OPEN
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960254
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
SUPRAPUBIC TUBE PLACEMENT, OPEN
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960254
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
SUPRA PUBIC TUBE PLACEMENT, PUNCH
|
Facility
|
IP
|
$291.00
|
|
| Hospital Charge Code |
2960396
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$148.29 |
| Max. Negotiated Rate |
$278.43 |
| Rate for Payer: Aetna Commercial |
$272.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$260.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.40
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$278.43
|
| Rate for Payer: Health EOS Commercial |
$269.35
|
| Rate for Payer: HFN Commercial |
$278.43
|
| Rate for Payer: Multiplan Commercial |
$242.11
|
| Rate for Payer: Preferred Network Access Commercial |
$278.43
|
| Rate for Payer: Quartz Beloit One Network |
$148.29
|
| Rate for Payer: Quartz Commercial |
$181.58
|
| Rate for Payer: WEA Trust Commercial |
$166.45
|
| Rate for Payer: WPS Commercial |
$224.16
|
|
