|
Stereotactic Cranial Linear Radiation Therapy
|
Facility
|
OP
|
$18,484.00
|
|
|
Service Code
|
CPT 77372
|
| Hospital Charge Code |
5586206
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$7,751.15 |
| Max. Negotiated Rate |
$31,004.60 |
| Rate for Payer: Aetna Commercial |
$17,301.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,532.09
|
| Rate for Payer: Aetna Managed Medicare |
$7,751.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30,018.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24,014.61
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22,813.88
|
| Rate for Payer: Anthem Medicare Advantage |
$7,751.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,188.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,751.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,751.15
|
| Rate for Payer: Cash Price |
$5,545.20
|
| Rate for Payer: Cash Price |
$5,545.20
|
| Rate for Payer: Cigna Commercial |
$17,685.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,751.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,757.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,751.15
|
| Rate for Payer: Health EOS Commercial |
$17,108.79
|
| Rate for Payer: HFN Commercial |
$17,685.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,834.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,751.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,751.15
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,751.15
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,751.15
|
| Rate for Payer: Multiplan Commercial |
$15,378.69
|
| Rate for Payer: NAPHCARE Commercial |
$11,626.73
|
| Rate for Payer: Preferred Network Access Commercial |
$17,685.49
|
| Rate for Payer: Quartz Beloit One Network |
$9,419.45
|
| Rate for Payer: Quartz Commercial |
$12,495.18
|
| Rate for Payer: Quartz Medicare Advantage |
$7,751.15
|
| Rate for Payer: The Alliance Commercial |
$31,004.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,751.15
|
| Rate for Payer: United Healthcare PPO |
$11,534.02
|
| Rate for Payer: WEA Trust Commercial |
$10,572.85
|
| Rate for Payer: Wellcare Medicare |
$7,751.15
|
| Rate for Payer: WPS Commercial |
$14,238.23
|
|
|
STEREOTACTIC RADIATION CRANIAL LESION TX MANAGEMENT 77432
|
Professional
|
Both
|
$5,762.00
|
|
|
Service Code
|
CPT 77432
|
| Hospital Charge Code |
5586200
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$420.12 |
| Max. Negotiated Rate |
$5,692.86 |
| Rate for Payer: Aetna Commercial |
$5,692.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,153.53
|
| Rate for Payer: Aetna Managed Medicare |
$420.12
|
| Rate for Payer: Anthem Medicare Advantage |
$420.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$420.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$420.12
|
| Rate for Payer: Cash Price |
$1,728.60
|
| Rate for Payer: Cash Price |
$1,728.60
|
| Rate for Payer: Cash Price |
$1,728.60
|
| Rate for Payer: Cigna Commercial |
$5,692.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,996.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$420.12
|
| Rate for Payer: Health EOS Commercial |
$5,453.16
|
| Rate for Payer: HFN Commercial |
$5,692.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,493.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,493.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$420.12
|
| Rate for Payer: Multiplan Commercial |
$4,793.98
|
| Rate for Payer: NAPHCARE Commercial |
$630.18
|
| Rate for Payer: Preferred Network Access Commercial |
$5,692.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,636.69
|
| Rate for Payer: Quartz Commercial |
$3,415.71
|
| Rate for Payer: Quartz Medicare Advantage |
$420.12
|
| Rate for Payer: The Alliance Commercial |
$1,596.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$420.12
|
| Rate for Payer: WEA Trust Commercial |
$3,295.86
|
| Rate for Payer: WPS Commercial |
$2,100.59
|
|
|
STERI-DRAPE INCISE IOBAN 2 LG ISOLATION 27 X 12IN WITH POUCH 6619
|
Facility
|
OP
|
$991.00
|
|
| Hospital Charge Code |
2963200
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$288.58 |
| Max. Negotiated Rate |
$948.19 |
| Rate for Payer: Aetna Commercial |
$927.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$886.35
|
| Rate for Payer: Aetna Managed Medicare |
$288.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$669.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$515.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$494.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$546.24
|
| Rate for Payer: Cash Price |
$297.30
|
| Rate for Payer: Cigna Commercial |
$948.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$576.76
|
| Rate for Payer: Health EOS Commercial |
$917.27
|
| Rate for Payer: HFN Commercial |
$948.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$772.98
|
| Rate for Payer: Multiplan Commercial |
$824.51
|
| Rate for Payer: NAPHCARE Commercial |
$618.38
|
| Rate for Payer: Preferred Network Access Commercial |
$948.19
|
| Rate for Payer: Quartz Beloit One Network |
$505.01
|
| Rate for Payer: Quartz Commercial |
$669.92
|
| Rate for Payer: Quartz Medicare Advantage |
$618.38
|
| Rate for Payer: The Alliance Commercial |
$515.32
|
| Rate for Payer: WEA Trust Commercial |
$566.85
|
| Rate for Payer: WPS Commercial |
$763.37
|
|
|
STERI-DRAPE INCISE IOBAN 2 LG ISOLATION 27 X 12IN WITH POUCH 6619
|
Facility
|
IP
|
$991.00
|
|
| Hospital Charge Code |
2963200
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$505.01 |
| Max. Negotiated Rate |
$948.19 |
| Rate for Payer: Aetna Commercial |
$927.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$886.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$546.24
|
| Rate for Payer: Cash Price |
$297.30
|
| Rate for Payer: Cigna Commercial |
$948.19
|
| Rate for Payer: Health EOS Commercial |
$917.27
|
| Rate for Payer: HFN Commercial |
$948.19
|
| Rate for Payer: Multiplan Commercial |
$824.51
|
| Rate for Payer: Preferred Network Access Commercial |
$948.19
|
| Rate for Payer: Quartz Beloit One Network |
$505.01
|
| Rate for Payer: Quartz Commercial |
$618.38
|
| Rate for Payer: WEA Trust Commercial |
$566.85
|
| Rate for Payer: WPS Commercial |
$763.37
|
|
|
STERI-DRAPE LARGE 23 X 33 1051
|
Facility
|
OP
|
$234.00
|
|
| Hospital Charge Code |
2963417
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.14 |
| Max. Negotiated Rate |
$223.89 |
| Rate for Payer: Aetna Commercial |
$219.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.29
|
| Rate for Payer: Aetna Managed Medicare |
$68.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$158.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$121.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$116.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.98
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$223.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.19
|
| Rate for Payer: Health EOS Commercial |
$216.59
|
| Rate for Payer: HFN Commercial |
$223.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$182.52
|
| Rate for Payer: Multiplan Commercial |
$194.69
|
| Rate for Payer: NAPHCARE Commercial |
$146.02
|
| Rate for Payer: Preferred Network Access Commercial |
$223.89
|
| Rate for Payer: Quartz Beloit One Network |
$119.25
|
| Rate for Payer: Quartz Commercial |
$158.18
|
| Rate for Payer: Quartz Medicare Advantage |
$146.02
|
| Rate for Payer: The Alliance Commercial |
$121.68
|
| Rate for Payer: WEA Trust Commercial |
$133.85
|
| Rate for Payer: WPS Commercial |
$180.25
|
|
|
STERI-DRAPE LARGE 23 X 33 1051
|
Facility
|
IP
|
$234.00
|
|
| Hospital Charge Code |
2963417
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$119.25 |
| Max. Negotiated Rate |
$223.89 |
| Rate for Payer: Aetna Commercial |
$219.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.98
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$223.89
|
| Rate for Payer: Health EOS Commercial |
$216.59
|
| Rate for Payer: HFN Commercial |
$223.89
|
| Rate for Payer: Multiplan Commercial |
$194.69
|
| Rate for Payer: Preferred Network Access Commercial |
$223.89
|
| Rate for Payer: Quartz Beloit One Network |
$119.25
|
| Rate for Payer: Quartz Commercial |
$146.02
|
| Rate for Payer: WEA Trust Commercial |
$133.85
|
| Rate for Payer: WPS Commercial |
$180.25
|
|
|
STERILE BLANK LATEX FREE #AM897AM
|
Facility
|
OP
|
$83.00
|
|
| Hospital Charge Code |
2971737
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.17 |
| Max. Negotiated Rate |
$79.41 |
| Rate for Payer: Aetna Commercial |
$77.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Aetna Managed Medicare |
$24.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.75
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$79.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.31
|
| Rate for Payer: Health EOS Commercial |
$76.82
|
| Rate for Payer: HFN Commercial |
$79.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.74
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: NAPHCARE Commercial |
$51.79
|
| Rate for Payer: Preferred Network Access Commercial |
$79.41
|
| Rate for Payer: Quartz Beloit One Network |
$42.30
|
| Rate for Payer: Quartz Commercial |
$56.11
|
| Rate for Payer: Quartz Medicare Advantage |
$51.79
|
| Rate for Payer: The Alliance Commercial |
$43.16
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: WPS Commercial |
$63.93
|
|
|
STERILE BLANK LATEX FREE #AM897AM
|
Facility
|
IP
|
$83.00
|
|
| Hospital Charge Code |
2971737
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.30 |
| Max. Negotiated Rate |
$79.41 |
| Rate for Payer: Aetna Commercial |
$77.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.75
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$79.41
|
| Rate for Payer: Health EOS Commercial |
$76.82
|
| Rate for Payer: HFN Commercial |
$79.41
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: Preferred Network Access Commercial |
$79.41
|
| Rate for Payer: Quartz Beloit One Network |
$42.30
|
| Rate for Payer: Quartz Commercial |
$51.79
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: WPS Commercial |
$63.93
|
|
|
STERILE CONTAINER 0.9 SODIUM
|
Facility
|
OP
|
$864.00
|
|
| Hospital Charge Code |
2974006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$251.60 |
| Max. Negotiated Rate |
$826.68 |
| Rate for Payer: Aetna Commercial |
$808.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$772.76
|
| Rate for Payer: Aetna Managed Medicare |
$251.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$584.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$449.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$431.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$476.24
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cigna Commercial |
$826.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$502.85
|
| Rate for Payer: Health EOS Commercial |
$799.72
|
| Rate for Payer: HFN Commercial |
$826.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$673.92
|
| Rate for Payer: Multiplan Commercial |
$718.85
|
| Rate for Payer: NAPHCARE Commercial |
$539.14
|
| Rate for Payer: Preferred Network Access Commercial |
$826.68
|
| Rate for Payer: Quartz Beloit One Network |
$440.29
|
| Rate for Payer: Quartz Commercial |
$584.06
|
| Rate for Payer: Quartz Medicare Advantage |
$539.14
|
| Rate for Payer: The Alliance Commercial |
$449.28
|
| Rate for Payer: WEA Trust Commercial |
$494.21
|
| Rate for Payer: WPS Commercial |
$665.54
|
|
|
STERILE CONTAINER 0.9 SODIUM
|
Facility
|
IP
|
$864.00
|
|
| Hospital Charge Code |
2974006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$440.29 |
| Max. Negotiated Rate |
$826.68 |
| Rate for Payer: Aetna Commercial |
$808.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$772.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$476.24
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cigna Commercial |
$826.68
|
| Rate for Payer: Health EOS Commercial |
$799.72
|
| Rate for Payer: HFN Commercial |
$826.68
|
| Rate for Payer: Multiplan Commercial |
$718.85
|
| Rate for Payer: Preferred Network Access Commercial |
$826.68
|
| Rate for Payer: Quartz Beloit One Network |
$440.29
|
| Rate for Payer: Quartz Commercial |
$539.14
|
| Rate for Payer: WEA Trust Commercial |
$494.21
|
| Rate for Payer: WPS Commercial |
$665.54
|
|
|
STERILE CUSTOM MED LATEX FREE #132174
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2971974
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.67 |
| Max. Negotiated Rate |
$66.98 |
| Rate for Payer: Aetna Commercial |
$65.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.58
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$66.98
|
| Rate for Payer: Health EOS Commercial |
$64.79
|
| Rate for Payer: HFN Commercial |
$66.98
|
| Rate for Payer: Multiplan Commercial |
$58.24
|
| Rate for Payer: Preferred Network Access Commercial |
$66.98
|
| Rate for Payer: Quartz Beloit One Network |
$35.67
|
| Rate for Payer: Quartz Commercial |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$40.04
|
| Rate for Payer: WPS Commercial |
$53.92
|
|
|
STERILE CUSTOM MED LATEX FREE #132174
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
2971974
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$66.98 |
| Rate for Payer: Aetna Commercial |
$65.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.61
|
| Rate for Payer: Aetna Managed Medicare |
$20.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$47.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.58
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$66.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.74
|
| Rate for Payer: Health EOS Commercial |
$64.79
|
| Rate for Payer: HFN Commercial |
$66.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.60
|
| Rate for Payer: Multiplan Commercial |
$58.24
|
| Rate for Payer: NAPHCARE Commercial |
$43.68
|
| Rate for Payer: Preferred Network Access Commercial |
$66.98
|
| Rate for Payer: Quartz Beloit One Network |
$35.67
|
| Rate for Payer: Quartz Commercial |
$47.32
|
| Rate for Payer: Quartz Medicare Advantage |
$43.68
|
| Rate for Payer: The Alliance Commercial |
$36.40
|
| Rate for Payer: WEA Trust Commercial |
$40.04
|
| Rate for Payer: WPS Commercial |
$53.92
|
|
|
STERIPACK SIDEKICK CORETRAK ARTICULATING XPCK1200
|
Facility
|
OP
|
$16,243.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6178282
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,729.96 |
| Max. Negotiated Rate |
$15,541.30 |
| Rate for Payer: Aetna Commercial |
$15,203.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,527.74
|
| Rate for Payer: Aetna Managed Medicare |
$4,729.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,980.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,446.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,108.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,953.14
|
| Rate for Payer: Cash Price |
$4,872.90
|
| Rate for Payer: Cigna Commercial |
$15,541.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,453.43
|
| Rate for Payer: Health EOS Commercial |
$15,034.52
|
| Rate for Payer: HFN Commercial |
$15,541.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,669.54
|
| Rate for Payer: Multiplan Commercial |
$13,514.18
|
| Rate for Payer: NAPHCARE Commercial |
$10,135.63
|
| Rate for Payer: Preferred Network Access Commercial |
$15,541.30
|
| Rate for Payer: Quartz Beloit One Network |
$8,277.43
|
| Rate for Payer: Quartz Commercial |
$10,980.27
|
| Rate for Payer: Quartz Medicare Advantage |
$10,135.63
|
| Rate for Payer: The Alliance Commercial |
$8,446.36
|
| Rate for Payer: WEA Trust Commercial |
$9,291.00
|
| Rate for Payer: WPS Commercial |
$12,511.98
|
|
|
STERIPACK SIDEKICK CORETRAK ARTICULATING XPCK1200
|
Facility
|
IP
|
$16,243.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6178282
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,277.43 |
| Max. Negotiated Rate |
$15,541.30 |
| Rate for Payer: Aetna Commercial |
$15,203.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,527.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,953.14
|
| Rate for Payer: Cash Price |
$4,872.90
|
| Rate for Payer: Cigna Commercial |
$15,541.30
|
| Rate for Payer: Health EOS Commercial |
$15,034.52
|
| Rate for Payer: HFN Commercial |
$15,541.30
|
| Rate for Payer: Multiplan Commercial |
$13,514.18
|
| Rate for Payer: Preferred Network Access Commercial |
$15,541.30
|
| Rate for Payer: Quartz Beloit One Network |
$8,277.43
|
| Rate for Payer: Quartz Commercial |
$10,135.63
|
| Rate for Payer: WEA Trust Commercial |
$9,291.00
|
| Rate for Payer: WPS Commercial |
$12,511.98
|
|
|
STERI STRIP 1/2 X 4 R1547
|
Facility
|
OP
|
$54.00
|
|
| Hospital Charge Code |
2963545
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.72 |
| Max. Negotiated Rate |
$51.67 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.43
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.12
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$33.70
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$36.50
|
| Rate for Payer: Quartz Medicare Advantage |
$33.70
|
| Rate for Payer: The Alliance Commercial |
$28.08
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
STERI STRIP 1/2 X 4 R1547
|
Facility
|
IP
|
$54.00
|
|
| Hospital Charge Code |
2963545
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.52 |
| Max. Negotiated Rate |
$51.67 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$33.70
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
STERI STRIP 1/4X 1 1/2
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
2974499
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.86 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna Commercial |
$25.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.15
|
| Rate for Payer: Aetna Managed Medicare |
$7.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.88
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$25.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.71
|
| Rate for Payer: Health EOS Commercial |
$24.99
|
| Rate for Payer: HFN Commercial |
$25.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.06
|
| Rate for Payer: Multiplan Commercial |
$22.46
|
| Rate for Payer: NAPHCARE Commercial |
$16.85
|
| Rate for Payer: Preferred Network Access Commercial |
$25.83
|
| Rate for Payer: Quartz Beloit One Network |
$13.76
|
| Rate for Payer: Quartz Commercial |
$18.25
|
| Rate for Payer: Quartz Medicare Advantage |
$16.85
|
| Rate for Payer: The Alliance Commercial |
$14.04
|
| Rate for Payer: WEA Trust Commercial |
$15.44
|
| Rate for Payer: WPS Commercial |
$20.80
|
|
|
STERI STRIP 1/4X 1 1/2
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
2974499
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.76 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna Commercial |
$25.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.88
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$25.83
|
| Rate for Payer: Health EOS Commercial |
$24.99
|
| Rate for Payer: HFN Commercial |
$25.83
|
| Rate for Payer: Multiplan Commercial |
$22.46
|
| Rate for Payer: Preferred Network Access Commercial |
$25.83
|
| Rate for Payer: Quartz Beloit One Network |
$13.76
|
| Rate for Payer: Quartz Commercial |
$16.85
|
| Rate for Payer: WEA Trust Commercial |
$15.44
|
| Rate for Payer: WPS Commercial |
$20.80
|
|
|
STERI STRIP 1/4 X 3 TAPE R1541"
|
Facility
|
OP
|
$84.00
|
|
| Hospital Charge Code |
2962791
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Aetna Managed Medicare |
$24.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.89
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.52
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: NAPHCARE Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$56.78
|
| Rate for Payer: Quartz Medicare Advantage |
$52.42
|
| Rate for Payer: The Alliance Commercial |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
STERI STRIP 1/4 X 3 TAPE R1541"
|
Facility
|
IP
|
$84.00
|
|
| Hospital Charge Code |
2962791
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.81 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$52.42
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
STERI STRIP 1 X 5 TAPE R1548
|
Facility
|
IP
|
$90.00
|
|
| Hospital Charge Code |
2963550
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.86 |
| Max. Negotiated Rate |
$86.11 |
| Rate for Payer: Aetna Commercial |
$84.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.61
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$86.11
|
| Rate for Payer: Health EOS Commercial |
$83.30
|
| Rate for Payer: HFN Commercial |
$86.11
|
| Rate for Payer: Multiplan Commercial |
$74.88
|
| Rate for Payer: Preferred Network Access Commercial |
$86.11
|
| Rate for Payer: Quartz Beloit One Network |
$45.86
|
| Rate for Payer: Quartz Commercial |
$56.16
|
| Rate for Payer: WEA Trust Commercial |
$51.48
|
| Rate for Payer: WPS Commercial |
$69.33
|
|
|
STERI STRIP 1 X 5 TAPE R1548
|
Facility
|
OP
|
$90.00
|
|
| Hospital Charge Code |
2963550
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.21 |
| Max. Negotiated Rate |
$86.11 |
| Rate for Payer: Aetna Commercial |
$84.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.50
|
| Rate for Payer: Aetna Managed Medicare |
$26.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.61
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$86.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.38
|
| Rate for Payer: Health EOS Commercial |
$83.30
|
| Rate for Payer: HFN Commercial |
$86.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.20
|
| Rate for Payer: Multiplan Commercial |
$74.88
|
| Rate for Payer: NAPHCARE Commercial |
$56.16
|
| Rate for Payer: Preferred Network Access Commercial |
$86.11
|
| Rate for Payer: Quartz Beloit One Network |
$45.86
|
| Rate for Payer: Quartz Commercial |
$60.84
|
| Rate for Payer: Quartz Medicare Advantage |
$56.16
|
| Rate for Payer: The Alliance Commercial |
$46.80
|
| Rate for Payer: WEA Trust Commercial |
$51.48
|
| Rate for Payer: WPS Commercial |
$69.33
|
|
|
Steri-Strips applied charge
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
2844920
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$66.98 |
| Rate for Payer: Aetna Commercial |
$65.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.61
|
| Rate for Payer: Aetna Managed Medicare |
$20.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$47.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.58
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$66.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.74
|
| Rate for Payer: Health EOS Commercial |
$64.79
|
| Rate for Payer: HFN Commercial |
$66.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.60
|
| Rate for Payer: Multiplan Commercial |
$58.24
|
| Rate for Payer: NAPHCARE Commercial |
$43.68
|
| Rate for Payer: Preferred Network Access Commercial |
$66.98
|
| Rate for Payer: Quartz Beloit One Network |
$35.67
|
| Rate for Payer: Quartz Commercial |
$47.32
|
| Rate for Payer: Quartz Medicare Advantage |
$43.68
|
| Rate for Payer: The Alliance Commercial |
$36.40
|
| Rate for Payer: WEA Trust Commercial |
$40.04
|
| Rate for Payer: WPS Commercial |
$53.92
|
|
|
Steri-Strips applied charge
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2844920
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$35.67 |
| Max. Negotiated Rate |
$66.98 |
| Rate for Payer: Aetna Commercial |
$65.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.58
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$66.98
|
| Rate for Payer: Health EOS Commercial |
$64.79
|
| Rate for Payer: HFN Commercial |
$66.98
|
| Rate for Payer: Multiplan Commercial |
$58.24
|
| Rate for Payer: Preferred Network Access Commercial |
$66.98
|
| Rate for Payer: Quartz Beloit One Network |
$35.67
|
| Rate for Payer: Quartz Commercial |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$40.04
|
| Rate for Payer: WPS Commercial |
$53.92
|
|
|
STERI STRIP TAPE 1/4 X 4 R1546
|
Facility
|
IP
|
$42.00
|
|
| Hospital Charge Code |
2965499
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.40 |
| Max. Negotiated Rate |
$40.19 |
| Rate for Payer: Aetna Commercial |
$39.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.15
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$40.19
|
| Rate for Payer: Health EOS Commercial |
$38.88
|
| Rate for Payer: HFN Commercial |
$40.19
|
| Rate for Payer: Multiplan Commercial |
$34.94
|
| Rate for Payer: Preferred Network Access Commercial |
$40.19
|
| Rate for Payer: Quartz Beloit One Network |
$21.40
|
| Rate for Payer: Quartz Commercial |
$26.21
|
| Rate for Payer: WEA Trust Commercial |
$24.02
|
| Rate for Payer: WPS Commercial |
$32.35
|
|
