|
Trailblazer .035 135cm
|
Facility
|
IP
|
$501.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549120
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$245.49 |
| Max. Negotiated Rate |
$460.92 |
| Rate for Payer: Aetna Commercial |
$450.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$430.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$265.53
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna Commercial |
$460.92
|
| Rate for Payer: Health EOS Commercial |
$445.89
|
| Rate for Payer: HFN Commercial |
$460.92
|
| Rate for Payer: Multiplan Commercial |
$400.80
|
| Rate for Payer: NAPHCARE Commercial |
$300.60
|
| Rate for Payer: Preferred Network Access Commercial |
$460.92
|
| Rate for Payer: Quartz Beloit One Network |
$245.49
|
| Rate for Payer: Quartz Commercial |
$300.60
|
| Rate for Payer: WEA Trust Commercial |
$275.55
|
| Rate for Payer: WPS Commercial |
$371.09
|
|
|
Trailblazer .035 135cm
|
Professional
|
Both
|
$501.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549120
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$220.44 |
| Max. Negotiated Rate |
$475.95 |
| Rate for Payer: Aetna Commercial |
$475.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$430.86
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna Commercial |
$475.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$250.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$300.60
|
| Rate for Payer: Health EOS Commercial |
$455.91
|
| Rate for Payer: HFN Commercial |
$475.95
|
| Rate for Payer: Multiplan Commercial |
$400.80
|
| Rate for Payer: Preferred Network Access Commercial |
$475.95
|
| Rate for Payer: Quartz Beloit One Network |
$220.44
|
| Rate for Payer: Quartz Commercial |
$285.57
|
| Rate for Payer: The Alliance Commercial |
$250.50
|
| Rate for Payer: WEA Trust Commercial |
$275.55
|
| Rate for Payer: WPS Commercial |
$371.09
|
|
|
Trailblazer .035 135cm
|
Facility
|
OP
|
$501.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549120
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$140.28 |
| Max. Negotiated Rate |
$2,004.00 |
| Rate for Payer: Aetna Commercial |
$450.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$430.86
|
| Rate for Payer: Aetna Managed Medicare |
$140.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$325.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$250.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$240.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$265.53
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna Commercial |
$460.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$280.36
|
| Rate for Payer: Health EOS Commercial |
$445.89
|
| Rate for Payer: HFN Commercial |
$460.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$375.75
|
| Rate for Payer: Multiplan Commercial |
$400.80
|
| Rate for Payer: NAPHCARE Commercial |
$300.60
|
| Rate for Payer: Preferred Network Access Commercial |
$460.92
|
| Rate for Payer: Quartz Beloit One Network |
$245.49
|
| Rate for Payer: Quartz Commercial |
$325.65
|
| Rate for Payer: Quartz Medicare Advantage |
$300.60
|
| Rate for Payer: The Alliance Commercial |
$2,004.00
|
| Rate for Payer: WEA Trust Commercial |
$275.55
|
| Rate for Payer: WPS Commercial |
$371.09
|
|
|
Trailblazer .035 65cm
|
Facility
|
OP
|
$501.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549116
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$140.28 |
| Max. Negotiated Rate |
$2,004.00 |
| Rate for Payer: Aetna Commercial |
$450.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$430.86
|
| Rate for Payer: Aetna Managed Medicare |
$140.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$325.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$250.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$240.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$265.53
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna Commercial |
$460.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$280.36
|
| Rate for Payer: Health EOS Commercial |
$445.89
|
| Rate for Payer: HFN Commercial |
$460.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$375.75
|
| Rate for Payer: Multiplan Commercial |
$400.80
|
| Rate for Payer: NAPHCARE Commercial |
$300.60
|
| Rate for Payer: Preferred Network Access Commercial |
$460.92
|
| Rate for Payer: Quartz Beloit One Network |
$245.49
|
| Rate for Payer: Quartz Commercial |
$325.65
|
| Rate for Payer: Quartz Medicare Advantage |
$300.60
|
| Rate for Payer: The Alliance Commercial |
$2,004.00
|
| Rate for Payer: WEA Trust Commercial |
$275.55
|
| Rate for Payer: WPS Commercial |
$371.09
|
|
|
Trailblazer .035 65cm
|
Facility
|
IP
|
$501.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549116
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$245.49 |
| Max. Negotiated Rate |
$460.92 |
| Rate for Payer: Aetna Commercial |
$450.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$430.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$265.53
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna Commercial |
$460.92
|
| Rate for Payer: Health EOS Commercial |
$445.89
|
| Rate for Payer: HFN Commercial |
$460.92
|
| Rate for Payer: Multiplan Commercial |
$400.80
|
| Rate for Payer: NAPHCARE Commercial |
$300.60
|
| Rate for Payer: Preferred Network Access Commercial |
$460.92
|
| Rate for Payer: Quartz Beloit One Network |
$245.49
|
| Rate for Payer: Quartz Commercial |
$300.60
|
| Rate for Payer: WEA Trust Commercial |
$275.55
|
| Rate for Payer: WPS Commercial |
$371.09
|
|
|
Trailblazer .035 65cm
|
Professional
|
Both
|
$501.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549116
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$220.44 |
| Max. Negotiated Rate |
$475.95 |
| Rate for Payer: Aetna Commercial |
$475.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$430.86
|
| Rate for Payer: Cash Price |
$150.30
|
| Rate for Payer: Cigna Commercial |
$475.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$250.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$300.60
|
| Rate for Payer: Health EOS Commercial |
$455.91
|
| Rate for Payer: HFN Commercial |
$475.95
|
| Rate for Payer: Multiplan Commercial |
$400.80
|
| Rate for Payer: Preferred Network Access Commercial |
$475.95
|
| Rate for Payer: Quartz Beloit One Network |
$220.44
|
| Rate for Payer: Quartz Commercial |
$285.57
|
| Rate for Payer: The Alliance Commercial |
$250.50
|
| Rate for Payer: WEA Trust Commercial |
$275.55
|
| Rate for Payer: WPS Commercial |
$371.09
|
|
|
TRAILBLAZER .035 X 65CM
|
Facility
|
OP
|
$2,139.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2973690
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$598.92 |
| Max. Negotiated Rate |
$8,556.00 |
| Rate for Payer: Aetna Commercial |
$1,925.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,839.54
|
| Rate for Payer: Aetna Managed Medicare |
$598.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,390.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,069.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,026.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.67
|
| Rate for Payer: Cash Price |
$641.70
|
| Rate for Payer: Cigna Commercial |
$1,967.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,196.98
|
| Rate for Payer: Health EOS Commercial |
$1,903.71
|
| Rate for Payer: HFN Commercial |
$1,967.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,604.25
|
| Rate for Payer: Multiplan Commercial |
$1,711.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,283.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,048.11
|
| Rate for Payer: Quartz Commercial |
$1,390.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1,283.40
|
| Rate for Payer: The Alliance Commercial |
$8,556.00
|
| Rate for Payer: WEA Trust Commercial |
$1,176.45
|
| Rate for Payer: WPS Commercial |
$1,584.36
|
|
|
TRAILBLAZER .035 X 65CM
|
Facility
|
IP
|
$2,139.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2973690
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,048.11 |
| Max. Negotiated Rate |
$1,967.88 |
| Rate for Payer: Aetna Commercial |
$1,925.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,839.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,133.67
|
| Rate for Payer: Cash Price |
$641.70
|
| Rate for Payer: Cigna Commercial |
$1,967.88
|
| Rate for Payer: Health EOS Commercial |
$1,903.71
|
| Rate for Payer: HFN Commercial |
$1,967.88
|
| Rate for Payer: Multiplan Commercial |
$1,711.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,283.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,967.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,048.11
|
| Rate for Payer: Quartz Commercial |
$1,283.40
|
| Rate for Payer: WEA Trust Commercial |
$1,176.45
|
| Rate for Payer: WPS Commercial |
$1,584.36
|
|
|
Tramadol Level
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
CPT 80373
|
| Hospital Charge Code |
4682606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$117.60 |
| Max. Negotiated Rate |
$220.80 |
| Rate for Payer: Aetna Commercial |
$216.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$206.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.20
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$220.80
|
| Rate for Payer: Health EOS Commercial |
$213.60
|
| Rate for Payer: HFN Commercial |
$220.80
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: NAPHCARE Commercial |
$144.00
|
| Rate for Payer: Preferred Network Access Commercial |
$220.80
|
| Rate for Payer: Quartz Beloit One Network |
$117.60
|
| Rate for Payer: Quartz Commercial |
$144.00
|
| Rate for Payer: WEA Trust Commercial |
$132.00
|
| Rate for Payer: WPS Commercial |
$177.77
|
|
|
Tramadol Level
|
Professional
|
Both
|
$240.00
|
|
|
Service Code
|
CPT 80373
|
| Hospital Charge Code |
4682606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$228.00 |
| Rate for Payer: Aetna Commercial |
$228.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$206.40
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$228.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$120.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.00
|
| Rate for Payer: Health EOS Commercial |
$218.40
|
| Rate for Payer: HFN Commercial |
$228.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: Preferred Network Access Commercial |
$228.00
|
| Rate for Payer: Quartz Beloit One Network |
$105.60
|
| Rate for Payer: Quartz Commercial |
$136.80
|
| Rate for Payer: The Alliance Commercial |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$132.00
|
| Rate for Payer: WPS Commercial |
$177.77
|
|
|
Tramadol Level
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
CPT 80373
|
| Hospital Charge Code |
4682606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$67.20 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$216.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$206.40
|
| Rate for Payer: Aetna Managed Medicare |
$67.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$156.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$120.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$115.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.20
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$220.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.30
|
| Rate for Payer: Health EOS Commercial |
$213.60
|
| Rate for Payer: HFN Commercial |
$220.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.00
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: NAPHCARE Commercial |
$144.00
|
| Rate for Payer: Preferred Network Access Commercial |
$220.80
|
| Rate for Payer: Quartz Beloit One Network |
$117.60
|
| Rate for Payer: Quartz Commercial |
$156.00
|
| Rate for Payer: Quartz Medicare Advantage |
$144.00
|
| Rate for Payer: The Alliance Commercial |
$960.00
|
| Rate for Payer: United Healthcare PPO |
$180.00
|
| Rate for Payer: WEA Trust Commercial |
$132.00
|
| Rate for Payer: WPS Commercial |
$177.77
|
|
|
Tramadol , Quantitative Urine
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 80373
|
| Hospital Charge Code |
5084606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$108.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Aetna Managed Medicare |
$33.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$60.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$57.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.15
|
| Rate for Payer: Health EOS Commercial |
$106.80
|
| Rate for Payer: HFN Commercial |
$110.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: NAPHCARE Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$110.40
|
| Rate for Payer: Quartz Beloit One Network |
$58.80
|
| Rate for Payer: Quartz Commercial |
$78.00
|
| Rate for Payer: Quartz Medicare Advantage |
$72.00
|
| Rate for Payer: The Alliance Commercial |
$480.00
|
| Rate for Payer: United Healthcare PPO |
$90.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
Tramadol , Quantitative Urine
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 80373
|
| Hospital Charge Code |
5084606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$108.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Health EOS Commercial |
$106.80
|
| Rate for Payer: HFN Commercial |
$110.40
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: NAPHCARE Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$110.40
|
| Rate for Payer: Quartz Beloit One Network |
$58.80
|
| Rate for Payer: Quartz Commercial |
$72.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
Tramadol , Quantitative Urine
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
CPT 80373
|
| Hospital Charge Code |
5084606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$114.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.00
|
| Rate for Payer: Health EOS Commercial |
$109.20
|
| Rate for Payer: HFN Commercial |
$114.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$114.00
|
| Rate for Payer: Quartz Beloit One Network |
$52.80
|
| Rate for Payer: Quartz Commercial |
$68.40
|
| Rate for Payer: The Alliance Commercial |
$60.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
.Tramadol Quant Urine
|
Professional
|
Both
|
$297.00
|
|
|
Service Code
|
CPT 80373
|
| Hospital Charge Code |
5088606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$282.15 |
| Rate for Payer: Aetna Commercial |
$282.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$255.42
|
| Rate for Payer: Cash Price |
$89.10
|
| Rate for Payer: Cash Price |
$89.10
|
| Rate for Payer: Cigna Commercial |
$282.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$148.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$178.20
|
| Rate for Payer: Health EOS Commercial |
$270.27
|
| Rate for Payer: HFN Commercial |
$282.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$237.60
|
| Rate for Payer: Preferred Network Access Commercial |
$282.15
|
| Rate for Payer: Quartz Beloit One Network |
$130.68
|
| Rate for Payer: Quartz Commercial |
$169.29
|
| Rate for Payer: The Alliance Commercial |
$148.50
|
| Rate for Payer: WEA Trust Commercial |
$163.35
|
| Rate for Payer: WPS Commercial |
$219.99
|
|
|
.Tramadol Quant Urine
|
Facility
|
IP
|
$297.00
|
|
|
Service Code
|
CPT 80373
|
| Hospital Charge Code |
5088606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$145.53 |
| Max. Negotiated Rate |
$273.24 |
| Rate for Payer: Aetna Commercial |
$267.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$255.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.41
|
| Rate for Payer: Cash Price |
$89.10
|
| Rate for Payer: Cigna Commercial |
$273.24
|
| Rate for Payer: Health EOS Commercial |
$264.33
|
| Rate for Payer: HFN Commercial |
$273.24
|
| Rate for Payer: Multiplan Commercial |
$237.60
|
| Rate for Payer: NAPHCARE Commercial |
$178.20
|
| Rate for Payer: Preferred Network Access Commercial |
$273.24
|
| Rate for Payer: Quartz Beloit One Network |
$145.53
|
| Rate for Payer: Quartz Commercial |
$178.20
|
| Rate for Payer: WEA Trust Commercial |
$163.35
|
| Rate for Payer: WPS Commercial |
$219.99
|
|
|
.Tramadol Quant Urine
|
Facility
|
OP
|
$297.00
|
|
|
Service Code
|
CPT 80373
|
| Hospital Charge Code |
5088606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.16 |
| Max. Negotiated Rate |
$1,188.00 |
| Rate for Payer: Aetna Commercial |
$267.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$255.42
|
| Rate for Payer: Aetna Managed Medicare |
$83.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$193.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$148.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$142.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.41
|
| Rate for Payer: Cash Price |
$89.10
|
| Rate for Payer: Cigna Commercial |
$273.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$166.20
|
| Rate for Payer: Health EOS Commercial |
$264.33
|
| Rate for Payer: HFN Commercial |
$273.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$222.75
|
| Rate for Payer: Multiplan Commercial |
$237.60
|
| Rate for Payer: NAPHCARE Commercial |
$178.20
|
| Rate for Payer: Preferred Network Access Commercial |
$273.24
|
| Rate for Payer: Quartz Beloit One Network |
$145.53
|
| Rate for Payer: Quartz Commercial |
$193.05
|
| Rate for Payer: Quartz Medicare Advantage |
$178.20
|
| Rate for Payer: The Alliance Commercial |
$1,188.00
|
| Rate for Payer: United Healthcare PPO |
$222.75
|
| Rate for Payer: WEA Trust Commercial |
$163.35
|
| Rate for Payer: WPS Commercial |
$219.99
|
|
|
TRANFIXING PIN 5MM X 300MM 5050-5-300
|
Facility
|
OP
|
$1,350.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685712
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$378.00 |
| Max. Negotiated Rate |
$5,400.00 |
| Rate for Payer: Aetna Commercial |
$1,215.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,161.00
|
| Rate for Payer: Aetna Managed Medicare |
$378.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$877.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$675.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$648.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$715.50
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna Commercial |
$1,242.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$755.46
|
| Rate for Payer: Health EOS Commercial |
$1,201.50
|
| Rate for Payer: HFN Commercial |
$1,242.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,012.50
|
| Rate for Payer: Multiplan Commercial |
$1,080.00
|
| Rate for Payer: NAPHCARE Commercial |
$810.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,242.00
|
| Rate for Payer: Quartz Beloit One Network |
$661.50
|
| Rate for Payer: Quartz Commercial |
$877.50
|
| Rate for Payer: Quartz Medicare Advantage |
$810.00
|
| Rate for Payer: The Alliance Commercial |
$5,400.00
|
| Rate for Payer: WEA Trust Commercial |
$742.50
|
| Rate for Payer: WPS Commercial |
$999.94
|
|
|
TRANFIXING PIN 5MM X 300MM 5050-5-300
|
Facility
|
IP
|
$1,350.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5685712
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$661.50 |
| Max. Negotiated Rate |
$1,242.00 |
| Rate for Payer: Aetna Commercial |
$1,215.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,161.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$715.50
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna Commercial |
$1,242.00
|
| Rate for Payer: Health EOS Commercial |
$1,201.50
|
| Rate for Payer: HFN Commercial |
$1,242.00
|
| Rate for Payer: Multiplan Commercial |
$1,080.00
|
| Rate for Payer: NAPHCARE Commercial |
$810.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,242.00
|
| Rate for Payer: Quartz Beloit One Network |
$661.50
|
| Rate for Payer: Quartz Commercial |
$810.00
|
| Rate for Payer: WEA Trust Commercial |
$742.50
|
| Rate for Payer: WPS Commercial |
$999.94
|
|
|
Transbronchial - Bronchoscopy Charge
|
Facility
|
IP
|
$4,954.00
|
|
|
Service Code
|
CPT 31628
|
| Hospital Charge Code |
2990186
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,427.46 |
| Max. Negotiated Rate |
$4,557.68 |
| Rate for Payer: Aetna Commercial |
$4,458.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,260.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,625.62
|
| Rate for Payer: Cash Price |
$1,486.20
|
| Rate for Payer: Cigna Commercial |
$4,557.68
|
| Rate for Payer: Health EOS Commercial |
$4,409.06
|
| Rate for Payer: HFN Commercial |
$4,557.68
|
| Rate for Payer: Multiplan Commercial |
$3,963.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,972.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,557.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,427.46
|
| Rate for Payer: Quartz Commercial |
$2,972.40
|
| Rate for Payer: WEA Trust Commercial |
$2,724.70
|
| Rate for Payer: WPS Commercial |
$3,669.43
|
|
|
Transbronchial - Bronchoscopy Charge
|
Facility
|
OP
|
$4,954.00
|
|
|
Service Code
|
CPT 31628
|
| Hospital Charge Code |
2990186
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,427.46 |
| Max. Negotiated Rate |
$13,769.28 |
| Rate for Payer: Aetna Commercial |
$4,458.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,260.44
|
| Rate for Payer: Aetna Managed Medicare |
$3,701.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,701.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,625.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,701.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,701.42
|
| Rate for Payer: Cash Price |
$1,486.20
|
| Rate for Payer: Cash Price |
$1,486.20
|
| Rate for Payer: Cash Price |
$1,486.20
|
| Rate for Payer: Cigna Commercial |
$4,557.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,701.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,701.42
|
| Rate for Payer: Health EOS Commercial |
$4,409.06
|
| Rate for Payer: HFN Commercial |
$4,557.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,769.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,701.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,701.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,701.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,701.42
|
| Rate for Payer: Multiplan Commercial |
$3,963.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,552.13
|
| Rate for Payer: Preferred Network Access Commercial |
$4,557.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,427.46
|
| Rate for Payer: Quartz Commercial |
$3,220.10
|
| Rate for Payer: Quartz Medicare Advantage |
$3,701.42
|
| Rate for Payer: The Alliance Commercial |
$6,292.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,701.42
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: WEA Trust Commercial |
$2,724.70
|
| Rate for Payer: Wellcare Medicare |
$3,701.42
|
| Rate for Payer: WPS Commercial |
$3,669.43
|
|
|
TRANSCATH IV STENT/PERC ADDL 37206
|
Professional
|
Both
|
$3,011.00
|
|
| Hospital Charge Code |
3014548
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1,324.84 |
| Max. Negotiated Rate |
$2,860.45 |
| Rate for Payer: Aetna Commercial |
$2,860.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,589.46
|
| Rate for Payer: Cash Price |
$903.30
|
| Rate for Payer: Cigna Commercial |
$2,860.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,505.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,806.60
|
| Rate for Payer: Health EOS Commercial |
$2,740.01
|
| Rate for Payer: HFN Commercial |
$2,860.45
|
| Rate for Payer: Multiplan Commercial |
$2,408.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,860.45
|
| Rate for Payer: Quartz Beloit One Network |
$1,324.84
|
| Rate for Payer: Quartz Commercial |
$1,716.27
|
| Rate for Payer: The Alliance Commercial |
$1,505.50
|
| Rate for Payer: WEA Trust Commercial |
$1,656.05
|
| Rate for Payer: WPS Commercial |
$2,230.25
|
|
|
TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE)
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960405
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,928.15 |
| Max. Negotiated Rate |
$3,620.20 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,361.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE)
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960405
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)
|
Facility
|
OP
|
$28,284.48
|
|
|
Service Code
|
CPT 27691
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,071.12 |
| Max. Negotiated Rate |
$28,284.48 |
| Rate for Payer: Aetna Managed Medicare |
$7,071.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,483.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,081.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,278.00
|
| Rate for Payer: Anthem Medicare Advantage |
$7,071.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,071.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,071.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,071.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,795.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,071.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,304.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,071.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,071.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,071.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,071.12
|
| Rate for Payer: NAPHCARE Commercial |
$10,606.68
|
| Rate for Payer: Quartz Medicare Advantage |
$7,071.12
|
| Rate for Payer: The Alliance Commercial |
$28,284.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,071.12
|
| Rate for Payer: United Healthcare PPO |
$8,452.00
|
| Rate for Payer: Wellcare Medicare |
$7,071.12
|
|
