|
Toradol 15 mg Charge
|
Professional
|
$7.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
2958957
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$0.55
|
| Rate for Payer: Anthem Medicare Advantage |
$0.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.55
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.70
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: Quartz Medicare Advantage |
$0.55
|
| Rate for Payer: The Alliance Commercial |
$1.50
|
| Rate for Payer: United Healthcare Medicaid |
$0.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.55
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$1.76
|
|
|
Toradol 15 mg Charge
|
Facility
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
2958957
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Toradol 30mg Vial (MED)
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
4595177
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Aetna Commercial |
$7.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.36
|
| Rate for Payer: Health EOS Commercial |
$7.12
|
| Rate for Payer: HFN Commercial |
$7.36
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: NAPHCARE Commercial |
$4.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7.36
|
| Rate for Payer: Quartz Beloit One Network |
$3.92
|
| Rate for Payer: Quartz Commercial |
$4.80
|
| Rate for Payer: WEA Trust Commercial |
$4.40
|
| Rate for Payer: WPS Commercial |
$5.93
|
|
|
Toradol 30mg Vial (MED)
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
4595177
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$17,002.00 |
| Rate for Payer: Aetna Commercial |
$7.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.88
|
| Rate for Payer: Aetna Managed Medicare |
$2.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.93
|
| Rate for Payer: Health EOS Commercial |
$7.12
|
| Rate for Payer: HFN Commercial |
$7.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: NAPHCARE Commercial |
$4.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7.36
|
| Rate for Payer: Quartz Beloit One Network |
$3.92
|
| Rate for Payer: Quartz Commercial |
$5.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4.80
|
| Rate for Payer: The Alliance Commercial |
$17,002.00
|
| Rate for Payer: WEA Trust Commercial |
$4.40
|
| Rate for Payer: WPS Commercial |
$1.76
|
|
|
Toradol JW Waste Charge
|
Professional
|
$7.00
|
|
|
Service Code
|
HCPCS J1885 JW
|
| Hospital Charge Code |
5246658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.20
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: The Alliance Commercial |
$3.50
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Toradol JW Waste Charge
|
Facility
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J1885 JW
|
| Hospital Charge Code |
5246658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.92
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Toradol JW Waste Charge
|
Facility
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J1885 JW
|
| Hospital Charge Code |
5246658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Torch Panel, Acute
|
Professional
|
$280.79
|
|
|
Service Code
|
CPT 86762
|
| Hospital Charge Code |
983427
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.39 |
| Max. Negotiated Rate |
$266.75 |
| Rate for Payer: Aetna Commercial |
$266.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.48
|
| Rate for Payer: Aetna Managed Medicare |
$14.39
|
| Rate for Payer: Anthem Medicare Advantage |
$14.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.39
|
| Rate for Payer: Cash Price |
$84.24
|
| Rate for Payer: Cash Price |
$84.24
|
| Rate for Payer: Cigna Commercial |
$266.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$140.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.39
|
| Rate for Payer: Health EOS Commercial |
$255.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$50.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.39
|
| Rate for Payer: Multiplan Commercial |
$224.63
|
| Rate for Payer: Preferred Network Access Commercial |
$266.75
|
| Rate for Payer: Quartz Beloit One Network |
$123.55
|
| Rate for Payer: Quartz Commercial |
$160.05
|
| Rate for Payer: Quartz Medicare Advantage |
$14.39
|
| Rate for Payer: The Alliance Commercial |
$56.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.39
|
| Rate for Payer: WEA Trust Commercial |
$154.43
|
| Rate for Payer: WPS Commercial |
$63.32
|
|
|
Torch Panel, Acute
|
Facility
IP
|
$280.79
|
|
|
Service Code
|
CPT 86762
|
| Hospital Charge Code |
983427
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.59 |
| Max. Negotiated Rate |
$258.33 |
| Rate for Payer: Aetna Commercial |
$252.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.82
|
| Rate for Payer: Cash Price |
$84.24
|
| Rate for Payer: Cigna Commercial |
$258.33
|
| Rate for Payer: Health EOS Commercial |
$249.90
|
| Rate for Payer: HFN Commercial |
$258.33
|
| Rate for Payer: Multiplan Commercial |
$224.63
|
| Rate for Payer: NAPHCARE Commercial |
$168.47
|
| Rate for Payer: Preferred Network Access Commercial |
$258.33
|
| Rate for Payer: Quartz Beloit One Network |
$137.59
|
| Rate for Payer: Quartz Commercial |
$168.47
|
| Rate for Payer: WEA Trust Commercial |
$154.43
|
| Rate for Payer: WPS Commercial |
$207.98
|
|
|
Torch Panel, Acute
|
Facility
OP
|
$280.79
|
|
|
Service Code
|
CPT 86762
|
| Hospital Charge Code |
983427
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.39 |
| Max. Negotiated Rate |
$1,123.16 |
| Rate for Payer: Aetna Commercial |
$252.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.48
|
| Rate for Payer: Aetna Managed Medicare |
$14.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.89
|
| Rate for Payer: Anthem Medicaid |
$14.87
|
| Rate for Payer: Anthem Medicare Advantage |
$14.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.39
|
| Rate for Payer: Cash Price |
$84.24
|
| Rate for Payer: Cash Price |
$84.24
|
| Rate for Payer: Cigna Commercial |
$258.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.87
|
| Rate for Payer: Dean Health Medicaid |
$14.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.39
|
| Rate for Payer: Health EOS Commercial |
$249.90
|
| Rate for Payer: HFN Commercial |
$258.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.39
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.39
|
| Rate for Payer: Managed Health Services Medicaid |
$15.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.39
|
| Rate for Payer: Multiplan Commercial |
$224.63
|
| Rate for Payer: NAPHCARE Commercial |
$21.58
|
| Rate for Payer: Preferred Network Access Commercial |
$258.33
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.87
|
| Rate for Payer: Quartz Beloit One Network |
$137.59
|
| Rate for Payer: Quartz Commercial |
$182.51
|
| Rate for Payer: Quartz Medicare Advantage |
$14.39
|
| Rate for Payer: The Alliance Commercial |
$1,123.16
|
| Rate for Payer: United Healthcare Medicaid |
$14.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.39
|
| Rate for Payer: United Healthcare PPO |
$210.59
|
| Rate for Payer: WEA Trust Commercial |
$154.43
|
| Rate for Payer: Wellcare Medicare |
$14.39
|
| Rate for Payer: WMAP Medicaid |
$14.87
|
| Rate for Payer: WPS Commercial |
$207.98
|
|
|
TORPEDO APS 4.0MM X 13CM AR-8400TD
|
Facility
OP
|
$959.00
|
|
| Hospital Charge Code |
4169033
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$268.52 |
| Max. Negotiated Rate |
$3,836.00 |
| Rate for Payer: Aetna Commercial |
$863.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$824.74
|
| Rate for Payer: Aetna Managed Medicare |
$268.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$623.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$479.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$460.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$508.27
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$882.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$536.66
|
| Rate for Payer: Health EOS Commercial |
$853.51
|
| Rate for Payer: HFN Commercial |
$882.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$719.25
|
| Rate for Payer: Multiplan Commercial |
$767.20
|
| Rate for Payer: NAPHCARE Commercial |
$575.40
|
| Rate for Payer: Preferred Network Access Commercial |
$882.28
|
| Rate for Payer: Quartz Beloit One Network |
$469.91
|
| Rate for Payer: Quartz Commercial |
$623.35
|
| Rate for Payer: Quartz Medicare Advantage |
$575.40
|
| Rate for Payer: The Alliance Commercial |
$3,836.00
|
| Rate for Payer: WEA Trust Commercial |
$527.45
|
| Rate for Payer: WPS Commercial |
$710.33
|
|
|
TORPEDO APS 4.0MM X 13CM AR-8400TD
|
Facility
IP
|
$959.00
|
|
| Hospital Charge Code |
4169033
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$469.91 |
| Max. Negotiated Rate |
$882.28 |
| Rate for Payer: Aetna Commercial |
$863.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$508.27
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$882.28
|
| Rate for Payer: Health EOS Commercial |
$853.51
|
| Rate for Payer: HFN Commercial |
$882.28
|
| Rate for Payer: Multiplan Commercial |
$767.20
|
| Rate for Payer: NAPHCARE Commercial |
$575.40
|
| Rate for Payer: Preferred Network Access Commercial |
$882.28
|
| Rate for Payer: Quartz Beloit One Network |
$469.91
|
| Rate for Payer: Quartz Commercial |
$575.40
|
| Rate for Payer: WEA Trust Commercial |
$527.45
|
| Rate for Payer: WPS Commercial |
$710.33
|
|
|
TORPEDO APS 4.0MM X 13CM CURVED AR-8400CTD
|
Facility
IP
|
$1,539.00
|
|
| Hospital Charge Code |
5348974
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$754.11 |
| Max. Negotiated Rate |
$1,415.88 |
| Rate for Payer: Aetna Commercial |
$1,385.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$815.67
|
| Rate for Payer: Cash Price |
$461.70
|
| Rate for Payer: Cigna Commercial |
$1,415.88
|
| Rate for Payer: Health EOS Commercial |
$1,369.71
|
| Rate for Payer: HFN Commercial |
$1,415.88
|
| Rate for Payer: Multiplan Commercial |
$1,231.20
|
| Rate for Payer: NAPHCARE Commercial |
$923.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,415.88
|
| Rate for Payer: Quartz Beloit One Network |
$754.11
|
| Rate for Payer: Quartz Commercial |
$923.40
|
| Rate for Payer: WEA Trust Commercial |
$846.45
|
| Rate for Payer: WPS Commercial |
$1,139.94
|
|
|
TORPEDO APS 4.0MM X 13CM CURVED AR-8400CTD
|
Facility
OP
|
$1,539.00
|
|
| Hospital Charge Code |
5348974
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$430.92 |
| Max. Negotiated Rate |
$6,156.00 |
| Rate for Payer: Aetna Commercial |
$1,385.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,323.54
|
| Rate for Payer: Aetna Managed Medicare |
$430.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,000.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$769.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$738.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$815.67
|
| Rate for Payer: Cash Price |
$461.70
|
| Rate for Payer: Cigna Commercial |
$1,415.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$861.22
|
| Rate for Payer: Health EOS Commercial |
$1,369.71
|
| Rate for Payer: HFN Commercial |
$1,415.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,154.25
|
| Rate for Payer: Multiplan Commercial |
$1,231.20
|
| Rate for Payer: NAPHCARE Commercial |
$923.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,415.88
|
| Rate for Payer: Quartz Beloit One Network |
$754.11
|
| Rate for Payer: Quartz Commercial |
$1,000.35
|
| Rate for Payer: Quartz Medicare Advantage |
$923.40
|
| Rate for Payer: The Alliance Commercial |
$6,156.00
|
| Rate for Payer: WEA Trust Commercial |
$846.45
|
| Rate for Payer: WPS Commercial |
$1,139.94
|
|
|
TORPEDO APS 5.0MM AR-8500TD
|
Facility
OP
|
$925.00
|
|
| Hospital Charge Code |
4509009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$259.00 |
| Max. Negotiated Rate |
$3,700.00 |
| Rate for Payer: Aetna Commercial |
$832.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$795.50
|
| Rate for Payer: Aetna Managed Medicare |
$259.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$601.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$462.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$444.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$490.25
|
| Rate for Payer: Cash Price |
$277.50
|
| Rate for Payer: Cigna Commercial |
$851.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$517.63
|
| Rate for Payer: Health EOS Commercial |
$823.25
|
| Rate for Payer: HFN Commercial |
$851.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$693.75
|
| Rate for Payer: Multiplan Commercial |
$740.00
|
| Rate for Payer: NAPHCARE Commercial |
$555.00
|
| Rate for Payer: Preferred Network Access Commercial |
$851.00
|
| Rate for Payer: Quartz Beloit One Network |
$453.25
|
| Rate for Payer: Quartz Commercial |
$601.25
|
| Rate for Payer: Quartz Medicare Advantage |
$555.00
|
| Rate for Payer: The Alliance Commercial |
$3,700.00
|
| Rate for Payer: WEA Trust Commercial |
$508.75
|
| Rate for Payer: WPS Commercial |
$685.15
|
|
|
TORPEDO APS 5.0MM AR-8500TD
|
Facility
IP
|
$925.00
|
|
| Hospital Charge Code |
4509009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$453.25 |
| Max. Negotiated Rate |
$851.00 |
| Rate for Payer: Aetna Commercial |
$832.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$490.25
|
| Rate for Payer: Cash Price |
$277.50
|
| Rate for Payer: Cigna Commercial |
$851.00
|
| Rate for Payer: Health EOS Commercial |
$823.25
|
| Rate for Payer: HFN Commercial |
$851.00
|
| Rate for Payer: Multiplan Commercial |
$740.00
|
| Rate for Payer: NAPHCARE Commercial |
$555.00
|
| Rate for Payer: Preferred Network Access Commercial |
$851.00
|
| Rate for Payer: Quartz Beloit One Network |
$453.25
|
| Rate for Payer: Quartz Commercial |
$555.00
|
| Rate for Payer: WEA Trust Commercial |
$508.75
|
| Rate for Payer: WPS Commercial |
$685.15
|
|
|
Total Complement
|
Facility
OP
|
$310.00
|
|
|
Service Code
|
CPT 86162
|
| Hospital Charge Code |
3403545
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.32 |
| Max. Negotiated Rate |
$1,240.00 |
| Rate for Payer: Aetna Commercial |
$279.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$266.60
|
| Rate for Payer: Aetna Managed Medicare |
$20.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$76.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.73
|
| Rate for Payer: Anthem Medicare Advantage |
$20.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$164.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.32
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$285.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20.32
|
| Rate for Payer: Health EOS Commercial |
$275.90
|
| Rate for Payer: HFN Commercial |
$285.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$75.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20.32
|
| Rate for Payer: Multiplan Commercial |
$248.00
|
| Rate for Payer: NAPHCARE Commercial |
$30.48
|
| Rate for Payer: Preferred Network Access Commercial |
$285.20
|
| Rate for Payer: Quartz Beloit One Network |
$151.90
|
| Rate for Payer: Quartz Commercial |
$201.50
|
| Rate for Payer: Quartz Medicare Advantage |
$20.32
|
| Rate for Payer: The Alliance Commercial |
$1,240.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.32
|
| Rate for Payer: United Healthcare PPO |
$232.50
|
| Rate for Payer: WEA Trust Commercial |
$170.50
|
| Rate for Payer: Wellcare Medicare |
$20.32
|
| Rate for Payer: WPS Commercial |
$229.62
|
|
|
Total Complement
|
Professional
|
$310.00
|
|
|
Service Code
|
CPT 86162
|
| Hospital Charge Code |
3403545
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.32 |
| Max. Negotiated Rate |
$294.50 |
| Rate for Payer: Aetna Commercial |
$294.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$266.60
|
| Rate for Payer: Aetna Managed Medicare |
$20.32
|
| Rate for Payer: Anthem Medicare Advantage |
$20.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.32
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$294.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$155.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.32
|
| Rate for Payer: Health EOS Commercial |
$282.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$71.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.32
|
| Rate for Payer: Multiplan Commercial |
$248.00
|
| Rate for Payer: Preferred Network Access Commercial |
$294.50
|
| Rate for Payer: Quartz Beloit One Network |
$136.40
|
| Rate for Payer: Quartz Commercial |
$176.70
|
| Rate for Payer: Quartz Medicare Advantage |
$20.32
|
| Rate for Payer: The Alliance Commercial |
$80.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.32
|
| Rate for Payer: WEA Trust Commercial |
$170.50
|
| Rate for Payer: WPS Commercial |
$89.41
|
|
|
Total Complement
|
Facility
IP
|
$310.00
|
|
|
Service Code
|
CPT 86162
|
| Hospital Charge Code |
3403545
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$151.90 |
| Max. Negotiated Rate |
$285.20 |
| Rate for Payer: Aetna Commercial |
$279.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$164.30
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$285.20
|
| Rate for Payer: Health EOS Commercial |
$275.90
|
| Rate for Payer: HFN Commercial |
$285.20
|
| Rate for Payer: Multiplan Commercial |
$248.00
|
| Rate for Payer: NAPHCARE Commercial |
$186.00
|
| Rate for Payer: Preferred Network Access Commercial |
$285.20
|
| Rate for Payer: Quartz Beloit One Network |
$151.90
|
| Rate for Payer: Quartz Commercial |
$186.00
|
| Rate for Payer: WEA Trust Commercial |
$170.50
|
| Rate for Payer: WPS Commercial |
$229.62
|
|
|
Total Glutathione, Whole Blood
|
Professional
|
$83.00
|
|
|
Service Code
|
CPT 82978
|
| Hospital Charge Code |
6171752
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.45 |
| Max. Negotiated Rate |
$78.85 |
| Rate for Payer: Aetna Commercial |
$78.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Aetna Managed Medicare |
$15.45
|
| Rate for Payer: Anthem Medicare Advantage |
$15.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.45
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$78.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.45
|
| Rate for Payer: Health EOS Commercial |
$75.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$54.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.45
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: Preferred Network Access Commercial |
$78.85
|
| Rate for Payer: Quartz Beloit One Network |
$36.52
|
| Rate for Payer: Quartz Commercial |
$47.31
|
| Rate for Payer: Quartz Medicare Advantage |
$15.45
|
| Rate for Payer: The Alliance Commercial |
$61.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.45
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$67.98
|
|
|
Total Glutathione, Whole Blood
|
Facility
IP
|
$83.00
|
|
|
Service Code
|
CPT 82978
|
| Hospital Charge Code |
6171752
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.67 |
| Max. Negotiated Rate |
$76.36 |
| Rate for Payer: Aetna Commercial |
$74.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.99
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: Health EOS Commercial |
$73.87
|
| Rate for Payer: HFN Commercial |
$76.36
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: NAPHCARE Commercial |
$49.80
|
| Rate for Payer: Preferred Network Access Commercial |
$76.36
|
| Rate for Payer: Quartz Beloit One Network |
$40.67
|
| Rate for Payer: Quartz Commercial |
$49.80
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
Total Glutathione, Whole Blood
|
Facility
OP
|
$83.00
|
|
|
Service Code
|
CPT 82978
|
| Hospital Charge Code |
6171752
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.45 |
| Max. Negotiated Rate |
$332.00 |
| Rate for Payer: Aetna Commercial |
$74.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Aetna Managed Medicare |
$15.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.65
|
| Rate for Payer: Anthem Medicaid |
$15.96
|
| Rate for Payer: Anthem Medicare Advantage |
$15.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.45
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.96
|
| Rate for Payer: Dean Health Medicaid |
$15.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.45
|
| Rate for Payer: Health EOS Commercial |
$73.87
|
| Rate for Payer: HFN Commercial |
$76.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.45
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.45
|
| Rate for Payer: Managed Health Services Medicaid |
$16.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.45
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: NAPHCARE Commercial |
$23.18
|
| Rate for Payer: Preferred Network Access Commercial |
$76.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.96
|
| Rate for Payer: Quartz Beloit One Network |
$40.67
|
| Rate for Payer: Quartz Commercial |
$53.95
|
| Rate for Payer: Quartz Medicare Advantage |
$15.45
|
| Rate for Payer: The Alliance Commercial |
$332.00
|
| Rate for Payer: United Healthcare Medicaid |
$15.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.45
|
| Rate for Payer: United Healthcare PPO |
$62.25
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: Wellcare Medicare |
$15.45
|
| Rate for Payer: WMAP Medicaid |
$15.96
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
TOURNI-COT FINGER MEDIUM #TCM
|
Facility
IP
|
$80.00
|
|
| Hospital Charge Code |
2974635
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$73.60 |
| Rate for Payer: Aetna Commercial |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$73.60
|
| Rate for Payer: Health EOS Commercial |
$71.20
|
| Rate for Payer: HFN Commercial |
$73.60
|
| Rate for Payer: Multiplan Commercial |
$64.00
|
| Rate for Payer: NAPHCARE Commercial |
$48.00
|
| Rate for Payer: Preferred Network Access Commercial |
$73.60
|
| Rate for Payer: Quartz Beloit One Network |
$39.20
|
| Rate for Payer: Quartz Commercial |
$48.00
|
| Rate for Payer: WEA Trust Commercial |
$44.00
|
| Rate for Payer: WPS Commercial |
$59.26
|
|
|
TOURNI-COT FINGER MEDIUM #TCM
|
Facility
OP
|
$80.00
|
|
| Hospital Charge Code |
2974635
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$320.00 |
| Rate for Payer: Aetna Commercial |
$72.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.80
|
| Rate for Payer: Aetna Managed Medicare |
$22.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$73.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.77
|
| Rate for Payer: Health EOS Commercial |
$71.20
|
| Rate for Payer: HFN Commercial |
$73.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$64.00
|
| Rate for Payer: NAPHCARE Commercial |
$48.00
|
| Rate for Payer: Preferred Network Access Commercial |
$73.60
|
| Rate for Payer: Quartz Beloit One Network |
$39.20
|
| Rate for Payer: Quartz Commercial |
$52.00
|
| Rate for Payer: Quartz Medicare Advantage |
$48.00
|
| Rate for Payer: The Alliance Commercial |
$320.00
|
| Rate for Payer: WEA Trust Commercial |
$44.00
|
| Rate for Payer: WPS Commercial |
$59.26
|
|
|
TOURNI-COT LARGE FINGER TCL-3001
|
Facility
OP
|
$82.00
|
|
| Hospital Charge Code |
2965769
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.96 |
| Max. Negotiated Rate |
$328.00 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| Rate for Payer: Aetna Managed Medicare |
$22.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.46
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$75.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.89
|
| Rate for Payer: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.50
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: NAPHCARE Commercial |
$49.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.44
|
| Rate for Payer: Quartz Beloit One Network |
$40.18
|
| Rate for Payer: Quartz Commercial |
$53.30
|
| Rate for Payer: Quartz Medicare Advantage |
$49.20
|
| Rate for Payer: The Alliance Commercial |
$328.00
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
