|
Systemic Lupus (SLE) Comprehensive Diagnostics Panel
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
CPT 86038
|
| Hospital Charge Code |
3398191
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.09 |
| Max. Negotiated Rate |
$160.08 |
| Rate for Payer: Aetna Commercial |
$156.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.64
|
| Rate for Payer: Aetna Managed Medicare |
$12.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.07
|
| Rate for Payer: Anthem Medicaid |
$12.49
|
| Rate for Payer: Anthem Medicare Advantage |
$12.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.09
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$160.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.37
|
| Rate for Payer: Dean Health Medicaid |
$12.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.09
|
| Rate for Payer: Health EOS Commercial |
$154.86
|
| Rate for Payer: HFN Commercial |
$160.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.09
|
| Rate for Payer: Managed Health Services Medicaid |
$12.99
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.09
|
| Rate for Payer: Multiplan Commercial |
$139.20
|
| Rate for Payer: NAPHCARE Commercial |
$18.14
|
| Rate for Payer: Preferred Network Access Commercial |
$160.08
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.49
|
| Rate for Payer: Quartz Beloit One Network |
$85.26
|
| Rate for Payer: Quartz Commercial |
$113.10
|
| Rate for Payer: Quartz Medicare Advantage |
$12.09
|
| Rate for Payer: The Alliance Commercial |
$48.36
|
| Rate for Payer: United Healthcare Medicaid |
$12.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.09
|
| Rate for Payer: United Healthcare PPO |
$130.50
|
| Rate for Payer: WEA Trust Commercial |
$95.70
|
| Rate for Payer: Wellcare Medicare |
$12.09
|
| Rate for Payer: WMAP Medicaid |
$12.49
|
| Rate for Payer: WPS Commercial |
$128.88
|
|
|
Systemic Lupus (SLE) Comprehensive Diagnostics Panel
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
CPT 86038
|
| Hospital Charge Code |
3398191
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$85.26 |
| Max. Negotiated Rate |
$160.08 |
| Rate for Payer: Aetna Commercial |
$156.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.22
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$160.08
|
| Rate for Payer: Health EOS Commercial |
$154.86
|
| Rate for Payer: HFN Commercial |
$160.08
|
| Rate for Payer: Multiplan Commercial |
$139.20
|
| Rate for Payer: NAPHCARE Commercial |
$104.40
|
| Rate for Payer: Preferred Network Access Commercial |
$160.08
|
| Rate for Payer: Quartz Beloit One Network |
$85.26
|
| Rate for Payer: Quartz Commercial |
$104.40
|
| Rate for Payer: WEA Trust Commercial |
$95.70
|
| Rate for Payer: WPS Commercial |
$128.88
|
|
|
Systemic Lupus (SLE) Comprehensive Diagnostics Panel
|
Professional
|
Both
|
$174.00
|
|
|
Service Code
|
CPT 86038
|
| Hospital Charge Code |
3398191
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.68 |
| Max. Negotiated Rate |
$165.30 |
| Rate for Payer: Aetna Commercial |
$165.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.64
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$165.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$87.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104.40
|
| Rate for Payer: Health EOS Commercial |
$158.34
|
| Rate for Payer: HFN Commercial |
$165.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.68
|
| Rate for Payer: Multiplan Commercial |
$139.20
|
| Rate for Payer: Preferred Network Access Commercial |
$165.30
|
| Rate for Payer: Quartz Beloit One Network |
$76.56
|
| Rate for Payer: Quartz Commercial |
$99.18
|
| Rate for Payer: The Alliance Commercial |
$87.00
|
| Rate for Payer: WEA Trust Commercial |
$95.70
|
| Rate for Payer: WPS Commercial |
$128.88
|
|
|
SYSTEM IRRIGATION IRRISEPT IRRISEPT
|
Facility
|
IP
|
$1,129.00
|
|
| Hospital Charge Code |
5349335
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$553.21 |
| Max. Negotiated Rate |
$1,038.68 |
| Rate for Payer: Aetna Commercial |
$1,016.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$970.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$598.37
|
| Rate for Payer: Cash Price |
$338.70
|
| Rate for Payer: Cigna Commercial |
$1,038.68
|
| Rate for Payer: Health EOS Commercial |
$1,004.81
|
| Rate for Payer: HFN Commercial |
$1,038.68
|
| Rate for Payer: Multiplan Commercial |
$903.20
|
| Rate for Payer: NAPHCARE Commercial |
$677.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,038.68
|
| Rate for Payer: Quartz Beloit One Network |
$553.21
|
| Rate for Payer: Quartz Commercial |
$677.40
|
| Rate for Payer: WEA Trust Commercial |
$620.95
|
| Rate for Payer: WPS Commercial |
$836.25
|
|
|
SYSTEM IRRIGATION IRRISEPT IRRISEPT
|
Facility
|
OP
|
$1,129.00
|
|
| Hospital Charge Code |
5349335
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$316.12 |
| Max. Negotiated Rate |
$4,516.00 |
| Rate for Payer: Aetna Commercial |
$1,016.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$970.94
|
| Rate for Payer: Aetna Managed Medicare |
$316.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$733.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$564.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$598.37
|
| Rate for Payer: Cash Price |
$338.70
|
| Rate for Payer: Cigna Commercial |
$1,038.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$631.79
|
| Rate for Payer: Health EOS Commercial |
$1,004.81
|
| Rate for Payer: HFN Commercial |
$1,038.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$846.75
|
| Rate for Payer: Multiplan Commercial |
$903.20
|
| Rate for Payer: NAPHCARE Commercial |
$677.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,038.68
|
| Rate for Payer: Quartz Beloit One Network |
$553.21
|
| Rate for Payer: Quartz Commercial |
$733.85
|
| Rate for Payer: Quartz Medicare Advantage |
$677.40
|
| Rate for Payer: The Alliance Commercial |
$4,516.00
|
| Rate for Payer: WEA Trust Commercial |
$620.95
|
| Rate for Payer: WPS Commercial |
$836.25
|
|
|
SYSTEM MAX CORE BIOPSY 18 X 20CM (GENERAL) MC1820
|
Facility
|
IP
|
$861.00
|
|
| Hospital Charge Code |
2969353
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$421.89 |
| Max. Negotiated Rate |
$792.12 |
| Rate for Payer: Aetna Commercial |
$774.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$740.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$456.33
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$792.12
|
| Rate for Payer: Health EOS Commercial |
$766.29
|
| Rate for Payer: HFN Commercial |
$792.12
|
| Rate for Payer: Multiplan Commercial |
$688.80
|
| Rate for Payer: NAPHCARE Commercial |
$516.60
|
| Rate for Payer: Preferred Network Access Commercial |
$792.12
|
| Rate for Payer: Quartz Beloit One Network |
$421.89
|
| Rate for Payer: Quartz Commercial |
$516.60
|
| Rate for Payer: WEA Trust Commercial |
$473.55
|
| Rate for Payer: WPS Commercial |
$637.74
|
|
|
SYSTEM MAX CORE BIOPSY 18 X 20CM (GENERAL) MC1820
|
Facility
|
OP
|
$861.00
|
|
| Hospital Charge Code |
2969353
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$241.08 |
| Max. Negotiated Rate |
$3,444.00 |
| Rate for Payer: Aetna Commercial |
$774.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$740.46
|
| Rate for Payer: Aetna Managed Medicare |
$241.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$559.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$430.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$413.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$456.33
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$792.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$481.82
|
| Rate for Payer: Health EOS Commercial |
$766.29
|
| Rate for Payer: HFN Commercial |
$792.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$645.75
|
| Rate for Payer: Multiplan Commercial |
$688.80
|
| Rate for Payer: NAPHCARE Commercial |
$516.60
|
| Rate for Payer: Preferred Network Access Commercial |
$792.12
|
| Rate for Payer: Quartz Beloit One Network |
$421.89
|
| Rate for Payer: Quartz Commercial |
$559.65
|
| Rate for Payer: Quartz Medicare Advantage |
$516.60
|
| Rate for Payer: The Alliance Commercial |
$3,444.00
|
| Rate for Payer: WEA Trust Commercial |
$473.55
|
| Rate for Payer: WPS Commercial |
$637.74
|
|
|
SYSTEM MAX CORE BIOPSY 18 X 25CM (URO) MC1825
|
Facility
|
OP
|
$2,998.00
|
|
| Hospital Charge Code |
3825392
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$839.44 |
| Max. Negotiated Rate |
$11,992.00 |
| Rate for Payer: Aetna Commercial |
$2,698.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,578.28
|
| Rate for Payer: Aetna Managed Medicare |
$839.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,948.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,499.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,439.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,588.94
|
| Rate for Payer: Cash Price |
$899.40
|
| Rate for Payer: Cigna Commercial |
$2,758.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,677.68
|
| Rate for Payer: Health EOS Commercial |
$2,668.22
|
| Rate for Payer: HFN Commercial |
$2,758.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,248.50
|
| Rate for Payer: Multiplan Commercial |
$2,398.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,798.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,758.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,469.02
|
| Rate for Payer: Quartz Commercial |
$1,948.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,798.80
|
| Rate for Payer: The Alliance Commercial |
$11,992.00
|
| Rate for Payer: WEA Trust Commercial |
$1,648.90
|
| Rate for Payer: WPS Commercial |
$2,220.62
|
|
|
SYSTEM MAX CORE BIOPSY 18 X 25CM (URO) MC1825
|
Facility
|
IP
|
$2,998.00
|
|
| Hospital Charge Code |
3825392
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,469.02 |
| Max. Negotiated Rate |
$2,758.16 |
| Rate for Payer: Aetna Commercial |
$2,698.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,578.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,588.94
|
| Rate for Payer: Cash Price |
$899.40
|
| Rate for Payer: Cigna Commercial |
$2,758.16
|
| Rate for Payer: Health EOS Commercial |
$2,668.22
|
| Rate for Payer: HFN Commercial |
$2,758.16
|
| Rate for Payer: Multiplan Commercial |
$2,398.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,798.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,758.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,469.02
|
| Rate for Payer: Quartz Commercial |
$1,798.80
|
| Rate for Payer: WEA Trust Commercial |
$1,648.90
|
| Rate for Payer: WPS Commercial |
$2,220.62
|
|
|
SYSTEM PREVENA CUSTOMIZABLE PRE4001US
|
Facility
|
OP
|
$4,940.00
|
|
| Hospital Charge Code |
5074884
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,383.20 |
| Max. Negotiated Rate |
$19,760.00 |
| Rate for Payer: Aetna Commercial |
$4,446.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,248.40
|
| Rate for Payer: Aetna Managed Medicare |
$1,383.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,211.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,470.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,371.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,618.20
|
| Rate for Payer: Cash Price |
$1,482.00
|
| Rate for Payer: Cigna Commercial |
$4,544.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,764.42
|
| Rate for Payer: Health EOS Commercial |
$4,396.60
|
| Rate for Payer: HFN Commercial |
$4,544.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,705.00
|
| Rate for Payer: Multiplan Commercial |
$3,952.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,964.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,544.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,420.60
|
| Rate for Payer: Quartz Commercial |
$3,211.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,964.00
|
| Rate for Payer: The Alliance Commercial |
$19,760.00
|
| Rate for Payer: WEA Trust Commercial |
$2,717.00
|
| Rate for Payer: WPS Commercial |
$3,659.06
|
|
|
SYSTEM PREVENA CUSTOMIZABLE PRE4001US
|
Facility
|
IP
|
$4,940.00
|
|
| Hospital Charge Code |
5074884
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,420.60 |
| Max. Negotiated Rate |
$4,544.80 |
| Rate for Payer: Aetna Commercial |
$4,446.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,248.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,618.20
|
| Rate for Payer: Cash Price |
$1,482.00
|
| Rate for Payer: Cigna Commercial |
$4,544.80
|
| Rate for Payer: Health EOS Commercial |
$4,396.60
|
| Rate for Payer: HFN Commercial |
$4,544.80
|
| Rate for Payer: Multiplan Commercial |
$3,952.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,964.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,544.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,420.60
|
| Rate for Payer: Quartz Commercial |
$2,964.00
|
| Rate for Payer: WEA Trust Commercial |
$2,717.00
|
| Rate for Payer: WPS Commercial |
$3,659.06
|
|
|
SYSTEM SEATED POSITIONING 7530
|
Facility
|
IP
|
$1,540.00
|
|
| Hospital Charge Code |
5459574
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$754.60 |
| Max. Negotiated Rate |
$1,416.80 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,324.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$816.20
|
| Rate for Payer: Cash Price |
$462.00
|
| Rate for Payer: Cigna Commercial |
$1,416.80
|
| Rate for Payer: Health EOS Commercial |
$1,370.60
|
| Rate for Payer: HFN Commercial |
$1,416.80
|
| Rate for Payer: Multiplan Commercial |
$1,232.00
|
| Rate for Payer: NAPHCARE Commercial |
$924.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,416.80
|
| Rate for Payer: Quartz Beloit One Network |
$754.60
|
| Rate for Payer: Quartz Commercial |
$924.00
|
| Rate for Payer: WEA Trust Commercial |
$847.00
|
| Rate for Payer: WPS Commercial |
$1,140.68
|
|
|
SYSTEM SEATED POSITIONING 7530
|
Facility
|
OP
|
$1,540.00
|
|
| Hospital Charge Code |
5459574
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$431.20 |
| Max. Negotiated Rate |
$6,160.00 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,324.40
|
| Rate for Payer: Aetna Managed Medicare |
$431.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,001.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$770.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$739.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$816.20
|
| Rate for Payer: Cash Price |
$462.00
|
| Rate for Payer: Cigna Commercial |
$1,416.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$861.78
|
| Rate for Payer: Health EOS Commercial |
$1,370.60
|
| Rate for Payer: HFN Commercial |
$1,416.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,155.00
|
| Rate for Payer: Multiplan Commercial |
$1,232.00
|
| Rate for Payer: NAPHCARE Commercial |
$924.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,416.80
|
| Rate for Payer: Quartz Beloit One Network |
$754.60
|
| Rate for Payer: Quartz Commercial |
$1,001.00
|
| Rate for Payer: Quartz Medicare Advantage |
$924.00
|
| Rate for Payer: The Alliance Commercial |
$6,160.00
|
| Rate for Payer: WEA Trust Commercial |
$847.00
|
| Rate for Payer: WPS Commercial |
$1,140.68
|
|
|
SYSTEM STRATOS ENDOSCOPIC CARPAL TUNNEL RELEASE 5500
|
Facility
|
IP
|
$9,102.00
|
|
| Hospital Charge Code |
4508723
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,459.98 |
| Max. Negotiated Rate |
$8,373.84 |
| Rate for Payer: Aetna Commercial |
$8,191.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,827.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,824.06
|
| Rate for Payer: Cash Price |
$2,730.60
|
| Rate for Payer: Cigna Commercial |
$8,373.84
|
| Rate for Payer: Health EOS Commercial |
$8,100.78
|
| Rate for Payer: HFN Commercial |
$8,373.84
|
| Rate for Payer: Multiplan Commercial |
$7,281.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,461.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,373.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,459.98
|
| Rate for Payer: Quartz Commercial |
$5,461.20
|
| Rate for Payer: WEA Trust Commercial |
$5,006.10
|
| Rate for Payer: WPS Commercial |
$6,741.85
|
|
|
SYSTEM STRATOS ENDOSCOPIC CARPAL TUNNEL RELEASE 5500
|
Facility
|
OP
|
$9,102.00
|
|
| Hospital Charge Code |
4508723
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,548.56 |
| Max. Negotiated Rate |
$36,408.00 |
| Rate for Payer: Aetna Commercial |
$8,191.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,827.72
|
| Rate for Payer: Aetna Managed Medicare |
$2,548.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,916.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,551.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,368.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,824.06
|
| Rate for Payer: Cash Price |
$2,730.60
|
| Rate for Payer: Cigna Commercial |
$8,373.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,093.48
|
| Rate for Payer: Health EOS Commercial |
$8,100.78
|
| Rate for Payer: HFN Commercial |
$8,373.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,826.50
|
| Rate for Payer: Multiplan Commercial |
$7,281.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,461.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,373.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,459.98
|
| Rate for Payer: Quartz Commercial |
$5,916.30
|
| Rate for Payer: Quartz Medicare Advantage |
$5,461.20
|
| Rate for Payer: The Alliance Commercial |
$36,408.00
|
| Rate for Payer: WEA Trust Commercial |
$5,006.10
|
| Rate for Payer: WPS Commercial |
$6,741.85
|
|
|
SYSTEM THROMBINATOR (DISP) ABS-10080
|
Facility
|
IP
|
$2,174.00
|
|
| Hospital Charge Code |
6234191
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,065.26 |
| Max. Negotiated Rate |
$2,000.08 |
| Rate for Payer: Aetna Commercial |
$1,956.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,869.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,152.22
|
| Rate for Payer: Cash Price |
$652.20
|
| Rate for Payer: Cigna Commercial |
$2,000.08
|
| Rate for Payer: Health EOS Commercial |
$1,934.86
|
| Rate for Payer: HFN Commercial |
$2,000.08
|
| Rate for Payer: Multiplan Commercial |
$1,739.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,304.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,000.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,065.26
|
| Rate for Payer: Quartz Commercial |
$1,304.40
|
| Rate for Payer: WEA Trust Commercial |
$1,195.70
|
| Rate for Payer: WPS Commercial |
$1,610.28
|
|
|
SYSTEM THROMBINATOR (DISP) ABS-10080
|
Facility
|
OP
|
$2,174.00
|
|
| Hospital Charge Code |
6234191
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$608.72 |
| Max. Negotiated Rate |
$8,696.00 |
| Rate for Payer: Aetna Commercial |
$1,956.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,869.64
|
| Rate for Payer: Aetna Managed Medicare |
$608.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,413.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,087.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,043.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,152.22
|
| Rate for Payer: Cash Price |
$652.20
|
| Rate for Payer: Cigna Commercial |
$2,000.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,216.57
|
| Rate for Payer: Health EOS Commercial |
$1,934.86
|
| Rate for Payer: HFN Commercial |
$2,000.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,630.50
|
| Rate for Payer: Multiplan Commercial |
$1,739.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,304.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,000.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,065.26
|
| Rate for Payer: Quartz Commercial |
$1,413.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,304.40
|
| Rate for Payer: The Alliance Commercial |
$8,696.00
|
| Rate for Payer: WEA Trust Commercial |
$1,195.70
|
| Rate for Payer: WPS Commercial |
$1,610.28
|
|
|
SYS TRANSFER PREVALON 3242
|
Facility
|
OP
|
$1,581.00
|
|
| Hospital Charge Code |
5414961
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$442.68 |
| Max. Negotiated Rate |
$6,324.00 |
| Rate for Payer: Aetna Commercial |
$1,422.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,359.66
|
| Rate for Payer: Aetna Managed Medicare |
$442.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,027.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$790.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$758.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$837.93
|
| Rate for Payer: Cash Price |
$474.30
|
| Rate for Payer: Cigna Commercial |
$1,454.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$884.73
|
| Rate for Payer: Health EOS Commercial |
$1,407.09
|
| Rate for Payer: HFN Commercial |
$1,454.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,185.75
|
| Rate for Payer: Multiplan Commercial |
$1,264.80
|
| Rate for Payer: NAPHCARE Commercial |
$948.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,454.52
|
| Rate for Payer: Quartz Beloit One Network |
$774.69
|
| Rate for Payer: Quartz Commercial |
$1,027.65
|
| Rate for Payer: Quartz Medicare Advantage |
$948.60
|
| Rate for Payer: The Alliance Commercial |
$6,324.00
|
| Rate for Payer: WEA Trust Commercial |
$869.55
|
| Rate for Payer: WPS Commercial |
$1,171.05
|
|
|
SYS TRANSFER PREVALON 3242
|
Facility
|
IP
|
$1,581.00
|
|
| Hospital Charge Code |
5414961
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$774.69 |
| Max. Negotiated Rate |
$1,454.52 |
| Rate for Payer: Aetna Commercial |
$1,422.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,359.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$837.93
|
| Rate for Payer: Cash Price |
$474.30
|
| Rate for Payer: Cigna Commercial |
$1,454.52
|
| Rate for Payer: Health EOS Commercial |
$1,407.09
|
| Rate for Payer: HFN Commercial |
$1,454.52
|
| Rate for Payer: Multiplan Commercial |
$1,264.80
|
| Rate for Payer: NAPHCARE Commercial |
$948.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,454.52
|
| Rate for Payer: Quartz Beloit One Network |
$774.69
|
| Rate for Payer: Quartz Commercial |
$948.60
|
| Rate for Payer: WEA Trust Commercial |
$869.55
|
| Rate for Payer: WPS Commercial |
$1,171.05
|
|
|
SYS XXL REPOSITIONER PREVALON AIRTAP 7231
|
Facility
|
IP
|
$4,296.00
|
|
| Hospital Charge Code |
5414962
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,105.04 |
| Max. Negotiated Rate |
$3,952.32 |
| Rate for Payer: Aetna Commercial |
$3,866.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,694.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,276.88
|
| Rate for Payer: Cash Price |
$1,288.80
|
| Rate for Payer: Cigna Commercial |
$3,952.32
|
| Rate for Payer: Health EOS Commercial |
$3,823.44
|
| Rate for Payer: HFN Commercial |
$3,952.32
|
| Rate for Payer: Multiplan Commercial |
$3,436.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,577.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,952.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,105.04
|
| Rate for Payer: Quartz Commercial |
$2,577.60
|
| Rate for Payer: WEA Trust Commercial |
$2,362.80
|
| Rate for Payer: WPS Commercial |
$3,182.05
|
|
|
SYS XXL REPOSITIONER PREVALON AIRTAP 7231
|
Facility
|
OP
|
$4,296.00
|
|
| Hospital Charge Code |
5414962
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,202.88 |
| Max. Negotiated Rate |
$17,184.00 |
| Rate for Payer: Aetna Commercial |
$3,866.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,694.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,202.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,792.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,148.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,062.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,276.88
|
| Rate for Payer: Cash Price |
$1,288.80
|
| Rate for Payer: Cigna Commercial |
$3,952.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,404.04
|
| Rate for Payer: Health EOS Commercial |
$3,823.44
|
| Rate for Payer: HFN Commercial |
$3,952.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,222.00
|
| Rate for Payer: Multiplan Commercial |
$3,436.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,577.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,952.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,105.04
|
| Rate for Payer: Quartz Commercial |
$2,792.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,577.60
|
| Rate for Payer: The Alliance Commercial |
$17,184.00
|
| Rate for Payer: WEA Trust Commercial |
$2,362.80
|
| Rate for Payer: WPS Commercial |
$3,182.05
|
|
|
T3 Free
|
Professional
|
Both
|
$210.00
|
|
|
Service Code
|
CPT 84481
|
| Hospital Charge Code |
633834
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$59.80 |
| Max. Negotiated Rate |
$199.50 |
| Rate for Payer: Aetna Commercial |
$199.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$180.60
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$199.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$105.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$126.00
|
| Rate for Payer: Health EOS Commercial |
$191.10
|
| Rate for Payer: HFN Commercial |
$199.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.80
|
| Rate for Payer: Multiplan Commercial |
$168.00
|
| Rate for Payer: Preferred Network Access Commercial |
$199.50
|
| Rate for Payer: Quartz Beloit One Network |
$92.40
|
| Rate for Payer: Quartz Commercial |
$119.70
|
| Rate for Payer: The Alliance Commercial |
$105.00
|
| Rate for Payer: WEA Trust Commercial |
$115.50
|
| Rate for Payer: WPS Commercial |
$155.55
|
|
|
T3 Free
|
Facility
|
OP
|
$210.00
|
|
|
Service Code
|
CPT 84481
|
| Hospital Charge Code |
633834
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.62 |
| Max. Negotiated Rate |
$193.20 |
| Rate for Payer: Aetna Commercial |
$189.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$180.60
|
| Rate for Payer: Aetna Managed Medicare |
$16.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.12
|
| Rate for Payer: Anthem Medicaid |
$16.62
|
| Rate for Payer: Anthem Medicare Advantage |
$16.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$111.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.94
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$193.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$117.52
|
| Rate for Payer: Dean Health Medicaid |
$16.62
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.94
|
| Rate for Payer: Health EOS Commercial |
$186.90
|
| Rate for Payer: HFN Commercial |
$193.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.94
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.94
|
| Rate for Payer: Managed Health Services Medicaid |
$17.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.94
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.94
|
| Rate for Payer: Multiplan Commercial |
$168.00
|
| Rate for Payer: NAPHCARE Commercial |
$25.41
|
| Rate for Payer: Preferred Network Access Commercial |
$193.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16.62
|
| Rate for Payer: Quartz Beloit One Network |
$102.90
|
| Rate for Payer: Quartz Commercial |
$136.50
|
| Rate for Payer: Quartz Medicare Advantage |
$16.94
|
| Rate for Payer: The Alliance Commercial |
$67.76
|
| Rate for Payer: United Healthcare Medicaid |
$16.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.94
|
| Rate for Payer: United Healthcare PPO |
$157.50
|
| Rate for Payer: WEA Trust Commercial |
$115.50
|
| Rate for Payer: Wellcare Medicare |
$16.94
|
| Rate for Payer: WMAP Medicaid |
$16.62
|
| Rate for Payer: WPS Commercial |
$155.55
|
|
|
T3 Free
|
Facility
|
IP
|
$210.00
|
|
|
Service Code
|
CPT 84481
|
| Hospital Charge Code |
633834
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$102.90 |
| Max. Negotiated Rate |
$193.20 |
| Rate for Payer: Aetna Commercial |
$189.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$180.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$111.30
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$193.20
|
| Rate for Payer: Health EOS Commercial |
$186.90
|
| Rate for Payer: HFN Commercial |
$193.20
|
| Rate for Payer: Multiplan Commercial |
$168.00
|
| Rate for Payer: NAPHCARE Commercial |
$126.00
|
| Rate for Payer: Preferred Network Access Commercial |
$193.20
|
| Rate for Payer: Quartz Beloit One Network |
$102.90
|
| Rate for Payer: Quartz Commercial |
$126.00
|
| Rate for Payer: WEA Trust Commercial |
$115.50
|
| Rate for Payer: WPS Commercial |
$155.55
|
|
|
T3 Resin Uptake
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
CPT 84479
|
| Hospital Charge Code |
633835
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$71.54 |
| Max. Negotiated Rate |
$134.32 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.38
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$134.32
|
| Rate for Payer: Health EOS Commercial |
$129.94
|
| Rate for Payer: HFN Commercial |
$134.32
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: NAPHCARE Commercial |
$87.60
|
| Rate for Payer: Preferred Network Access Commercial |
$134.32
|
| Rate for Payer: Quartz Beloit One Network |
$71.54
|
| Rate for Payer: Quartz Commercial |
$87.60
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
