|
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 |
$285.20 |
| 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 DHI/DHP/ASO |
$173.48
|
| 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 |
$81.28
|
| 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
|
Both
|
$310.00
|
|
|
Service Code
|
CPT 86162
|
| Hospital Charge Code |
3403545
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$71.73 |
| Max. Negotiated Rate |
$294.50 |
| Rate for Payer: Aetna Commercial |
$294.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$266.60
|
| 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 |
$186.00
|
| Rate for Payer: Health EOS Commercial |
$282.10
|
| Rate for Payer: HFN Commercial |
$294.50
|
| 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: 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: The Alliance Commercial |
$155.00
|
| Rate for Payer: WEA Trust Commercial |
$170.50
|
| Rate for Payer: WPS Commercial |
$229.62
|
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$266.60
|
| 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
|
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: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| 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 |
$76.36 |
| 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 DHI/DHP/ASO |
$46.45
|
| 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 |
$61.80
|
| 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
|
|
|
Total Glutathione, Whole Blood
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
CPT 82978
|
| Hospital Charge Code |
6171752
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.52 |
| Max. Negotiated Rate |
$78.85 |
| Rate for Payer: Aetna Commercial |
$78.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| 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 |
$49.80
|
| Rate for Payer: Health EOS Commercial |
$75.53
|
| Rate for Payer: HFN Commercial |
$78.85
|
| 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: 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: The Alliance Commercial |
$41.50
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| 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: Aetna Gatekeeper/Not Gatekeeper |
$68.80
|
| 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
|
IP
|
$82.00
|
|
| Hospital Charge Code |
2965769
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.18 |
| Max. Negotiated Rate |
$75.44 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| 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: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| 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 |
$49.20
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
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
|
|
|
TOURNI-COT MEDIUM FINGER TCM-2001
|
Facility
|
OP
|
$82.00
|
|
| Hospital Charge Code |
2965770
|
|
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
|
|
|
TOURNI-COT MEDIUM FINGER TCM-2001
|
Facility
|
IP
|
$82.00
|
|
| Hospital Charge Code |
2965770
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.18 |
| Max. Negotiated Rate |
$75.44 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| 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: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| 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 |
$49.20
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
TOURNI-COT SMALL FINGER TCS-1001
|
Facility
|
IP
|
$96.00
|
|
| Hospital Charge Code |
4594693
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.04 |
| Max. Negotiated Rate |
$88.32 |
| Rate for Payer: Aetna Commercial |
$86.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.88
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$88.32
|
| Rate for Payer: Health EOS Commercial |
$85.44
|
| Rate for Payer: HFN Commercial |
$88.32
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: NAPHCARE Commercial |
$57.60
|
| Rate for Payer: Preferred Network Access Commercial |
$88.32
|
| Rate for Payer: Quartz Beloit One Network |
$47.04
|
| Rate for Payer: Quartz Commercial |
$57.60
|
| Rate for Payer: WEA Trust Commercial |
$52.80
|
| Rate for Payer: WPS Commercial |
$71.11
|
|
|
TOURNI-COT SMALL FINGER TCS-1001
|
Facility
|
OP
|
$96.00
|
|
| Hospital Charge Code |
4594693
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.88 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$86.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.56
|
| Rate for Payer: Aetna Managed Medicare |
$26.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.88
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$88.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.72
|
| Rate for Payer: Health EOS Commercial |
$85.44
|
| Rate for Payer: HFN Commercial |
$88.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.00
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: NAPHCARE Commercial |
$57.60
|
| Rate for Payer: Preferred Network Access Commercial |
$88.32
|
| Rate for Payer: Quartz Beloit One Network |
$47.04
|
| Rate for Payer: Quartz Commercial |
$62.40
|
| Rate for Payer: Quartz Medicare Advantage |
$57.60
|
| Rate for Payer: The Alliance Commercial |
$384.00
|
| Rate for Payer: WEA Trust Commercial |
$52.80
|
| Rate for Payer: WPS Commercial |
$71.11
|
|
|
TOURNI-COT X-LG FINGER TXL-4001
|
Facility
|
OP
|
$80.00
|
|
| Hospital Charge Code |
2965771
|
|
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 X-LG FINGER TXL-4001
|
Facility
|
IP
|
$80.00
|
|
| Hospital Charge Code |
2965771
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$73.60 |
| Rate for Payer: Aetna Commercial |
$72.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.80
|
| 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
|
|
|
TOURNIQUET CUFF 12 IN WITH SLEEVE DISP 60707015200 / MACDT11235SBDT
|
Facility
|
IP
|
$553.00
|
|
| Hospital Charge Code |
3583502
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$270.97 |
| Max. Negotiated Rate |
$508.76 |
| Rate for Payer: Aetna Commercial |
$497.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.09
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$508.76
|
| Rate for Payer: Health EOS Commercial |
$492.17
|
| Rate for Payer: HFN Commercial |
$508.76
|
| Rate for Payer: Multiplan Commercial |
$442.40
|
| Rate for Payer: NAPHCARE Commercial |
$331.80
|
| Rate for Payer: Preferred Network Access Commercial |
$508.76
|
| Rate for Payer: Quartz Beloit One Network |
$270.97
|
| Rate for Payer: Quartz Commercial |
$331.80
|
| Rate for Payer: WEA Trust Commercial |
$304.15
|
| Rate for Payer: WPS Commercial |
$409.61
|
|
|
TOURNIQUET CUFF 12 IN WITH SLEEVE DISP 60707015200 / MACDT11235SBDT
|
Facility
|
OP
|
$553.00
|
|
| Hospital Charge Code |
3583502
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$154.84 |
| Max. Negotiated Rate |
$2,212.00 |
| Rate for Payer: Aetna Commercial |
$497.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.58
|
| Rate for Payer: Aetna Managed Medicare |
$154.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$359.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$276.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$265.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.09
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$508.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$309.46
|
| Rate for Payer: Health EOS Commercial |
$492.17
|
| Rate for Payer: HFN Commercial |
$508.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$414.75
|
| Rate for Payer: Multiplan Commercial |
$442.40
|
| Rate for Payer: NAPHCARE Commercial |
$331.80
|
| Rate for Payer: Preferred Network Access Commercial |
$508.76
|
| Rate for Payer: Quartz Beloit One Network |
$270.97
|
| Rate for Payer: Quartz Commercial |
$359.45
|
| Rate for Payer: Quartz Medicare Advantage |
$331.80
|
| Rate for Payer: The Alliance Commercial |
$2,212.00
|
| Rate for Payer: WEA Trust Commercial |
$304.15
|
| Rate for Payer: WPS Commercial |
$409.61
|
|
|
TOURNIQUET CUFF 18 IN DISP 60707015300/60707010300 / MACDTQ184SBDT
|
Facility
|
IP
|
$634.00
|
|
| Hospital Charge Code |
5106986
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$310.66 |
| Max. Negotiated Rate |
$583.28 |
| Rate for Payer: Aetna Commercial |
$570.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$545.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$336.02
|
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Cigna Commercial |
$583.28
|
| Rate for Payer: Health EOS Commercial |
$564.26
|
| Rate for Payer: HFN Commercial |
$583.28
|
| Rate for Payer: Multiplan Commercial |
$507.20
|
| Rate for Payer: NAPHCARE Commercial |
$380.40
|
| Rate for Payer: Preferred Network Access Commercial |
$583.28
|
| Rate for Payer: Quartz Beloit One Network |
$310.66
|
| Rate for Payer: Quartz Commercial |
$380.40
|
| Rate for Payer: WEA Trust Commercial |
$348.70
|
| Rate for Payer: WPS Commercial |
$469.60
|
|
|
TOURNIQUET CUFF 18 IN DISP 60707015300/60707010300 / MACDTQ184SBDT
|
Facility
|
OP
|
$634.00
|
|
| Hospital Charge Code |
5106986
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$177.52 |
| Max. Negotiated Rate |
$2,536.00 |
| Rate for Payer: Aetna Commercial |
$570.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$545.24
|
| Rate for Payer: Aetna Managed Medicare |
$177.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$412.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$317.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$304.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$336.02
|
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Cigna Commercial |
$583.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$354.79
|
| Rate for Payer: Health EOS Commercial |
$564.26
|
| Rate for Payer: HFN Commercial |
$583.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$475.50
|
| Rate for Payer: Multiplan Commercial |
$507.20
|
| Rate for Payer: NAPHCARE Commercial |
$380.40
|
| Rate for Payer: Preferred Network Access Commercial |
$583.28
|
| Rate for Payer: Quartz Beloit One Network |
$310.66
|
| Rate for Payer: Quartz Commercial |
$412.10
|
| Rate for Payer: Quartz Medicare Advantage |
$380.40
|
| Rate for Payer: The Alliance Commercial |
$2,536.00
|
| Rate for Payer: WEA Trust Commercial |
$348.70
|
| Rate for Payer: WPS Commercial |
$469.60
|
|
|
TOURNIQUET CUFF 18 IN DUAL PORT DISP 60707010300SUB
|
Facility
|
IP
|
$439.00
|
|
| Hospital Charge Code |
5307078
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$215.11 |
| Max. Negotiated Rate |
$403.88 |
| Rate for Payer: Aetna Commercial |
$395.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$377.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$232.67
|
| Rate for Payer: Cash Price |
$131.70
|
| Rate for Payer: Cigna Commercial |
$403.88
|
| Rate for Payer: Health EOS Commercial |
$390.71
|
| Rate for Payer: HFN Commercial |
$403.88
|
| Rate for Payer: Multiplan Commercial |
$351.20
|
| Rate for Payer: NAPHCARE Commercial |
$263.40
|
| Rate for Payer: Preferred Network Access Commercial |
$403.88
|
| Rate for Payer: Quartz Beloit One Network |
$215.11
|
| Rate for Payer: Quartz Commercial |
$263.40
|
| Rate for Payer: WEA Trust Commercial |
$241.45
|
| Rate for Payer: WPS Commercial |
$325.17
|
|
|
TOURNIQUET CUFF 18 IN DUAL PORT DISP 60707010300SUB
|
Facility
|
OP
|
$439.00
|
|
| Hospital Charge Code |
5307078
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$122.92 |
| Max. Negotiated Rate |
$1,756.00 |
| Rate for Payer: Aetna Commercial |
$395.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$377.54
|
| Rate for Payer: Aetna Managed Medicare |
$122.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$285.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$219.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$210.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$232.67
|
| Rate for Payer: Cash Price |
$131.70
|
| Rate for Payer: Cigna Commercial |
$403.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$245.66
|
| Rate for Payer: Health EOS Commercial |
$390.71
|
| Rate for Payer: HFN Commercial |
$403.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$329.25
|
| Rate for Payer: Multiplan Commercial |
$351.20
|
| Rate for Payer: NAPHCARE Commercial |
$263.40
|
| Rate for Payer: Preferred Network Access Commercial |
$403.88
|
| Rate for Payer: Quartz Beloit One Network |
$215.11
|
| Rate for Payer: Quartz Commercial |
$285.35
|
| Rate for Payer: Quartz Medicare Advantage |
$263.40
|
| Rate for Payer: The Alliance Commercial |
$1,756.00
|
| Rate for Payer: WEA Trust Commercial |
$241.45
|
| Rate for Payer: WPS Commercial |
$325.17
|
|
|
TOURNIQUET CUFF 24 IN DISP 60707015400/60707010400 / MACDTQ244SBDT
|
Facility
|
OP
|
$698.00
|
|
| Hospital Charge Code |
4595307
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$195.44 |
| Max. Negotiated Rate |
$2,792.00 |
| Rate for Payer: Aetna Commercial |
$628.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$600.28
|
| Rate for Payer: Aetna Managed Medicare |
$195.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$453.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$349.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$335.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$369.94
|
| Rate for Payer: Cash Price |
$209.40
|
| Rate for Payer: Cigna Commercial |
$642.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$390.60
|
| Rate for Payer: Health EOS Commercial |
$621.22
|
| Rate for Payer: HFN Commercial |
$642.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$523.50
|
| Rate for Payer: Multiplan Commercial |
$558.40
|
| Rate for Payer: NAPHCARE Commercial |
$418.80
|
| Rate for Payer: Preferred Network Access Commercial |
$642.16
|
| Rate for Payer: Quartz Beloit One Network |
$342.02
|
| Rate for Payer: Quartz Commercial |
$453.70
|
| Rate for Payer: Quartz Medicare Advantage |
$418.80
|
| Rate for Payer: The Alliance Commercial |
$2,792.00
|
| Rate for Payer: WEA Trust Commercial |
$383.90
|
| Rate for Payer: WPS Commercial |
$517.01
|
|
|
TOURNIQUET CUFF 24 IN DISP 60707015400/60707010400 / MACDTQ244SBDT
|
Facility
|
IP
|
$698.00
|
|
| Hospital Charge Code |
4595307
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$342.02 |
| Max. Negotiated Rate |
$642.16 |
| Rate for Payer: Aetna Commercial |
$628.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$600.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$369.94
|
| Rate for Payer: Cash Price |
$209.40
|
| Rate for Payer: Cigna Commercial |
$642.16
|
| Rate for Payer: Health EOS Commercial |
$621.22
|
| Rate for Payer: HFN Commercial |
$642.16
|
| Rate for Payer: Multiplan Commercial |
$558.40
|
| Rate for Payer: NAPHCARE Commercial |
$418.80
|
| Rate for Payer: Preferred Network Access Commercial |
$642.16
|
| Rate for Payer: Quartz Beloit One Network |
$342.02
|
| Rate for Payer: Quartz Commercial |
$418.80
|
| Rate for Payer: WEA Trust Commercial |
$383.90
|
| Rate for Payer: WPS Commercial |
$517.01
|
|
|
TOURNIQUET CUFF 24 IN DUAL PORT DISP 60707010400SUB
|
Facility
|
OP
|
$468.00
|
|
| Hospital Charge Code |
5459181
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$131.04 |
| Max. Negotiated Rate |
$1,872.00 |
| Rate for Payer: Aetna Commercial |
$421.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$402.48
|
| Rate for Payer: Aetna Managed Medicare |
$131.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$304.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$234.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$224.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$248.04
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cigna Commercial |
$430.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$261.89
|
| Rate for Payer: Health EOS Commercial |
$416.52
|
| Rate for Payer: HFN Commercial |
$430.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$351.00
|
| Rate for Payer: Multiplan Commercial |
$374.40
|
| Rate for Payer: NAPHCARE Commercial |
$280.80
|
| Rate for Payer: Preferred Network Access Commercial |
$430.56
|
| Rate for Payer: Quartz Beloit One Network |
$229.32
|
| Rate for Payer: Quartz Commercial |
$304.20
|
| Rate for Payer: Quartz Medicare Advantage |
$280.80
|
| Rate for Payer: The Alliance Commercial |
$1,872.00
|
| Rate for Payer: WEA Trust Commercial |
$257.40
|
| Rate for Payer: WPS Commercial |
$346.65
|
|
