|
TRAY EPIDURAL SINGLE SHOT 20GA 4947-20
|
Facility
|
IP
|
$405.00
|
|
| Hospital Charge Code |
2969064
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$206.39 |
| Max. Negotiated Rate |
$387.50 |
| Rate for Payer: Aetna Commercial |
$379.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.24
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$387.50
|
| Rate for Payer: Health EOS Commercial |
$374.87
|
| Rate for Payer: HFN Commercial |
$387.50
|
| Rate for Payer: Multiplan Commercial |
$336.96
|
| Rate for Payer: Preferred Network Access Commercial |
$387.50
|
| Rate for Payer: Quartz Beloit One Network |
$206.39
|
| Rate for Payer: Quartz Commercial |
$252.72
|
| Rate for Payer: WEA Trust Commercial |
$231.66
|
| Rate for Payer: WPS Commercial |
$311.97
|
|
|
TRAY EXCHANGE TRANSFUSION
|
Facility
|
IP
|
$1,254.00
|
|
| Hospital Charge Code |
2963389
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$639.04 |
| Max. Negotiated Rate |
$1,199.83 |
| Rate for Payer: Aetna Commercial |
$1,173.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,121.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$691.20
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cigna Commercial |
$1,199.83
|
| Rate for Payer: Health EOS Commercial |
$1,160.70
|
| Rate for Payer: HFN Commercial |
$1,199.83
|
| Rate for Payer: Multiplan Commercial |
$1,043.33
|
| Rate for Payer: Preferred Network Access Commercial |
$1,199.83
|
| Rate for Payer: Quartz Beloit One Network |
$639.04
|
| Rate for Payer: Quartz Commercial |
$782.50
|
| Rate for Payer: WEA Trust Commercial |
$717.29
|
| Rate for Payer: WPS Commercial |
$965.96
|
|
|
TRAY EXCHANGE TRANSFUSION
|
Facility
|
OP
|
$1,254.00
|
|
| Hospital Charge Code |
2963389
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$365.16 |
| Max. Negotiated Rate |
$1,199.83 |
| Rate for Payer: Aetna Commercial |
$1,173.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,121.58
|
| Rate for Payer: Aetna Managed Medicare |
$365.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$847.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$652.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$626.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$691.20
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cigna Commercial |
$1,199.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$729.83
|
| Rate for Payer: Health EOS Commercial |
$1,160.70
|
| Rate for Payer: HFN Commercial |
$1,199.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$978.12
|
| Rate for Payer: Multiplan Commercial |
$1,043.33
|
| Rate for Payer: NAPHCARE Commercial |
$782.50
|
| Rate for Payer: Preferred Network Access Commercial |
$1,199.83
|
| Rate for Payer: Quartz Beloit One Network |
$639.04
|
| Rate for Payer: Quartz Commercial |
$847.70
|
| Rate for Payer: Quartz Medicare Advantage |
$782.50
|
| Rate for Payer: The Alliance Commercial |
$652.08
|
| Rate for Payer: WEA Trust Commercial |
$717.29
|
| Rate for Payer: WPS Commercial |
$965.96
|
|
|
TRAY EXCHANGE TRANSFUSION 275.00
|
Facility
|
IP
|
$1,331.00
|
|
| Hospital Charge Code |
3802746
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$678.28 |
| Max. Negotiated Rate |
$1,273.50 |
| Rate for Payer: Aetna Commercial |
$1,245.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,190.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$733.65
|
| Rate for Payer: Cash Price |
$399.30
|
| Rate for Payer: Cigna Commercial |
$1,273.50
|
| Rate for Payer: Health EOS Commercial |
$1,231.97
|
| Rate for Payer: HFN Commercial |
$1,273.50
|
| Rate for Payer: Multiplan Commercial |
$1,107.39
|
| Rate for Payer: Preferred Network Access Commercial |
$1,273.50
|
| Rate for Payer: Quartz Beloit One Network |
$678.28
|
| Rate for Payer: Quartz Commercial |
$830.54
|
| Rate for Payer: WEA Trust Commercial |
$761.33
|
| Rate for Payer: WPS Commercial |
$1,025.27
|
|
|
TRAY EXCHANGE TRANSFUSION 275.00
|
Facility
|
OP
|
$1,331.00
|
|
| Hospital Charge Code |
3802746
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$387.59 |
| Max. Negotiated Rate |
$1,273.50 |
| Rate for Payer: Aetna Commercial |
$1,245.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,190.45
|
| Rate for Payer: Aetna Managed Medicare |
$387.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$899.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$692.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$664.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$733.65
|
| Rate for Payer: Cash Price |
$399.30
|
| Rate for Payer: Cigna Commercial |
$1,273.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$774.64
|
| Rate for Payer: Health EOS Commercial |
$1,231.97
|
| Rate for Payer: HFN Commercial |
$1,273.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,038.18
|
| Rate for Payer: Multiplan Commercial |
$1,107.39
|
| Rate for Payer: NAPHCARE Commercial |
$830.54
|
| Rate for Payer: Preferred Network Access Commercial |
$1,273.50
|
| Rate for Payer: Quartz Beloit One Network |
$678.28
|
| Rate for Payer: Quartz Commercial |
$899.76
|
| Rate for Payer: Quartz Medicare Advantage |
$830.54
|
| Rate for Payer: The Alliance Commercial |
$692.12
|
| Rate for Payer: WEA Trust Commercial |
$761.33
|
| Rate for Payer: WPS Commercial |
$1,025.27
|
|
|
TRAY FOLEY 16FR SURESTEP LATEX A300316A
|
Facility
|
OP
|
$154.00
|
|
| Hospital Charge Code |
2963134
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$44.84 |
| Max. Negotiated Rate |
$147.35 |
| Rate for Payer: Aetna Commercial |
$144.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.74
|
| Rate for Payer: Aetna Managed Medicare |
$44.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$104.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$80.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.88
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$147.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.63
|
| Rate for Payer: Health EOS Commercial |
$142.54
|
| Rate for Payer: HFN Commercial |
$147.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.12
|
| Rate for Payer: Multiplan Commercial |
$128.13
|
| Rate for Payer: NAPHCARE Commercial |
$96.10
|
| Rate for Payer: Preferred Network Access Commercial |
$147.35
|
| Rate for Payer: Quartz Beloit One Network |
$78.48
|
| Rate for Payer: Quartz Commercial |
$104.10
|
| Rate for Payer: Quartz Medicare Advantage |
$96.10
|
| Rate for Payer: The Alliance Commercial |
$80.08
|
| Rate for Payer: WEA Trust Commercial |
$88.09
|
| Rate for Payer: WPS Commercial |
$118.63
|
|
|
TRAY FOLEY 16FR SURESTEP LATEX A300316A
|
Facility
|
IP
|
$154.00
|
|
| Hospital Charge Code |
2963134
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$78.48 |
| Max. Negotiated Rate |
$147.35 |
| Rate for Payer: Aetna Commercial |
$144.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.88
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$147.35
|
| Rate for Payer: Health EOS Commercial |
$142.54
|
| Rate for Payer: HFN Commercial |
$147.35
|
| Rate for Payer: Multiplan Commercial |
$128.13
|
| Rate for Payer: Preferred Network Access Commercial |
$147.35
|
| Rate for Payer: Quartz Beloit One Network |
$78.48
|
| Rate for Payer: Quartz Commercial |
$96.10
|
| Rate for Payer: WEA Trust Commercial |
$88.09
|
| Rate for Payer: WPS Commercial |
$118.63
|
|
|
TRAY FOLEY 16FR SURESTEP LF A300416A
|
Facility
|
IP
|
$321.00
|
|
| Hospital Charge Code |
2963118
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$163.58 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$200.30
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
TRAY FOLEY 16FR SURESTEP LF A300416A
|
Facility
|
OP
|
$321.00
|
|
| Hospital Charge Code |
2963118
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$93.48 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Aetna Managed Medicare |
$93.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$166.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.82
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.38
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: NAPHCARE Commercial |
$200.30
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$217.00
|
| Rate for Payer: Quartz Medicare Advantage |
$200.30
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
TRAY FOLEY 18FR SURESTEP LATEX A300318A
|
Facility
|
OP
|
$154.00
|
|
|
Service Code
|
HCPCS A4314
|
| Hospital Charge Code |
2969251
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$44.84 |
| Max. Negotiated Rate |
$149.88 |
| Rate for Payer: Aetna Commercial |
$144.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.74
|
| Rate for Payer: Aetna Managed Medicare |
$44.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$104.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$80.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.88
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$147.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.63
|
| Rate for Payer: Health EOS Commercial |
$142.54
|
| Rate for Payer: HFN Commercial |
$147.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.12
|
| Rate for Payer: Multiplan Commercial |
$128.13
|
| Rate for Payer: NAPHCARE Commercial |
$96.10
|
| Rate for Payer: Preferred Network Access Commercial |
$147.35
|
| Rate for Payer: Quartz Beloit One Network |
$78.48
|
| Rate for Payer: Quartz Commercial |
$104.10
|
| Rate for Payer: Quartz Medicare Advantage |
$96.10
|
| Rate for Payer: The Alliance Commercial |
$149.88
|
| Rate for Payer: WEA Trust Commercial |
$88.09
|
| Rate for Payer: WPS Commercial |
$118.63
|
|
|
TRAY FOLEY 18FR SURESTEP LATEX A300318A
|
Facility
|
IP
|
$154.00
|
|
|
Service Code
|
HCPCS A4314
|
| Hospital Charge Code |
2969251
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$78.48 |
| Max. Negotiated Rate |
$147.35 |
| Rate for Payer: Aetna Commercial |
$144.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.88
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$147.35
|
| Rate for Payer: Health EOS Commercial |
$142.54
|
| Rate for Payer: HFN Commercial |
$147.35
|
| Rate for Payer: Multiplan Commercial |
$128.13
|
| Rate for Payer: Preferred Network Access Commercial |
$147.35
|
| Rate for Payer: Quartz Beloit One Network |
$78.48
|
| Rate for Payer: Quartz Commercial |
$96.10
|
| Rate for Payer: WEA Trust Commercial |
$88.09
|
| Rate for Payer: WPS Commercial |
$118.63
|
|
|
TRAY FOLEY 18FR SURESTEP LF A300418A
|
Facility
|
IP
|
$321.00
|
|
| Hospital Charge Code |
2963117
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$163.58 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$200.30
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
TRAY FOLEY 18FR SURESTEP LF A300418A
|
Facility
|
OP
|
$321.00
|
|
| Hospital Charge Code |
2963117
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$93.48 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Aetna Managed Medicare |
$93.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$166.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.82
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.38
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: NAPHCARE Commercial |
$200.30
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$217.00
|
| Rate for Payer: Quartz Medicare Advantage |
$200.30
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
TRAY FOLEY/METER 16FR SURESTEP LATEX A303316A
|
Facility
|
OP
|
$496.00
|
|
| Hospital Charge Code |
2963044
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$144.44 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Aetna Managed Medicare |
$144.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$335.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$257.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$247.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$288.67
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$386.88
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: NAPHCARE Commercial |
$309.50
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$335.30
|
| Rate for Payer: Quartz Medicare Advantage |
$309.50
|
| Rate for Payer: The Alliance Commercial |
$257.92
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
TRAY FOLEY/METER 16FR SURESTEP LATEX A303316A
|
Facility
|
IP
|
$496.00
|
|
| Hospital Charge Code |
2963044
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$252.76 |
| Max. Negotiated Rate |
$474.57 |
| Rate for Payer: Aetna Commercial |
$464.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$443.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$273.40
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cigna Commercial |
$474.57
|
| Rate for Payer: Health EOS Commercial |
$459.10
|
| Rate for Payer: HFN Commercial |
$474.57
|
| Rate for Payer: Multiplan Commercial |
$412.67
|
| Rate for Payer: Preferred Network Access Commercial |
$474.57
|
| Rate for Payer: Quartz Beloit One Network |
$252.76
|
| Rate for Payer: Quartz Commercial |
$309.50
|
| Rate for Payer: WEA Trust Commercial |
$283.71
|
| Rate for Payer: WPS Commercial |
$382.07
|
|
|
TRAY FOLEY w/o CATHETR #782102**disc
|
Facility
|
OP
|
$67.00
|
|
| Hospital Charge Code |
2974597
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.51 |
| Max. Negotiated Rate |
$64.11 |
| Rate for Payer: Aetna Commercial |
$62.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Aetna Managed Medicare |
$19.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.93
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$64.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.99
|
| Rate for Payer: Health EOS Commercial |
$62.02
|
| Rate for Payer: HFN Commercial |
$64.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.26
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: NAPHCARE Commercial |
$41.81
|
| Rate for Payer: Preferred Network Access Commercial |
$64.11
|
| Rate for Payer: Quartz Beloit One Network |
$34.14
|
| Rate for Payer: Quartz Commercial |
$45.29
|
| Rate for Payer: Quartz Medicare Advantage |
$41.81
|
| Rate for Payer: The Alliance Commercial |
$34.84
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$51.61
|
|
|
TRAY FOLEY w/o CATHETR #782102**disc
|
Facility
|
IP
|
$67.00
|
|
| Hospital Charge Code |
2974597
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.14 |
| Max. Negotiated Rate |
$64.11 |
| Rate for Payer: Aetna Commercial |
$62.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.93
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$64.11
|
| Rate for Payer: Health EOS Commercial |
$62.02
|
| Rate for Payer: HFN Commercial |
$64.11
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: Preferred Network Access Commercial |
$64.11
|
| Rate for Payer: Quartz Beloit One Network |
$34.14
|
| Rate for Payer: Quartz Commercial |
$41.81
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$51.61
|
|
|
TRAY HUMERAL ADAPTER +0MM EQUINOXE REVERSE SHOULDER 320-10-00
|
Facility
|
IP
|
$7,502.01
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6240165
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,823.02 |
| Max. Negotiated Rate |
$7,177.92 |
| Rate for Payer: Aetna Commercial |
$7,021.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,709.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,135.11
|
| Rate for Payer: Cash Price |
$2,250.60
|
| Rate for Payer: Cigna Commercial |
$7,177.92
|
| Rate for Payer: Health EOS Commercial |
$6,943.86
|
| Rate for Payer: HFN Commercial |
$7,177.92
|
| Rate for Payer: Multiplan Commercial |
$6,241.67
|
| Rate for Payer: Preferred Network Access Commercial |
$7,177.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,823.02
|
| Rate for Payer: Quartz Commercial |
$4,681.25
|
| Rate for Payer: WEA Trust Commercial |
$4,291.15
|
| Rate for Payer: WPS Commercial |
$5,778.80
|
|
|
TRAY HUMERAL ADAPTER +0MM EQUINOXE REVERSE SHOULDER 320-10-00
|
Facility
|
OP
|
$7,502.01
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6240165
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,184.59 |
| Max. Negotiated Rate |
$7,177.92 |
| Rate for Payer: Aetna Commercial |
$7,021.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,709.80
|
| Rate for Payer: Aetna Managed Medicare |
$2,184.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,071.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,901.05
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,745.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,135.11
|
| Rate for Payer: Cash Price |
$2,250.60
|
| Rate for Payer: Cigna Commercial |
$7,177.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,366.17
|
| Rate for Payer: Health EOS Commercial |
$6,943.86
|
| Rate for Payer: HFN Commercial |
$7,177.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,851.57
|
| Rate for Payer: Multiplan Commercial |
$6,241.67
|
| Rate for Payer: NAPHCARE Commercial |
$4,681.25
|
| Rate for Payer: Preferred Network Access Commercial |
$7,177.92
|
| Rate for Payer: Quartz Beloit One Network |
$3,823.02
|
| Rate for Payer: Quartz Commercial |
$5,071.36
|
| Rate for Payer: Quartz Medicare Advantage |
$4,681.25
|
| Rate for Payer: The Alliance Commercial |
$3,901.05
|
| Rate for Payer: WEA Trust Commercial |
$4,291.15
|
| Rate for Payer: WPS Commercial |
$5,778.80
|
|
|
TRAY IRRIGATION W/PISTON 60CC 750301***DEDE 11/20
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
2963727
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.27 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Aetna Managed Medicare |
$14.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.52
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.22
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: NAPHCARE Commercial |
$30.58
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$33.12
|
| Rate for Payer: Quartz Medicare Advantage |
$30.58
|
| Rate for Payer: The Alliance Commercial |
$25.48
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
TRAY IRRIGATION W/PISTON 60CC 750301***DEDE 11/20
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
2963727
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.97 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$30.58
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
TRAY KNEE ARTHROSCOPY DYNJS0811
|
Facility
|
OP
|
$1,523.00
|
|
| Hospital Charge Code |
2963075
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$443.50 |
| Max. Negotiated Rate |
$1,457.21 |
| Rate for Payer: Aetna Commercial |
$1,425.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,362.17
|
| Rate for Payer: Aetna Managed Medicare |
$443.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,029.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$791.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$760.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$839.48
|
| Rate for Payer: Cash Price |
$456.90
|
| Rate for Payer: Cigna Commercial |
$1,457.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$886.39
|
| Rate for Payer: Health EOS Commercial |
$1,409.69
|
| Rate for Payer: HFN Commercial |
$1,457.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,187.94
|
| Rate for Payer: Multiplan Commercial |
$1,267.14
|
| Rate for Payer: NAPHCARE Commercial |
$950.35
|
| Rate for Payer: Preferred Network Access Commercial |
$1,457.21
|
| Rate for Payer: Quartz Beloit One Network |
$776.12
|
| Rate for Payer: Quartz Commercial |
$1,029.55
|
| Rate for Payer: Quartz Medicare Advantage |
$950.35
|
| Rate for Payer: The Alliance Commercial |
$791.96
|
| Rate for Payer: WEA Trust Commercial |
$871.16
|
| Rate for Payer: WPS Commercial |
$1,173.17
|
|
|
TRAY KNEE ARTHROSCOPY DYNJS0811
|
Facility
|
IP
|
$1,523.00
|
|
| Hospital Charge Code |
2963075
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$776.12 |
| Max. Negotiated Rate |
$1,457.21 |
| Rate for Payer: Aetna Commercial |
$1,425.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,362.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$839.48
|
| Rate for Payer: Cash Price |
$456.90
|
| Rate for Payer: Cigna Commercial |
$1,457.21
|
| Rate for Payer: Health EOS Commercial |
$1,409.69
|
| Rate for Payer: HFN Commercial |
$1,457.21
|
| Rate for Payer: Multiplan Commercial |
$1,267.14
|
| Rate for Payer: Preferred Network Access Commercial |
$1,457.21
|
| Rate for Payer: Quartz Beloit One Network |
$776.12
|
| Rate for Payer: Quartz Commercial |
$950.35
|
| Rate for Payer: WEA Trust Commercial |
$871.16
|
| Rate for Payer: WPS Commercial |
$1,173.17
|
|
|
TRAY LUMBAR PUNCTURE ADULT 20G QUINCKE
|
Facility
|
OP
|
$292.00
|
|
| Hospital Charge Code |
2963196
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$85.03 |
| Max. Negotiated Rate |
$279.39 |
| Rate for Payer: Aetna Commercial |
$273.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$261.16
|
| Rate for Payer: Aetna Managed Medicare |
$85.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$197.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$151.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$145.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.95
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cigna Commercial |
$279.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$169.94
|
| Rate for Payer: Health EOS Commercial |
$270.28
|
| Rate for Payer: HFN Commercial |
$279.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$227.76
|
| Rate for Payer: Multiplan Commercial |
$242.94
|
| Rate for Payer: NAPHCARE Commercial |
$182.21
|
| Rate for Payer: Preferred Network Access Commercial |
$279.39
|
| Rate for Payer: Quartz Beloit One Network |
$148.80
|
| Rate for Payer: Quartz Commercial |
$197.39
|
| Rate for Payer: Quartz Medicare Advantage |
$182.21
|
| Rate for Payer: The Alliance Commercial |
$151.84
|
| Rate for Payer: WEA Trust Commercial |
$167.02
|
| Rate for Payer: WPS Commercial |
$224.93
|
|
|
TRAY LUMBAR PUNCTURE ADULT 20G QUINCKE
|
Facility
|
IP
|
$292.00
|
|
| Hospital Charge Code |
2963196
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$148.80 |
| Max. Negotiated Rate |
$279.39 |
| Rate for Payer: Aetna Commercial |
$273.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$261.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.95
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Cigna Commercial |
$279.39
|
| Rate for Payer: Health EOS Commercial |
$270.28
|
| Rate for Payer: HFN Commercial |
$279.39
|
| Rate for Payer: Multiplan Commercial |
$242.94
|
| Rate for Payer: Preferred Network Access Commercial |
$279.39
|
| Rate for Payer: Quartz Beloit One Network |
$148.80
|
| Rate for Payer: Quartz Commercial |
$182.21
|
| Rate for Payer: WEA Trust Commercial |
$167.02
|
| Rate for Payer: WPS Commercial |
$224.93
|
|
