|
UTERINE MANIPULATOR ADVINCULA DELINEATOR 2.5CM AD750SC-KE25
|
Facility
|
IP
|
$2,512.00
|
|
| Hospital Charge Code |
5459712
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,280.12 |
| Max. Negotiated Rate |
$2,403.48 |
| Rate for Payer: Aetna Commercial |
$2,351.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,246.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,384.61
|
| Rate for Payer: Cash Price |
$753.60
|
| Rate for Payer: Cigna Commercial |
$2,403.48
|
| Rate for Payer: Health EOS Commercial |
$2,325.11
|
| Rate for Payer: HFN Commercial |
$2,403.48
|
| Rate for Payer: Multiplan Commercial |
$2,089.98
|
| Rate for Payer: Preferred Network Access Commercial |
$2,403.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,280.12
|
| Rate for Payer: Quartz Commercial |
$1,567.49
|
| Rate for Payer: WEA Trust Commercial |
$1,436.86
|
| Rate for Payer: WPS Commercial |
$1,934.99
|
|
|
UTERINE MANIPULATOR ADVINCULA DELINEATOR 2.5CM AD750SC-KE25
|
Facility
|
OP
|
$2,512.00
|
|
| Hospital Charge Code |
5459712
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$731.49 |
| Max. Negotiated Rate |
$2,403.48 |
| Rate for Payer: Aetna Commercial |
$2,351.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,246.73
|
| Rate for Payer: Aetna Managed Medicare |
$731.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,698.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,306.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,253.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,384.61
|
| Rate for Payer: Cash Price |
$753.60
|
| Rate for Payer: Cigna Commercial |
$2,403.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,461.98
|
| Rate for Payer: Health EOS Commercial |
$2,325.11
|
| Rate for Payer: HFN Commercial |
$2,403.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,959.36
|
| Rate for Payer: Multiplan Commercial |
$2,089.98
|
| Rate for Payer: NAPHCARE Commercial |
$1,567.49
|
| Rate for Payer: Preferred Network Access Commercial |
$2,403.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,280.12
|
| Rate for Payer: Quartz Commercial |
$1,698.11
|
| Rate for Payer: Quartz Medicare Advantage |
$1,567.49
|
| Rate for Payer: The Alliance Commercial |
$1,306.24
|
| Rate for Payer: WEA Trust Commercial |
$1,436.86
|
| Rate for Payer: WPS Commercial |
$1,934.99
|
|
|
UTERINE MANIPULATOR ADVINCULA DELINEATOR 3.0CM AD750SC-KE30
|
Facility
|
IP
|
$2,608.00
|
|
| Hospital Charge Code |
5459713
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,329.04 |
| Max. Negotiated Rate |
$2,495.33 |
| Rate for Payer: Aetna Commercial |
$2,441.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,332.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,437.53
|
| Rate for Payer: Cash Price |
$782.40
|
| Rate for Payer: Cigna Commercial |
$2,495.33
|
| Rate for Payer: Health EOS Commercial |
$2,413.96
|
| Rate for Payer: HFN Commercial |
$2,495.33
|
| Rate for Payer: Multiplan Commercial |
$2,169.86
|
| Rate for Payer: Preferred Network Access Commercial |
$2,495.33
|
| Rate for Payer: Quartz Beloit One Network |
$1,329.04
|
| Rate for Payer: Quartz Commercial |
$1,627.39
|
| Rate for Payer: WEA Trust Commercial |
$1,491.78
|
| Rate for Payer: WPS Commercial |
$2,008.94
|
|
|
UTERINE MANIPULATOR ADVINCULA DELINEATOR 3.0CM AD750SC-KE30
|
Facility
|
OP
|
$2,608.00
|
|
| Hospital Charge Code |
5459713
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$759.45 |
| Max. Negotiated Rate |
$2,495.33 |
| Rate for Payer: Aetna Commercial |
$2,441.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,332.60
|
| Rate for Payer: Aetna Managed Medicare |
$759.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,763.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,356.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,301.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,437.53
|
| Rate for Payer: Cash Price |
$782.40
|
| Rate for Payer: Cigna Commercial |
$2,495.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,517.86
|
| Rate for Payer: Health EOS Commercial |
$2,413.96
|
| Rate for Payer: HFN Commercial |
$2,495.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,034.24
|
| Rate for Payer: Multiplan Commercial |
$2,169.86
|
| Rate for Payer: NAPHCARE Commercial |
$1,627.39
|
| Rate for Payer: Preferred Network Access Commercial |
$2,495.33
|
| Rate for Payer: Quartz Beloit One Network |
$1,329.04
|
| Rate for Payer: Quartz Commercial |
$1,763.01
|
| Rate for Payer: Quartz Medicare Advantage |
$1,627.39
|
| Rate for Payer: The Alliance Commercial |
$1,356.16
|
| Rate for Payer: WEA Trust Commercial |
$1,491.78
|
| Rate for Payer: WPS Commercial |
$2,008.94
|
|
|
UTERINE MANIPULATOR ADVINCULA DELINEATOR 3.5CM AD750SC-KE35
|
Facility
|
OP
|
$2,608.00
|
|
| Hospital Charge Code |
5459563
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$759.45 |
| Max. Negotiated Rate |
$2,495.33 |
| Rate for Payer: Aetna Commercial |
$2,441.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,332.60
|
| Rate for Payer: Aetna Managed Medicare |
$759.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,763.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,356.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,301.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,437.53
|
| Rate for Payer: Cash Price |
$782.40
|
| Rate for Payer: Cigna Commercial |
$2,495.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,517.86
|
| Rate for Payer: Health EOS Commercial |
$2,413.96
|
| Rate for Payer: HFN Commercial |
$2,495.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,034.24
|
| Rate for Payer: Multiplan Commercial |
$2,169.86
|
| Rate for Payer: NAPHCARE Commercial |
$1,627.39
|
| Rate for Payer: Preferred Network Access Commercial |
$2,495.33
|
| Rate for Payer: Quartz Beloit One Network |
$1,329.04
|
| Rate for Payer: Quartz Commercial |
$1,763.01
|
| Rate for Payer: Quartz Medicare Advantage |
$1,627.39
|
| Rate for Payer: The Alliance Commercial |
$1,356.16
|
| Rate for Payer: WEA Trust Commercial |
$1,491.78
|
| Rate for Payer: WPS Commercial |
$2,008.94
|
|
|
UTERINE MANIPULATOR ADVINCULA DELINEATOR 3.5CM AD750SC-KE35
|
Facility
|
IP
|
$2,608.00
|
|
| Hospital Charge Code |
5459563
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,329.04 |
| Max. Negotiated Rate |
$2,495.33 |
| Rate for Payer: Aetna Commercial |
$2,441.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,332.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,437.53
|
| Rate for Payer: Cash Price |
$782.40
|
| Rate for Payer: Cigna Commercial |
$2,495.33
|
| Rate for Payer: Health EOS Commercial |
$2,413.96
|
| Rate for Payer: HFN Commercial |
$2,495.33
|
| Rate for Payer: Multiplan Commercial |
$2,169.86
|
| Rate for Payer: Preferred Network Access Commercial |
$2,495.33
|
| Rate for Payer: Quartz Beloit One Network |
$1,329.04
|
| Rate for Payer: Quartz Commercial |
$1,627.39
|
| Rate for Payer: WEA Trust Commercial |
$1,491.78
|
| Rate for Payer: WPS Commercial |
$2,008.94
|
|
|
UTERINE MANIPULATOR ADVINCULA DELINEATOR 4.0CM AD750SC-KE40
|
Facility
|
IP
|
$2,608.00
|
|
| Hospital Charge Code |
5459714
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,329.04 |
| Max. Negotiated Rate |
$2,495.33 |
| Rate for Payer: Aetna Commercial |
$2,441.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,332.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,437.53
|
| Rate for Payer: Cash Price |
$782.40
|
| Rate for Payer: Cigna Commercial |
$2,495.33
|
| Rate for Payer: Health EOS Commercial |
$2,413.96
|
| Rate for Payer: HFN Commercial |
$2,495.33
|
| Rate for Payer: Multiplan Commercial |
$2,169.86
|
| Rate for Payer: Preferred Network Access Commercial |
$2,495.33
|
| Rate for Payer: Quartz Beloit One Network |
$1,329.04
|
| Rate for Payer: Quartz Commercial |
$1,627.39
|
| Rate for Payer: WEA Trust Commercial |
$1,491.78
|
| Rate for Payer: WPS Commercial |
$2,008.94
|
|
|
UTERINE MANIPULATOR ADVINCULA DELINEATOR 4.0CM AD750SC-KE40
|
Facility
|
OP
|
$2,608.00
|
|
| Hospital Charge Code |
5459714
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$759.45 |
| Max. Negotiated Rate |
$2,495.33 |
| Rate for Payer: Aetna Commercial |
$2,441.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,332.60
|
| Rate for Payer: Aetna Managed Medicare |
$759.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,763.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,356.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,301.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,437.53
|
| Rate for Payer: Cash Price |
$782.40
|
| Rate for Payer: Cigna Commercial |
$2,495.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,517.86
|
| Rate for Payer: Health EOS Commercial |
$2,413.96
|
| Rate for Payer: HFN Commercial |
$2,495.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,034.24
|
| Rate for Payer: Multiplan Commercial |
$2,169.86
|
| Rate for Payer: NAPHCARE Commercial |
$1,627.39
|
| Rate for Payer: Preferred Network Access Commercial |
$2,495.33
|
| Rate for Payer: Quartz Beloit One Network |
$1,329.04
|
| Rate for Payer: Quartz Commercial |
$1,763.01
|
| Rate for Payer: Quartz Medicare Advantage |
$1,627.39
|
| Rate for Payer: The Alliance Commercial |
$1,356.16
|
| Rate for Payer: WEA Trust Commercial |
$1,491.78
|
| Rate for Payer: WPS Commercial |
$2,008.94
|
|
|
UTERINE MANIPULATOR FORNISEE DEVICE 30MM CUP 110030
|
Facility
|
IP
|
$2,396.00
|
|
| Hospital Charge Code |
5603652
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,221.00 |
| Max. Negotiated Rate |
$2,292.49 |
| Rate for Payer: Aetna Commercial |
$2,242.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,142.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,320.68
|
| Rate for Payer: Cash Price |
$718.80
|
| Rate for Payer: Cigna Commercial |
$2,292.49
|
| Rate for Payer: Health EOS Commercial |
$2,217.74
|
| Rate for Payer: HFN Commercial |
$2,292.49
|
| Rate for Payer: Multiplan Commercial |
$1,993.47
|
| Rate for Payer: Preferred Network Access Commercial |
$2,292.49
|
| Rate for Payer: Quartz Beloit One Network |
$1,221.00
|
| Rate for Payer: Quartz Commercial |
$1,495.10
|
| Rate for Payer: WEA Trust Commercial |
$1,370.51
|
| Rate for Payer: WPS Commercial |
$1,845.64
|
|
|
UTERINE MANIPULATOR FORNISEE DEVICE 30MM CUP 110030
|
Facility
|
OP
|
$2,396.00
|
|
| Hospital Charge Code |
5603652
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$697.72 |
| Max. Negotiated Rate |
$2,292.49 |
| Rate for Payer: Aetna Commercial |
$2,242.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,142.98
|
| Rate for Payer: Aetna Managed Medicare |
$697.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,619.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,245.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,196.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,320.68
|
| Rate for Payer: Cash Price |
$718.80
|
| Rate for Payer: Cigna Commercial |
$2,292.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,394.47
|
| Rate for Payer: Health EOS Commercial |
$2,217.74
|
| Rate for Payer: HFN Commercial |
$2,292.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,868.88
|
| Rate for Payer: Multiplan Commercial |
$1,993.47
|
| Rate for Payer: NAPHCARE Commercial |
$1,495.10
|
| Rate for Payer: Preferred Network Access Commercial |
$2,292.49
|
| Rate for Payer: Quartz Beloit One Network |
$1,221.00
|
| Rate for Payer: Quartz Commercial |
$1,619.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,495.10
|
| Rate for Payer: The Alliance Commercial |
$1,245.92
|
| Rate for Payer: WEA Trust Commercial |
$1,370.51
|
| Rate for Payer: WPS Commercial |
$1,845.64
|
|
|
UTERINE MANIPULATOR FORNISEE DEVICE 35MM CUP 110035
|
Facility
|
IP
|
$2,396.00
|
|
| Hospital Charge Code |
5603653
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,221.00 |
| Max. Negotiated Rate |
$2,292.49 |
| Rate for Payer: Aetna Commercial |
$2,242.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,142.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,320.68
|
| Rate for Payer: Cash Price |
$718.80
|
| Rate for Payer: Cigna Commercial |
$2,292.49
|
| Rate for Payer: Health EOS Commercial |
$2,217.74
|
| Rate for Payer: HFN Commercial |
$2,292.49
|
| Rate for Payer: Multiplan Commercial |
$1,993.47
|
| Rate for Payer: Preferred Network Access Commercial |
$2,292.49
|
| Rate for Payer: Quartz Beloit One Network |
$1,221.00
|
| Rate for Payer: Quartz Commercial |
$1,495.10
|
| Rate for Payer: WEA Trust Commercial |
$1,370.51
|
| Rate for Payer: WPS Commercial |
$1,845.64
|
|
|
UTERINE MANIPULATOR FORNISEE DEVICE 35MM CUP 110035
|
Facility
|
OP
|
$2,396.00
|
|
| Hospital Charge Code |
5603653
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$697.72 |
| Max. Negotiated Rate |
$2,292.49 |
| Rate for Payer: Aetna Commercial |
$2,242.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,142.98
|
| Rate for Payer: Aetna Managed Medicare |
$697.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,619.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,245.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,196.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,320.68
|
| Rate for Payer: Cash Price |
$718.80
|
| Rate for Payer: Cigna Commercial |
$2,292.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,394.47
|
| Rate for Payer: Health EOS Commercial |
$2,217.74
|
| Rate for Payer: HFN Commercial |
$2,292.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,868.88
|
| Rate for Payer: Multiplan Commercial |
$1,993.47
|
| Rate for Payer: NAPHCARE Commercial |
$1,495.10
|
| Rate for Payer: Preferred Network Access Commercial |
$2,292.49
|
| Rate for Payer: Quartz Beloit One Network |
$1,221.00
|
| Rate for Payer: Quartz Commercial |
$1,619.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,495.10
|
| Rate for Payer: The Alliance Commercial |
$1,245.92
|
| Rate for Payer: WEA Trust Commercial |
$1,370.51
|
| Rate for Payer: WPS Commercial |
$1,845.64
|
|
|
UTERINE MANIPULATOR FORNISEE DEVICE 40MM CUP 110040
|
Facility
|
IP
|
$2,396.00
|
|
| Hospital Charge Code |
5603654
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,221.00 |
| Max. Negotiated Rate |
$2,292.49 |
| Rate for Payer: Aetna Commercial |
$2,242.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,142.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,320.68
|
| Rate for Payer: Cash Price |
$718.80
|
| Rate for Payer: Cigna Commercial |
$2,292.49
|
| Rate for Payer: Health EOS Commercial |
$2,217.74
|
| Rate for Payer: HFN Commercial |
$2,292.49
|
| Rate for Payer: Multiplan Commercial |
$1,993.47
|
| Rate for Payer: Preferred Network Access Commercial |
$2,292.49
|
| Rate for Payer: Quartz Beloit One Network |
$1,221.00
|
| Rate for Payer: Quartz Commercial |
$1,495.10
|
| Rate for Payer: WEA Trust Commercial |
$1,370.51
|
| Rate for Payer: WPS Commercial |
$1,845.64
|
|
|
UTERINE MANIPULATOR FORNISEE DEVICE 40MM CUP 110040
|
Facility
|
OP
|
$2,396.00
|
|
| Hospital Charge Code |
5603654
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$697.72 |
| Max. Negotiated Rate |
$2,292.49 |
| Rate for Payer: Aetna Commercial |
$2,242.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,142.98
|
| Rate for Payer: Aetna Managed Medicare |
$697.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,619.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,245.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,196.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,320.68
|
| Rate for Payer: Cash Price |
$718.80
|
| Rate for Payer: Cigna Commercial |
$2,292.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,394.47
|
| Rate for Payer: Health EOS Commercial |
$2,217.74
|
| Rate for Payer: HFN Commercial |
$2,292.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,868.88
|
| Rate for Payer: Multiplan Commercial |
$1,993.47
|
| Rate for Payer: NAPHCARE Commercial |
$1,495.10
|
| Rate for Payer: Preferred Network Access Commercial |
$2,292.49
|
| Rate for Payer: Quartz Beloit One Network |
$1,221.00
|
| Rate for Payer: Quartz Commercial |
$1,619.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,495.10
|
| Rate for Payer: The Alliance Commercial |
$1,245.92
|
| Rate for Payer: WEA Trust Commercial |
$1,370.51
|
| Rate for Payer: WPS Commercial |
$1,845.64
|
|
|
UVULECTOMY
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960484
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
UVULECTOMY
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960484
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
UVULOPALATOPHARYNOGOPLASTY/UVULECTOMY/UVULOPLASTY
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960467
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
UVULOPALATOPHARYNOGOPLASTY/UVULECTOMY/UVULOPLASTY
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960467
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
VACCINE ADMINISTRATION
|
Facility
|
OP
|
$8.60
|
|
|
Service Code
|
EAPG 00459
|
| Min. Negotiated Rate |
$8.27 |
| Max. Negotiated Rate |
$8.60 |
| Rate for Payer: Anthem Medicaid |
$8.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.27
|
| Rate for Payer: Dean Health Medicaid |
$8.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.27
|
| Rate for Payer: Managed Health Services Medicaid |
$8.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.27
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.27
|
| Rate for Payer: United Healthcare Medicaid |
$8.27
|
|
|
Vaccine/Toxoid Injection
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
3040438
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$58.91 |
| Max. Negotiated Rate |
$303.10 |
| Rate for Payer: Aetna Commercial |
$110.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.54
|
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$79.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.91
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.77
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$112.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| Rate for Payer: Health EOS Commercial |
$109.22
|
| Rate for Payer: HFN Commercial |
$112.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$75.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$75.77
|
| Rate for Payer: Multiplan Commercial |
$98.18
|
| Rate for Payer: NAPHCARE Commercial |
$113.66
|
| Rate for Payer: Preferred Network Access Commercial |
$112.90
|
| Rate for Payer: Quartz Beloit One Network |
$60.13
|
| Rate for Payer: Quartz Commercial |
$79.77
|
| Rate for Payer: Quartz Medicare Advantage |
$75.77
|
| Rate for Payer: The Alliance Commercial |
$303.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.77
|
| Rate for Payer: United Healthcare PPO |
$92.04
|
| Rate for Payer: WEA Trust Commercial |
$67.50
|
| Rate for Payer: Wellcare Medicare |
$75.77
|
| Rate for Payer: WPS Commercial |
$90.90
|
|
|
Vaccine/Toxoid Injection
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
CPT 90471
|
| Hospital Charge Code |
3040438
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$60.13 |
| Max. Negotiated Rate |
$112.90 |
| Rate for Payer: Aetna Commercial |
$110.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.04
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$112.90
|
| Rate for Payer: Health EOS Commercial |
$109.22
|
| Rate for Payer: HFN Commercial |
$112.90
|
| Rate for Payer: Multiplan Commercial |
$98.18
|
| Rate for Payer: Preferred Network Access Commercial |
$112.90
|
| Rate for Payer: Quartz Beloit One Network |
$60.13
|
| Rate for Payer: Quartz Commercial |
$73.63
|
| Rate for Payer: WEA Trust Commercial |
$67.50
|
| Rate for Payer: WPS Commercial |
$90.90
|
|
|
VACURETTE 10MM CURVE 022110
|
Facility
|
IP
|
$89.00
|
|
| Hospital Charge Code |
2965911
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.35 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$55.54
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
|
VACURETTE 10MM CURVE 022110
|
Facility
|
OP
|
$89.00
|
|
| Hospital Charge Code |
2965911
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.92 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Aetna Managed Medicare |
$25.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.80
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.42
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: NAPHCARE Commercial |
$55.54
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$60.16
|
| Rate for Payer: Quartz Medicare Advantage |
$55.54
|
| Rate for Payer: The Alliance Commercial |
$46.28
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
|
VACURETTE 10MM STRAIGHT 022210
|
Facility
|
OP
|
$134.00
|
|
| Hospital Charge Code |
2965921
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$39.02 |
| Max. Negotiated Rate |
$128.21 |
| Rate for Payer: Aetna Commercial |
$125.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.85
|
| Rate for Payer: Aetna Managed Medicare |
$39.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$90.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.86
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$128.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.99
|
| Rate for Payer: Health EOS Commercial |
$124.03
|
| Rate for Payer: HFN Commercial |
$128.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$104.52
|
| Rate for Payer: Multiplan Commercial |
$111.49
|
| Rate for Payer: NAPHCARE Commercial |
$83.62
|
| Rate for Payer: Preferred Network Access Commercial |
$128.21
|
| Rate for Payer: Quartz Beloit One Network |
$68.29
|
| Rate for Payer: Quartz Commercial |
$90.58
|
| Rate for Payer: Quartz Medicare Advantage |
$83.62
|
| Rate for Payer: The Alliance Commercial |
$69.68
|
| Rate for Payer: WEA Trust Commercial |
$76.65
|
| Rate for Payer: WPS Commercial |
$103.22
|
|
|
VACURETTE 10MM STRAIGHT 022210
|
Facility
|
IP
|
$134.00
|
|
| Hospital Charge Code |
2965921
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.29 |
| Max. Negotiated Rate |
$128.21 |
| Rate for Payer: Aetna Commercial |
$125.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.86
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$128.21
|
| Rate for Payer: Health EOS Commercial |
$124.03
|
| Rate for Payer: HFN Commercial |
$128.21
|
| Rate for Payer: Multiplan Commercial |
$111.49
|
| Rate for Payer: Preferred Network Access Commercial |
$128.21
|
| Rate for Payer: Quartz Beloit One Network |
$68.29
|
| Rate for Payer: Quartz Commercial |
$83.62
|
| Rate for Payer: WEA Trust Commercial |
$76.65
|
| Rate for Payer: WPS Commercial |
$103.22
|
|
