|
Y-PLATE 2.0MM 3H HEAD/ 8H SHAFT 247.612
|
Facility
|
IP
|
$4,330.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,206.57 |
| Max. Negotiated Rate |
$4,142.94 |
| Rate for Payer: Aetna Commercial |
$4,052.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,872.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,386.70
|
| Rate for Payer: Cash Price |
$1,299.00
|
| Rate for Payer: Cigna Commercial |
$4,142.94
|
| Rate for Payer: Health EOS Commercial |
$4,007.85
|
| Rate for Payer: HFN Commercial |
$4,142.94
|
| Rate for Payer: Multiplan Commercial |
$3,602.56
|
| Rate for Payer: Preferred Network Access Commercial |
$4,142.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,206.57
|
| Rate for Payer: Quartz Commercial |
$2,701.92
|
| Rate for Payer: WEA Trust Commercial |
$2,476.76
|
| Rate for Payer: WPS Commercial |
$3,335.40
|
|
|
Y-PLATE 2.4MM 3HL HEAD/8HL SHAFT 249.915
|
Facility
|
OP
|
$4,597.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508775
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,338.65 |
| Max. Negotiated Rate |
$4,398.41 |
| Rate for Payer: Aetna Commercial |
$4,302.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,111.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,338.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,107.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,390.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,294.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,533.87
|
| Rate for Payer: Cash Price |
$1,379.10
|
| Rate for Payer: Cigna Commercial |
$4,398.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,675.45
|
| Rate for Payer: Health EOS Commercial |
$4,254.98
|
| Rate for Payer: HFN Commercial |
$4,398.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,585.66
|
| Rate for Payer: Multiplan Commercial |
$3,824.70
|
| Rate for Payer: NAPHCARE Commercial |
$2,868.53
|
| Rate for Payer: Preferred Network Access Commercial |
$4,398.41
|
| Rate for Payer: Quartz Beloit One Network |
$2,342.63
|
| Rate for Payer: Quartz Commercial |
$3,107.57
|
| Rate for Payer: Quartz Medicare Advantage |
$2,868.53
|
| Rate for Payer: The Alliance Commercial |
$2,390.44
|
| Rate for Payer: WEA Trust Commercial |
$2,629.48
|
| Rate for Payer: WPS Commercial |
$3,541.07
|
|
|
Y-PLATE 2.4MM 3HL HEAD/8HL SHAFT 249.915
|
Facility
|
IP
|
$4,597.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508775
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,342.63 |
| Max. Negotiated Rate |
$4,398.41 |
| Rate for Payer: Aetna Commercial |
$4,302.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,111.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,533.87
|
| Rate for Payer: Cash Price |
$1,379.10
|
| Rate for Payer: Cigna Commercial |
$4,398.41
|
| Rate for Payer: Health EOS Commercial |
$4,254.98
|
| Rate for Payer: HFN Commercial |
$4,398.41
|
| Rate for Payer: Multiplan Commercial |
$3,824.70
|
| Rate for Payer: Preferred Network Access Commercial |
$4,398.41
|
| Rate for Payer: Quartz Beloit One Network |
$2,342.63
|
| Rate for Payer: Quartz Commercial |
$2,868.53
|
| Rate for Payer: WEA Trust Commercial |
$2,629.48
|
| Rate for Payer: WPS Commercial |
$3,541.07
|
|
|
Y-PLATE 3Di CROSSCHECK 5820YPX1
|
Facility
|
IP
|
$11,517.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6185022
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,869.06 |
| Max. Negotiated Rate |
$11,019.47 |
| Rate for Payer: Aetna Commercial |
$10,779.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,300.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,348.17
|
| Rate for Payer: Cash Price |
$3,455.10
|
| Rate for Payer: Cigna Commercial |
$11,019.47
|
| Rate for Payer: Health EOS Commercial |
$10,660.14
|
| Rate for Payer: HFN Commercial |
$11,019.47
|
| Rate for Payer: Multiplan Commercial |
$9,582.14
|
| Rate for Payer: Preferred Network Access Commercial |
$11,019.47
|
| Rate for Payer: Quartz Beloit One Network |
$5,869.06
|
| Rate for Payer: Quartz Commercial |
$7,186.61
|
| Rate for Payer: WEA Trust Commercial |
$6,587.72
|
| Rate for Payer: WPS Commercial |
$8,871.55
|
|
|
Y-PLATE 3Di CROSSCHECK 5820YPX1
|
Facility
|
OP
|
$11,517.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6185022
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,353.75 |
| Max. Negotiated Rate |
$11,019.47 |
| Rate for Payer: Aetna Commercial |
$10,779.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,300.80
|
| Rate for Payer: Aetna Managed Medicare |
$3,353.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,785.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,988.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,749.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,348.17
|
| Rate for Payer: Cash Price |
$3,455.10
|
| Rate for Payer: Cigna Commercial |
$11,019.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,702.89
|
| Rate for Payer: Health EOS Commercial |
$10,660.14
|
| Rate for Payer: HFN Commercial |
$11,019.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,983.26
|
| Rate for Payer: Multiplan Commercial |
$9,582.14
|
| Rate for Payer: NAPHCARE Commercial |
$7,186.61
|
| Rate for Payer: Preferred Network Access Commercial |
$11,019.47
|
| Rate for Payer: Quartz Beloit One Network |
$5,869.06
|
| Rate for Payer: Quartz Commercial |
$7,785.49
|
| Rate for Payer: Quartz Medicare Advantage |
$7,186.61
|
| Rate for Payer: The Alliance Commercial |
$5,988.84
|
| Rate for Payer: WEA Trust Commercial |
$6,587.72
|
| Rate for Payer: WPS Commercial |
$8,871.55
|
|
|
Y-PLATE 5TH METATARSAL RT 5202500R
|
Facility
|
IP
|
$6,953.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6172201
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,543.25 |
| Max. Negotiated Rate |
$6,652.63 |
| Rate for Payer: Aetna Commercial |
$6,508.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,218.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,832.49
|
| Rate for Payer: Cash Price |
$2,085.90
|
| Rate for Payer: Cigna Commercial |
$6,652.63
|
| Rate for Payer: Health EOS Commercial |
$6,435.70
|
| Rate for Payer: HFN Commercial |
$6,652.63
|
| Rate for Payer: Multiplan Commercial |
$5,784.90
|
| Rate for Payer: Preferred Network Access Commercial |
$6,652.63
|
| Rate for Payer: Quartz Beloit One Network |
$3,543.25
|
| Rate for Payer: Quartz Commercial |
$4,338.67
|
| Rate for Payer: WEA Trust Commercial |
$3,977.12
|
| Rate for Payer: WPS Commercial |
$5,355.90
|
|
|
Y-PLATE 5TH METATARSAL RT 5202500R
|
Facility
|
OP
|
$6,953.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6172201
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.71 |
| Max. Negotiated Rate |
$6,652.63 |
| Rate for Payer: Aetna Commercial |
$6,508.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,218.76
|
| Rate for Payer: Aetna Managed Medicare |
$2,024.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,700.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,615.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,470.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,832.49
|
| Rate for Payer: Cash Price |
$2,085.90
|
| Rate for Payer: Cigna Commercial |
$6,652.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,046.65
|
| Rate for Payer: Health EOS Commercial |
$6,435.70
|
| Rate for Payer: HFN Commercial |
$6,652.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,423.34
|
| Rate for Payer: Multiplan Commercial |
$5,784.90
|
| Rate for Payer: NAPHCARE Commercial |
$4,338.67
|
| Rate for Payer: Preferred Network Access Commercial |
$6,652.63
|
| Rate for Payer: Quartz Beloit One Network |
$3,543.25
|
| Rate for Payer: Quartz Commercial |
$4,700.23
|
| Rate for Payer: Quartz Medicare Advantage |
$4,338.67
|
| Rate for Payer: The Alliance Commercial |
$3,615.56
|
| Rate for Payer: WEA Trust Commercial |
$3,977.12
|
| Rate for Payer: WPS Commercial |
$5,355.90
|
|
|
Y-PLATE MATRIX MIDFACE 1.0 X 3HL 0.7MM THICK TI 04.503.377
|
Facility
|
OP
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5349172
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$734.99 |
| Max. Negotiated Rate |
$2,414.96 |
| Rate for Payer: Aetna Commercial |
$2,362.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,257.47
|
| Rate for Payer: Aetna Managed Medicare |
$734.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,706.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,312.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,259.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,391.23
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,414.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,468.97
|
| Rate for Payer: Health EOS Commercial |
$2,336.21
|
| Rate for Payer: HFN Commercial |
$2,414.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,968.72
|
| Rate for Payer: Multiplan Commercial |
$2,099.97
|
| Rate for Payer: NAPHCARE Commercial |
$1,574.98
|
| Rate for Payer: Preferred Network Access Commercial |
$2,414.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,286.23
|
| Rate for Payer: Quartz Commercial |
$1,706.22
|
| Rate for Payer: Quartz Medicare Advantage |
$1,574.98
|
| Rate for Payer: The Alliance Commercial |
$1,312.48
|
| Rate for Payer: WEA Trust Commercial |
$1,443.73
|
| Rate for Payer: WPS Commercial |
$1,944.24
|
|
|
Y-PLATE MATRIX MIDFACE 1.0 X 3HL 0.7MM THICK TI 04.503.377
|
Facility
|
IP
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5349172
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,286.23 |
| Max. Negotiated Rate |
$2,414.96 |
| Rate for Payer: Aetna Commercial |
$2,362.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,257.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,391.23
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,414.96
|
| Rate for Payer: Health EOS Commercial |
$2,336.21
|
| Rate for Payer: HFN Commercial |
$2,414.96
|
| Rate for Payer: Multiplan Commercial |
$2,099.97
|
| Rate for Payer: Preferred Network Access Commercial |
$2,414.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,286.23
|
| Rate for Payer: Quartz Commercial |
$1,574.98
|
| Rate for Payer: WEA Trust Commercial |
$1,443.73
|
| Rate for Payer: WPS Commercial |
$1,944.24
|
|
|
Zantac 25 mg Charge
|
Professional
|
Both
|
$87.00
|
|
|
Service Code
|
HCPCS J2780
|
| Hospital Charge Code |
2958939
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$85.96 |
| Rate for Payer: Aetna Commercial |
$85.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$85.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.29
|
| Rate for Payer: Health EOS Commercial |
$82.34
|
| Rate for Payer: HFN Commercial |
$85.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.30
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: Preferred Network Access Commercial |
$85.96
|
| Rate for Payer: Quartz Beloit One Network |
$39.81
|
| Rate for Payer: Quartz Commercial |
$51.57
|
| Rate for Payer: The Alliance Commercial |
$45.24
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
Zantac 25 mg Charge
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS J2780
|
| Hospital Charge Code |
2958939
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.33 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Aetna Managed Medicare |
$25.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.63
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.86
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: NAPHCARE Commercial |
$54.29
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$58.81
|
| Rate for Payer: Quartz Medicare Advantage |
$54.29
|
| Rate for Payer: The Alliance Commercial |
$45.24
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
Zantac 25 mg Charge
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS J2780
|
| Hospital Charge Code |
2958939
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$54.29
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
Zemplar Supplies
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
3005576
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Aetna Managed Medicare |
$1.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.91
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: NAPHCARE Commercial |
$3.12
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.38
|
| Rate for Payer: Quartz Medicare Advantage |
$3.12
|
| Rate for Payer: The Alliance Commercial |
$2.60
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
Zemplar Supplies
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
3005576
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
ZENKERS DIVERTICULECTOMY
|
Facility
|
IP
|
$4,460.00
|
|
| Hospital Charge Code |
2960514
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,272.82 |
| Max. Negotiated Rate |
$4,267.33 |
| Rate for Payer: Aetna Commercial |
$4,174.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,989.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,458.35
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,267.33
|
| Rate for Payer: Health EOS Commercial |
$4,128.18
|
| Rate for Payer: HFN Commercial |
$4,267.33
|
| Rate for Payer: Multiplan Commercial |
$3,710.72
|
| Rate for Payer: Preferred Network Access Commercial |
$4,267.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,272.82
|
| Rate for Payer: Quartz Commercial |
$2,783.04
|
| Rate for Payer: WEA Trust Commercial |
$2,551.12
|
| Rate for Payer: WPS Commercial |
$3,435.54
|
|
|
ZENKERS DIVERTICULECTOMY
|
Facility
|
OP
|
$4,460.00
|
|
| Hospital Charge Code |
2960514
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,298.75 |
| Max. Negotiated Rate |
$4,267.33 |
| Rate for Payer: Aetna Commercial |
$4,174.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,989.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,298.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,014.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,319.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,226.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,458.35
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,267.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,595.72
|
| Rate for Payer: Health EOS Commercial |
$4,128.18
|
| Rate for Payer: HFN Commercial |
$4,267.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,478.80
|
| Rate for Payer: Multiplan Commercial |
$3,710.72
|
| Rate for Payer: NAPHCARE Commercial |
$2,783.04
|
| Rate for Payer: Preferred Network Access Commercial |
$4,267.33
|
| Rate for Payer: Quartz Beloit One Network |
$2,272.82
|
| Rate for Payer: Quartz Commercial |
$3,014.96
|
| Rate for Payer: Quartz Medicare Advantage |
$2,783.04
|
| Rate for Payer: The Alliance Commercial |
$2,319.20
|
| Rate for Payer: WEA Trust Commercial |
$2,551.12
|
| Rate for Payer: WPS Commercial |
$3,435.54
|
|
|
Z-Flo Specialty Pillow - CCC Z-Flo Specialty Pillow
|
Facility
|
IP
|
$988.00
|
|
| Hospital Charge Code |
5804416
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$503.48 |
| Max. Negotiated Rate |
$945.32 |
| Rate for Payer: Aetna Commercial |
$924.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$883.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$544.59
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cigna Commercial |
$945.32
|
| Rate for Payer: Health EOS Commercial |
$914.49
|
| Rate for Payer: HFN Commercial |
$945.32
|
| Rate for Payer: Multiplan Commercial |
$822.02
|
| Rate for Payer: Preferred Network Access Commercial |
$945.32
|
| Rate for Payer: Quartz Beloit One Network |
$503.48
|
| Rate for Payer: Quartz Commercial |
$616.51
|
| Rate for Payer: WEA Trust Commercial |
$565.14
|
| Rate for Payer: WPS Commercial |
$761.06
|
|
|
Z-Flo Specialty Pillow - CCC Z-Flo Specialty Pillow
|
Facility
|
OP
|
$988.00
|
|
| Hospital Charge Code |
5804416
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$287.71 |
| Max. Negotiated Rate |
$945.32 |
| Rate for Payer: Aetna Commercial |
$924.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$883.67
|
| Rate for Payer: Aetna Managed Medicare |
$287.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$667.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$513.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$493.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$544.59
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cigna Commercial |
$945.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$575.02
|
| Rate for Payer: Health EOS Commercial |
$914.49
|
| Rate for Payer: HFN Commercial |
$945.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$770.64
|
| Rate for Payer: Multiplan Commercial |
$822.02
|
| Rate for Payer: NAPHCARE Commercial |
$616.51
|
| Rate for Payer: Preferred Network Access Commercial |
$945.32
|
| Rate for Payer: Quartz Beloit One Network |
$503.48
|
| Rate for Payer: Quartz Commercial |
$667.89
|
| Rate for Payer: Quartz Medicare Advantage |
$616.51
|
| Rate for Payer: The Alliance Commercial |
$513.76
|
| Rate for Payer: WEA Trust Commercial |
$565.14
|
| Rate for Payer: WPS Commercial |
$761.06
|
|
|
Zika Virus RNA, Qualitative PCR
|
Facility
|
IP
|
$783.00
|
|
|
Service Code
|
CPT 87662
|
| Hospital Charge Code |
4638630
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$399.02 |
| Max. Negotiated Rate |
$749.17 |
| Rate for Payer: Aetna Commercial |
$732.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$700.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$431.59
|
| Rate for Payer: Cash Price |
$234.90
|
| Rate for Payer: Cigna Commercial |
$749.17
|
| Rate for Payer: Health EOS Commercial |
$724.74
|
| Rate for Payer: HFN Commercial |
$749.17
|
| Rate for Payer: Multiplan Commercial |
$651.46
|
| Rate for Payer: Preferred Network Access Commercial |
$749.17
|
| Rate for Payer: Quartz Beloit One Network |
$399.02
|
| Rate for Payer: Quartz Commercial |
$488.59
|
| Rate for Payer: WEA Trust Commercial |
$447.88
|
| Rate for Payer: WPS Commercial |
$603.14
|
|
|
Zika Virus RNA, Qualitative PCR
|
Facility
|
OP
|
$783.00
|
|
|
Service Code
|
CPT 87662
|
| Hospital Charge Code |
4638630
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.36 |
| Max. Negotiated Rate |
$749.17 |
| Rate for Payer: Aetna Commercial |
$732.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$700.32
|
| Rate for Payer: Aetna Managed Medicare |
$53.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$200.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$93.38
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$88.58
|
| Rate for Payer: Anthem Medicare Advantage |
$53.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$431.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$53.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$53.36
|
| Rate for Payer: Cash Price |
$234.90
|
| Rate for Payer: Cash Price |
$234.90
|
| Rate for Payer: Cigna Commercial |
$749.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$53.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$455.71
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$53.36
|
| Rate for Payer: Health EOS Commercial |
$724.74
|
| Rate for Payer: HFN Commercial |
$749.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$198.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$53.36
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$53.36
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$53.36
|
| Rate for Payer: Multiplan Commercial |
$651.46
|
| Rate for Payer: NAPHCARE Commercial |
$80.04
|
| Rate for Payer: Preferred Network Access Commercial |
$749.17
|
| Rate for Payer: Quartz Beloit One Network |
$399.02
|
| Rate for Payer: Quartz Commercial |
$529.31
|
| Rate for Payer: Quartz Medicare Advantage |
$53.36
|
| Rate for Payer: The Alliance Commercial |
$213.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.36
|
| Rate for Payer: United Healthcare PPO |
$610.74
|
| Rate for Payer: WEA Trust Commercial |
$447.88
|
| Rate for Payer: Wellcare Medicare |
$53.36
|
| Rate for Payer: WPS Commercial |
$603.14
|
|
|
Zika Virus RNA, Qualitative PCR
|
Professional
|
Both
|
$783.00
|
|
|
Service Code
|
CPT 87662
|
| Hospital Charge Code |
4638630
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.36 |
| Max. Negotiated Rate |
$773.60 |
| Rate for Payer: Aetna Commercial |
$773.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$700.32
|
| Rate for Payer: Aetna Managed Medicare |
$53.36
|
| Rate for Payer: Anthem Medicare Advantage |
$53.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$53.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$53.36
|
| Rate for Payer: Cash Price |
$234.90
|
| Rate for Payer: Cash Price |
$234.90
|
| Rate for Payer: Cigna Commercial |
$773.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$407.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.36
|
| Rate for Payer: Health EOS Commercial |
$741.03
|
| Rate for Payer: HFN Commercial |
$773.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$188.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$188.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$53.36
|
| Rate for Payer: Multiplan Commercial |
$651.46
|
| Rate for Payer: NAPHCARE Commercial |
$80.04
|
| Rate for Payer: Preferred Network Access Commercial |
$773.60
|
| Rate for Payer: Quartz Beloit One Network |
$358.30
|
| Rate for Payer: Quartz Commercial |
$464.16
|
| Rate for Payer: Quartz Medicare Advantage |
$53.36
|
| Rate for Payer: The Alliance Commercial |
$210.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.36
|
| Rate for Payer: WEA Trust Commercial |
$447.88
|
| Rate for Payer: WPS Commercial |
$234.79
|
|
|
Zilretta 32mg/5 mL inj - Zilretta Med Charge
|
Facility
|
OP
|
$1,321.00
|
|
|
Service Code
|
HCPCS J3304
|
| Hospital Charge Code |
6222269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.05 |
| Max. Negotiated Rate |
$1,263.93 |
| Rate for Payer: Aetna Commercial |
$1,236.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,181.50
|
| Rate for Payer: Aetna Managed Medicare |
$20.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$893.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$686.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$659.44
|
| Rate for Payer: Anthem Medicare Advantage |
$20.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.05
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,263.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.07
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20.05
|
| Rate for Payer: Health EOS Commercial |
$1,222.72
|
| Rate for Payer: HFN Commercial |
$1,263.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$74.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.05
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20.05
|
| Rate for Payer: Multiplan Commercial |
$1,099.07
|
| Rate for Payer: NAPHCARE Commercial |
$30.08
|
| Rate for Payer: Preferred Network Access Commercial |
$1,263.93
|
| Rate for Payer: Quartz Beloit One Network |
$673.18
|
| Rate for Payer: Quartz Commercial |
$893.00
|
| Rate for Payer: Quartz Medicare Advantage |
$20.05
|
| Rate for Payer: The Alliance Commercial |
$80.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.05
|
| Rate for Payer: WEA Trust Commercial |
$755.61
|
| Rate for Payer: Wellcare Medicare |
$20.05
|
| Rate for Payer: WPS Commercial |
$45.48
|
|
|
Zilretta 32mg/5 mL inj - Zilretta Med Charge
|
Facility
|
IP
|
$1,321.00
|
|
|
Service Code
|
HCPCS J3304
|
| Hospital Charge Code |
6222269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$673.18 |
| Max. Negotiated Rate |
$1,263.93 |
| Rate for Payer: Quartz Commercial |
$824.30
|
| Rate for Payer: Aetna Commercial |
$1,236.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,181.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.14
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,263.93
|
| Rate for Payer: Health EOS Commercial |
$1,222.72
|
| Rate for Payer: HFN Commercial |
$1,263.93
|
| Rate for Payer: Multiplan Commercial |
$1,099.07
|
| Rate for Payer: Preferred Network Access Commercial |
$1,263.93
|
| Rate for Payer: Quartz Beloit One Network |
$673.18
|
| Rate for Payer: WEA Trust Commercial |
$755.61
|
| Rate for Payer: WPS Commercial |
$1,017.57
|
|
|
Zilretta 32mg/5 mL inj - Zilretta Med Charge
|
Professional
|
Both
|
$1,321.00
|
|
|
Service Code
|
HCPCS J3304
|
| Hospital Charge Code |
6222269
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.19 |
| Max. Negotiated Rate |
$1,305.15 |
| Rate for Payer: Aetna Commercial |
$1,305.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,181.50
|
| Rate for Payer: Aetna Managed Medicare |
$20.05
|
| Rate for Payer: Anthem Medicare Advantage |
$20.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.05
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,305.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.19
|
| Rate for Payer: Health EOS Commercial |
$1,250.19
|
| Rate for Payer: HFN Commercial |
$1,305.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$27.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.05
|
| Rate for Payer: Multiplan Commercial |
$1,099.07
|
| Rate for Payer: NAPHCARE Commercial |
$30.08
|
| Rate for Payer: Preferred Network Access Commercial |
$1,305.15
|
| Rate for Payer: Quartz Beloit One Network |
$604.49
|
| Rate for Payer: Quartz Commercial |
$783.09
|
| Rate for Payer: Quartz Medicare Advantage |
$20.05
|
| Rate for Payer: The Alliance Commercial |
$55.14
|
| Rate for Payer: United Healthcare Medicaid |
$19.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.05
|
| Rate for Payer: WEA Trust Commercial |
$755.61
|
| Rate for Payer: WPS Commercial |
$45.48
|
|
|
Zilretta (triamcinalone) 32mg/5mL injt J3304
|
Facility
|
IP
|
$1,321.00
|
|
|
Service Code
|
HCPCS J3304
|
| Hospital Charge Code |
6230197
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$673.18 |
| Max. Negotiated Rate |
$1,263.93 |
| Rate for Payer: Aetna Commercial |
$1,236.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,181.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$728.14
|
| Rate for Payer: Cash Price |
$396.30
|
| Rate for Payer: Cigna Commercial |
$1,263.93
|
| Rate for Payer: Health EOS Commercial |
$1,222.72
|
| Rate for Payer: HFN Commercial |
$1,263.93
|
| Rate for Payer: Multiplan Commercial |
$1,099.07
|
| Rate for Payer: Preferred Network Access Commercial |
$1,263.93
|
| Rate for Payer: Quartz Beloit One Network |
$673.18
|
| Rate for Payer: Quartz Commercial |
$824.30
|
| Rate for Payer: WEA Trust Commercial |
$755.61
|
| Rate for Payer: WPS Commercial |
$1,017.57
|
|
