|
BRUSH TIP FEMORAL CANAL 0210-004-000
|
Facility
IP
|
$456.00
|
|
| Hospital Charge Code |
2963164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$223.44 |
| Max. Negotiated Rate |
$419.52 |
| Rate for Payer: Aetna Commercial |
$410.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.68
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$419.52
|
| Rate for Payer: Health EOS Commercial |
$405.84
|
| Rate for Payer: HFN Commercial |
$419.52
|
| Rate for Payer: Multiplan Commercial |
$364.80
|
| Rate for Payer: NAPHCARE Commercial |
$273.60
|
| Rate for Payer: Preferred Network Access Commercial |
$419.52
|
| Rate for Payer: Quartz Beloit One Network |
$223.44
|
| Rate for Payer: Quartz Commercial |
$273.60
|
| Rate for Payer: WEA Trust Commercial |
$250.80
|
| Rate for Payer: WPS Commercial |
$337.76
|
|
|
BRUSH TIP FEMORAL CANAL 0210-004-000
|
Facility
OP
|
$456.00
|
|
| Hospital Charge Code |
2963164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$127.68 |
| Max. Negotiated Rate |
$1,824.00 |
| Rate for Payer: Aetna Commercial |
$410.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$392.16
|
| Rate for Payer: Aetna Managed Medicare |
$127.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$296.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$228.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$218.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$241.68
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$419.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$255.18
|
| Rate for Payer: Health EOS Commercial |
$405.84
|
| Rate for Payer: HFN Commercial |
$419.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$342.00
|
| Rate for Payer: Multiplan Commercial |
$364.80
|
| Rate for Payer: NAPHCARE Commercial |
$273.60
|
| Rate for Payer: Preferred Network Access Commercial |
$419.52
|
| Rate for Payer: Quartz Beloit One Network |
$223.44
|
| Rate for Payer: Quartz Commercial |
$296.40
|
| Rate for Payer: Quartz Medicare Advantage |
$273.60
|
| Rate for Payer: The Alliance Commercial |
$1,824.00
|
| Rate for Payer: WEA Trust Commercial |
$250.80
|
| Rate for Payer: WPS Commercial |
$337.76
|
|
|
BRUSH ULTRADEX SCRUB
|
Facility
OP
|
$22.00
|
|
| Hospital Charge Code |
2963141
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$88.00 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.92
|
| Rate for Payer: Aetna Managed Medicare |
$6.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.31
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16.50
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$14.30
|
| Rate for Payer: Quartz Medicare Advantage |
$13.20
|
| Rate for Payer: The Alliance Commercial |
$88.00
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
BRUSH ULTRADEX SCRUB
|
Facility
IP
|
$22.00
|
|
| Hospital Charge Code |
2963141
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.66
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$20.24
|
| Rate for Payer: Health EOS Commercial |
$19.58
|
| Rate for Payer: HFN Commercial |
$20.24
|
| Rate for Payer: Multiplan Commercial |
$17.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.20
|
| Rate for Payer: Preferred Network Access Commercial |
$20.24
|
| Rate for Payer: Quartz Beloit One Network |
$10.78
|
| Rate for Payer: Quartz Commercial |
$13.20
|
| Rate for Payer: WEA Trust Commercial |
$12.10
|
| Rate for Payer: WPS Commercial |
$16.30
|
|
|
B-SCAN, OPH US DX 76512
|
Professional
|
$508.00
|
|
|
Service Code
|
CPT 76512
|
| Hospital Charge Code |
6180170
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$46.55 |
| Max. Negotiated Rate |
$482.60 |
| Rate for Payer: Aetna Commercial |
$482.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$436.88
|
| Rate for Payer: Aetna Managed Medicare |
$46.55
|
| Rate for Payer: Anthem Medicare Advantage |
$46.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$46.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$46.55
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$482.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$254.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.55
|
| Rate for Payer: Health EOS Commercial |
$462.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$168.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$168.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$46.55
|
| Rate for Payer: Multiplan Commercial |
$406.40
|
| Rate for Payer: Preferred Network Access Commercial |
$482.60
|
| Rate for Payer: Quartz Beloit One Network |
$223.52
|
| Rate for Payer: Quartz Commercial |
$289.56
|
| Rate for Payer: Quartz Medicare Advantage |
$46.55
|
| Rate for Payer: The Alliance Commercial |
$176.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.55
|
| Rate for Payer: WEA Trust Commercial |
$279.40
|
| Rate for Payer: WPS Commercial |
$232.75
|
|
|
B-SCAN, OPH US DX 76512-26
|
Professional
|
$508.00
|
|
|
Service Code
|
CPT 76512 26
|
| Hospital Charge Code |
6194961
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.71 |
| Max. Negotiated Rate |
$482.60 |
| Rate for Payer: Aetna Commercial |
$482.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$436.88
|
| Rate for Payer: Aetna Managed Medicare |
$29.71
|
| Rate for Payer: Anthem Medicare Advantage |
$29.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29.71
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$482.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$254.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.71
|
| Rate for Payer: Health EOS Commercial |
$462.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$106.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$106.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29.71
|
| Rate for Payer: Multiplan Commercial |
$406.40
|
| Rate for Payer: Preferred Network Access Commercial |
$482.60
|
| Rate for Payer: Quartz Beloit One Network |
$223.52
|
| Rate for Payer: Quartz Commercial |
$289.56
|
| Rate for Payer: Quartz Medicare Advantage |
$29.71
|
| Rate for Payer: The Alliance Commercial |
$112.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.71
|
| Rate for Payer: WEA Trust Commercial |
$279.40
|
| Rate for Payer: WPS Commercial |
$148.55
|
|
|
B-SCAN, OPH US DX, BILAT 76512-50
|
Professional
|
$1,014.00
|
|
|
Service Code
|
CPT 76512 50
|
| Hospital Charge Code |
6210132
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$446.16 |
| Max. Negotiated Rate |
$963.30 |
| Rate for Payer: Aetna Commercial |
$963.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$872.04
|
| Rate for Payer: Cash Price |
$304.20
|
| Rate for Payer: Cash Price |
$304.20
|
| Rate for Payer: Cigna Commercial |
$963.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$507.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$608.40
|
| Rate for Payer: Health EOS Commercial |
$922.74
|
| Rate for Payer: Multiplan Commercial |
$811.20
|
| Rate for Payer: Preferred Network Access Commercial |
$963.30
|
| Rate for Payer: Quartz Beloit One Network |
$446.16
|
| Rate for Payer: Quartz Commercial |
$577.98
|
| Rate for Payer: The Alliance Commercial |
$507.00
|
| Rate for Payer: WEA Trust Commercial |
$557.70
|
| Rate for Payer: WPS Commercial |
$751.07
|
|
|
BUDDY LOOPS 1 BLACK #9272-78
|
Facility
IP
|
$82.00
|
|
| Hospital Charge Code |
2970950
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$40.18 |
| Max. Negotiated Rate |
$75.44 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.46
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$75.44
|
| Rate for Payer: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: NAPHCARE Commercial |
$49.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.44
|
| Rate for Payer: Quartz Beloit One Network |
$40.18
|
| Rate for Payer: Quartz Commercial |
$49.20
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
BUDDY LOOPS 1 BLACK #9272-78
|
Facility
OP
|
$82.00
|
|
| Hospital Charge Code |
2970950
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.96 |
| Max. Negotiated Rate |
$328.00 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| Rate for Payer: Aetna Managed Medicare |
$22.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.46
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$75.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.89
|
| Rate for Payer: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.50
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: NAPHCARE Commercial |
$49.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.44
|
| Rate for Payer: Quartz Beloit One Network |
$40.18
|
| Rate for Payer: Quartz Commercial |
$53.30
|
| Rate for Payer: Quartz Medicare Advantage |
$49.20
|
| Rate for Payer: The Alliance Commercial |
$328.00
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
BULB ESOPHAGEAL INTUBATION EID200
|
Facility
IP
|
$148.00
|
|
| Hospital Charge Code |
2963256
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$72.52 |
| Max. Negotiated Rate |
$136.16 |
| Rate for Payer: Aetna Commercial |
$133.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$78.44
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$136.16
|
| Rate for Payer: Health EOS Commercial |
$131.72
|
| Rate for Payer: HFN Commercial |
$136.16
|
| Rate for Payer: Multiplan Commercial |
$118.40
|
| Rate for Payer: NAPHCARE Commercial |
$88.80
|
| Rate for Payer: Preferred Network Access Commercial |
$136.16
|
| Rate for Payer: Quartz Beloit One Network |
$72.52
|
| Rate for Payer: Quartz Commercial |
$88.80
|
| Rate for Payer: WEA Trust Commercial |
$81.40
|
| Rate for Payer: WPS Commercial |
$109.62
|
|
|
BULB ESOPHAGEAL INTUBATION EID200
|
Facility
OP
|
$148.00
|
|
| Hospital Charge Code |
2963256
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.44 |
| Max. Negotiated Rate |
$592.00 |
| Rate for Payer: Aetna Commercial |
$133.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.28
|
| Rate for Payer: Aetna Managed Medicare |
$41.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$96.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$74.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$71.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$78.44
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$136.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.82
|
| Rate for Payer: Health EOS Commercial |
$131.72
|
| Rate for Payer: HFN Commercial |
$136.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$111.00
|
| Rate for Payer: Multiplan Commercial |
$118.40
|
| Rate for Payer: NAPHCARE Commercial |
$88.80
|
| Rate for Payer: Preferred Network Access Commercial |
$136.16
|
| Rate for Payer: Quartz Beloit One Network |
$72.52
|
| Rate for Payer: Quartz Commercial |
$96.20
|
| Rate for Payer: Quartz Medicare Advantage |
$88.80
|
| Rate for Payer: The Alliance Commercial |
$592.00
|
| Rate for Payer: WEA Trust Commercial |
$81.40
|
| Rate for Payer: WPS Commercial |
$109.62
|
|
|
BULB PATHFINDER PLUS PA 701
|
Facility
OP
|
$884.00
|
|
| Hospital Charge Code |
2967373
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$247.52 |
| Max. Negotiated Rate |
$3,536.00 |
| Rate for Payer: Aetna Commercial |
$795.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$760.24
|
| Rate for Payer: Aetna Managed Medicare |
$247.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$574.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$442.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$424.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$468.52
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cigna Commercial |
$813.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$494.69
|
| Rate for Payer: Health EOS Commercial |
$786.76
|
| Rate for Payer: HFN Commercial |
$813.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$663.00
|
| Rate for Payer: Multiplan Commercial |
$707.20
|
| Rate for Payer: NAPHCARE Commercial |
$530.40
|
| Rate for Payer: Preferred Network Access Commercial |
$813.28
|
| Rate for Payer: Quartz Beloit One Network |
$433.16
|
| Rate for Payer: Quartz Commercial |
$574.60
|
| Rate for Payer: Quartz Medicare Advantage |
$530.40
|
| Rate for Payer: The Alliance Commercial |
$3,536.00
|
| Rate for Payer: WEA Trust Commercial |
$486.20
|
| Rate for Payer: WPS Commercial |
$654.78
|
|
|
BULB PATHFINDER PLUS PA 701
|
Facility
IP
|
$884.00
|
|
| Hospital Charge Code |
2967373
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$433.16 |
| Max. Negotiated Rate |
$813.28 |
| Rate for Payer: Aetna Commercial |
$795.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$468.52
|
| Rate for Payer: Cash Price |
$265.20
|
| Rate for Payer: Cigna Commercial |
$813.28
|
| Rate for Payer: Health EOS Commercial |
$786.76
|
| Rate for Payer: HFN Commercial |
$813.28
|
| Rate for Payer: Multiplan Commercial |
$707.20
|
| Rate for Payer: NAPHCARE Commercial |
$530.40
|
| Rate for Payer: Preferred Network Access Commercial |
$813.28
|
| Rate for Payer: Quartz Beloit One Network |
$433.16
|
| Rate for Payer: Quartz Commercial |
$530.40
|
| Rate for Payer: WEA Trust Commercial |
$486.20
|
| Rate for Payer: WPS Commercial |
$654.78
|
|
|
Bulb Syringe
|
Facility
IP
|
$1.00
|
|
| Hospital Charge Code |
3040349
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.53
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.92
|
| Rate for Payer: Health EOS Commercial |
$0.89
|
| Rate for Payer: HFN Commercial |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: NAPHCARE Commercial |
$0.60
|
| Rate for Payer: Preferred Network Access Commercial |
$0.92
|
| Rate for Payer: Quartz Beloit One Network |
$0.49
|
| Rate for Payer: Quartz Commercial |
$0.60
|
| Rate for Payer: WEA Trust Commercial |
$0.55
|
| Rate for Payer: WPS Commercial |
$0.74
|
|
|
Bulb Syringe
|
Facility
OP
|
$1.00
|
|
| Hospital Charge Code |
3040349
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial |
$0.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.86
|
| Rate for Payer: Aetna Managed Medicare |
$0.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$0.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$0.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.53
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.56
|
| Rate for Payer: Health EOS Commercial |
$0.89
|
| Rate for Payer: HFN Commercial |
$0.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: NAPHCARE Commercial |
$0.60
|
| Rate for Payer: Preferred Network Access Commercial |
$0.92
|
| Rate for Payer: Quartz Beloit One Network |
$0.49
|
| Rate for Payer: Quartz Commercial |
$0.65
|
| Rate for Payer: Quartz Medicare Advantage |
$0.60
|
| Rate for Payer: The Alliance Commercial |
$4.00
|
| Rate for Payer: WEA Trust Commercial |
$0.55
|
| Rate for Payer: WPS Commercial |
$0.74
|
|
|
BULB XENON REPL.KIT/DISP.LARNG
|
Facility
OP
|
$266.00
|
|
| Hospital Charge Code |
2963526
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$74.48 |
| Max. Negotiated Rate |
$1,064.00 |
| Rate for Payer: Aetna Commercial |
$239.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$228.76
|
| Rate for Payer: Aetna Managed Medicare |
$74.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$172.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$133.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$127.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.98
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna Commercial |
$244.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$148.85
|
| Rate for Payer: Health EOS Commercial |
$236.74
|
| Rate for Payer: HFN Commercial |
$244.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$199.50
|
| Rate for Payer: Multiplan Commercial |
$212.80
|
| Rate for Payer: NAPHCARE Commercial |
$159.60
|
| Rate for Payer: Preferred Network Access Commercial |
$244.72
|
| Rate for Payer: Quartz Beloit One Network |
$130.34
|
| Rate for Payer: Quartz Commercial |
$172.90
|
| Rate for Payer: Quartz Medicare Advantage |
$159.60
|
| Rate for Payer: The Alliance Commercial |
$1,064.00
|
| Rate for Payer: WEA Trust Commercial |
$146.30
|
| Rate for Payer: WPS Commercial |
$197.03
|
|
|
BULB XENON REPL.KIT/DISP.LARNG
|
Facility
IP
|
$266.00
|
|
| Hospital Charge Code |
2963526
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$130.34 |
| Max. Negotiated Rate |
$244.72 |
| Rate for Payer: Aetna Commercial |
$239.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.98
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cigna Commercial |
$244.72
|
| Rate for Payer: Health EOS Commercial |
$236.74
|
| Rate for Payer: HFN Commercial |
$244.72
|
| Rate for Payer: Multiplan Commercial |
$212.80
|
| Rate for Payer: NAPHCARE Commercial |
$159.60
|
| Rate for Payer: Preferred Network Access Commercial |
$244.72
|
| Rate for Payer: Quartz Beloit One Network |
$130.34
|
| Rate for Payer: Quartz Commercial |
$159.60
|
| Rate for Payer: WEA Trust Commercial |
$146.30
|
| Rate for Payer: WPS Commercial |
$197.03
|
|
|
BULKING AGENT COAPTITE 1CC M0068903000
|
Facility
IP
|
$4,336.00
|
|
|
Service Code
|
HCPCS L8606
|
| Hospital Charge Code |
5382978
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,124.64 |
| Max. Negotiated Rate |
$3,989.12 |
| Rate for Payer: Aetna Commercial |
$3,902.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,298.08
|
| Rate for Payer: Cash Price |
$1,300.80
|
| Rate for Payer: Cigna Commercial |
$3,989.12
|
| Rate for Payer: Health EOS Commercial |
$3,859.04
|
| Rate for Payer: HFN Commercial |
$3,989.12
|
| Rate for Payer: Multiplan Commercial |
$3,468.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,601.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,989.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,124.64
|
| Rate for Payer: Quartz Commercial |
$2,601.60
|
| Rate for Payer: WEA Trust Commercial |
$2,384.80
|
| Rate for Payer: WPS Commercial |
$3,211.68
|
|
|
BULKING AGENT COAPTITE 1CC M0068903000
|
Facility
OP
|
$4,336.00
|
|
|
Service Code
|
HCPCS L8606
|
| Hospital Charge Code |
5382978
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$158.03 |
| Max. Negotiated Rate |
$3,989.12 |
| Rate for Payer: Aetna Commercial |
$3,902.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,728.96
|
| Rate for Payer: Aetna Managed Medicare |
$1,214.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$158.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$158.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$158.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,298.08
|
| Rate for Payer: Cash Price |
$1,300.80
|
| Rate for Payer: Cash Price |
$1,300.80
|
| Rate for Payer: Cigna Commercial |
$3,989.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,426.43
|
| Rate for Payer: Health EOS Commercial |
$3,859.04
|
| Rate for Payer: HFN Commercial |
$3,989.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,252.00
|
| Rate for Payer: Multiplan Commercial |
$3,468.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,601.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,989.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,124.64
|
| Rate for Payer: Quartz Commercial |
$2,818.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,601.60
|
| Rate for Payer: The Alliance Commercial |
$419.00
|
| Rate for Payer: WEA Trust Commercial |
$2,384.80
|
| Rate for Payer: WPS Commercial |
$3,211.68
|
|
|
Bullous Pemphigoid IgG Antibodies
|
Professional
|
$384.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
5308742
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$364.80 |
| Rate for Payer: Aetna Commercial |
$364.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.24
|
| Rate for Payer: Aetna Managed Medicare |
$11.53
|
| Rate for Payer: Anthem Medicare Advantage |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.53
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$364.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$192.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.53
|
| Rate for Payer: Health EOS Commercial |
$349.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.53
|
| Rate for Payer: Multiplan Commercial |
$307.20
|
| Rate for Payer: Preferred Network Access Commercial |
$364.80
|
| Rate for Payer: Quartz Beloit One Network |
$168.96
|
| Rate for Payer: Quartz Commercial |
$218.88
|
| Rate for Payer: Quartz Medicare Advantage |
$11.53
|
| Rate for Payer: The Alliance Commercial |
$45.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.53
|
| Rate for Payer: WEA Trust Commercial |
$211.20
|
| Rate for Payer: WPS Commercial |
$50.73
|
|
|
Bullous Pemphigoid IgG Antibodies
|
Facility
OP
|
$384.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
5308742
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$1,536.00 |
| Rate for Payer: Aetna Commercial |
$345.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.24
|
| Rate for Payer: Aetna Managed Medicare |
$11.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.14
|
| Rate for Payer: Anthem Medicaid |
$11.91
|
| Rate for Payer: Anthem Medicare Advantage |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.53
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$353.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.91
|
| Rate for Payer: Dean Health Medicaid |
$11.91
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.53
|
| Rate for Payer: Health EOS Commercial |
$341.76
|
| Rate for Payer: HFN Commercial |
$353.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.53
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.53
|
| Rate for Payer: Managed Health Services Medicaid |
$12.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.53
|
| Rate for Payer: Multiplan Commercial |
$307.20
|
| Rate for Payer: NAPHCARE Commercial |
$17.30
|
| Rate for Payer: Preferred Network Access Commercial |
$353.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11.91
|
| Rate for Payer: Quartz Beloit One Network |
$188.16
|
| Rate for Payer: Quartz Commercial |
$249.60
|
| Rate for Payer: Quartz Medicare Advantage |
$11.53
|
| Rate for Payer: The Alliance Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare Medicaid |
$11.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.53
|
| Rate for Payer: United Healthcare PPO |
$288.00
|
| Rate for Payer: WEA Trust Commercial |
$211.20
|
| Rate for Payer: Wellcare Medicare |
$11.53
|
| Rate for Payer: WMAP Medicaid |
$11.91
|
| Rate for Payer: WPS Commercial |
$284.43
|
|
|
Bullous Pemphigoid IgG Antibodies
|
Facility
IP
|
$384.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
5308742
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$188.16 |
| Max. Negotiated Rate |
$353.28 |
| Rate for Payer: Aetna Commercial |
$345.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.52
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$353.28
|
| Rate for Payer: Health EOS Commercial |
$341.76
|
| Rate for Payer: HFN Commercial |
$353.28
|
| Rate for Payer: Multiplan Commercial |
$307.20
|
| Rate for Payer: NAPHCARE Commercial |
$230.40
|
| Rate for Payer: Preferred Network Access Commercial |
$353.28
|
| Rate for Payer: Quartz Beloit One Network |
$188.16
|
| Rate for Payer: Quartz Commercial |
$230.40
|
| Rate for Payer: WEA Trust Commercial |
$211.20
|
| Rate for Payer: WPS Commercial |
$284.43
|
|
|
Bumetanide 0.5mg S0171
|
Professional
|
$5.00
|
|
| Hospital Charge Code |
4253676
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.00
|
| Rate for Payer: Health EOS Commercial |
$4.55
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.75
|
| Rate for Payer: Quartz Beloit One Network |
$2.20
|
| Rate for Payer: Quartz Commercial |
$2.85
|
| Rate for Payer: The Alliance Commercial |
$2.50
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
Bumetanide 0.5mg S0171
|
Facility
IP
|
$5.00
|
|
| Hospital Charge Code |
4253676
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
Bumetanide 0.5mg S0171
|
Facility
OP
|
$5.00
|
|
| Hospital Charge Code |
4253676
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Aetna Managed Medicare |
$1.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.80
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.75
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3.00
|
| Rate for Payer: The Alliance Commercial |
$20.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
