|
C4 Complement
|
Facility
IP
|
$220.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
3403544
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$107.80 |
| Max. Negotiated Rate |
$202.40 |
| Rate for Payer: Aetna Commercial |
$198.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$116.60
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$202.40
|
| Rate for Payer: Health EOS Commercial |
$195.80
|
| Rate for Payer: HFN Commercial |
$202.40
|
| Rate for Payer: Multiplan Commercial |
$176.00
|
| Rate for Payer: NAPHCARE Commercial |
$132.00
|
| Rate for Payer: Preferred Network Access Commercial |
$202.40
|
| Rate for Payer: Quartz Beloit One Network |
$107.80
|
| Rate for Payer: Quartz Commercial |
$132.00
|
| Rate for Payer: WEA Trust Commercial |
$121.00
|
| Rate for Payer: WPS Commercial |
$162.95
|
|
|
C4 Complement
|
Facility
IP
|
$238.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
633685
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$116.62 |
| Max. Negotiated Rate |
$218.96 |
| Rate for Payer: Aetna Commercial |
$214.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.14
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$218.96
|
| Rate for Payer: Health EOS Commercial |
$211.82
|
| Rate for Payer: HFN Commercial |
$218.96
|
| Rate for Payer: Multiplan Commercial |
$190.40
|
| Rate for Payer: NAPHCARE Commercial |
$142.80
|
| Rate for Payer: Preferred Network Access Commercial |
$218.96
|
| Rate for Payer: Quartz Beloit One Network |
$116.62
|
| Rate for Payer: Quartz Commercial |
$142.80
|
| Rate for Payer: WEA Trust Commercial |
$130.90
|
| Rate for Payer: WPS Commercial |
$176.29
|
|
|
C4 Complement
|
Professional
|
$238.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
633685
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$226.10 |
| Rate for Payer: Aetna Commercial |
$226.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.68
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$226.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$119.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$216.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$190.40
|
| Rate for Payer: Preferred Network Access Commercial |
$226.10
|
| Rate for Payer: Quartz Beloit One Network |
$104.72
|
| Rate for Payer: Quartz Commercial |
$135.66
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$47.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$130.90
|
| Rate for Payer: WPS Commercial |
$52.80
|
|
|
C4 Complement
|
Facility
OP
|
$220.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
3403544
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$880.00 |
| Rate for Payer: Aetna Commercial |
$198.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$189.20
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.92
|
| Rate for Payer: Anthem Medicaid |
$12.40
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$116.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$202.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.40
|
| Rate for Payer: Dean Health Medicaid |
$12.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$195.80
|
| Rate for Payer: HFN Commercial |
$202.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Managed Health Services Medicaid |
$12.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$176.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$202.40
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.40
|
| Rate for Payer: Quartz Beloit One Network |
$107.80
|
| Rate for Payer: Quartz Commercial |
$143.00
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$880.00
|
| Rate for Payer: United Healthcare Medicaid |
$12.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: United Healthcare PPO |
$165.00
|
| Rate for Payer: WEA Trust Commercial |
$121.00
|
| Rate for Payer: Wellcare Medicare |
$12.00
|
| Rate for Payer: WMAP Medicaid |
$12.40
|
| Rate for Payer: WPS Commercial |
$162.95
|
|
|
C4 Complement
|
Facility
OP
|
$238.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
633685
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$952.00 |
| Rate for Payer: Aetna Commercial |
$214.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.68
|
| Rate for Payer: Aetna Managed Medicare |
$12.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.92
|
| Rate for Payer: Anthem Medicaid |
$12.40
|
| Rate for Payer: Anthem Medicare Advantage |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.00
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$218.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.40
|
| Rate for Payer: Dean Health Medicaid |
$12.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.00
|
| Rate for Payer: Health EOS Commercial |
$211.82
|
| Rate for Payer: HFN Commercial |
$218.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.00
|
| Rate for Payer: Managed Health Services Medicaid |
$12.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$190.40
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$218.96
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.40
|
| Rate for Payer: Quartz Beloit One Network |
$116.62
|
| Rate for Payer: Quartz Commercial |
$154.70
|
| Rate for Payer: Quartz Medicare Advantage |
$12.00
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: United Healthcare Medicaid |
$12.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.00
|
| Rate for Payer: United Healthcare PPO |
$178.50
|
| Rate for Payer: WEA Trust Commercial |
$130.90
|
| Rate for Payer: Wellcare Medicare |
$12.00
|
| Rate for Payer: WMAP Medicaid |
$12.40
|
| Rate for Payer: WPS Commercial |
$176.29
|
|
|
CA 19-9, Peritoneal Fluid
|
Facility
IP
|
$135.00
|
|
|
Service Code
|
CPT 86301
|
| Hospital Charge Code |
5791655
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$66.15 |
| Max. Negotiated Rate |
$124.20 |
| Rate for Payer: Aetna Commercial |
$121.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.55
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$124.20
|
| Rate for Payer: Health EOS Commercial |
$120.15
|
| Rate for Payer: HFN Commercial |
$124.20
|
| Rate for Payer: Multiplan Commercial |
$108.00
|
| Rate for Payer: NAPHCARE Commercial |
$81.00
|
| Rate for Payer: Preferred Network Access Commercial |
$124.20
|
| Rate for Payer: Quartz Beloit One Network |
$66.15
|
| Rate for Payer: Quartz Commercial |
$81.00
|
| Rate for Payer: WEA Trust Commercial |
$74.25
|
| Rate for Payer: WPS Commercial |
$99.99
|
|
|
CA 19-9, Peritoneal Fluid
|
Professional
|
$135.00
|
|
|
Service Code
|
CPT 86301
|
| Hospital Charge Code |
5791655
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.81 |
| Max. Negotiated Rate |
$128.25 |
| Rate for Payer: Aetna Commercial |
$128.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$116.10
|
| Rate for Payer: Aetna Managed Medicare |
$20.81
|
| Rate for Payer: Anthem Medicare Advantage |
$20.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.81
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$128.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.81
|
| Rate for Payer: Health EOS Commercial |
$122.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$73.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.81
|
| Rate for Payer: Multiplan Commercial |
$108.00
|
| Rate for Payer: Preferred Network Access Commercial |
$128.25
|
| Rate for Payer: Quartz Beloit One Network |
$59.40
|
| Rate for Payer: Quartz Commercial |
$76.95
|
| Rate for Payer: Quartz Medicare Advantage |
$20.81
|
| Rate for Payer: The Alliance Commercial |
$82.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.81
|
| Rate for Payer: WEA Trust Commercial |
$74.25
|
| Rate for Payer: WPS Commercial |
$91.56
|
|
|
CA 19-9, Peritoneal Fluid
|
Facility
OP
|
$135.00
|
|
|
Service Code
|
CPT 86301
|
| Hospital Charge Code |
5791655
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.81 |
| Max. Negotiated Rate |
$540.00 |
| Rate for Payer: Aetna Commercial |
$121.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$116.10
|
| Rate for Payer: Aetna Managed Medicare |
$20.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.54
|
| Rate for Payer: Anthem Medicaid |
$21.50
|
| Rate for Payer: Anthem Medicare Advantage |
$20.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.81
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$124.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.50
|
| Rate for Payer: Dean Health Medicaid |
$21.50
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20.81
|
| Rate for Payer: Health EOS Commercial |
$120.15
|
| Rate for Payer: HFN Commercial |
$124.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$77.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.81
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$21.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.81
|
| Rate for Payer: Managed Health Services Medicaid |
$22.36
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20.81
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20.81
|
| Rate for Payer: Multiplan Commercial |
$108.00
|
| Rate for Payer: NAPHCARE Commercial |
$31.22
|
| Rate for Payer: Preferred Network Access Commercial |
$124.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$21.50
|
| Rate for Payer: Quartz Beloit One Network |
$66.15
|
| Rate for Payer: Quartz Commercial |
$87.75
|
| Rate for Payer: Quartz Medicare Advantage |
$20.81
|
| Rate for Payer: The Alliance Commercial |
$540.00
|
| Rate for Payer: United Healthcare Medicaid |
$21.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.81
|
| Rate for Payer: United Healthcare PPO |
$101.25
|
| Rate for Payer: WEA Trust Commercial |
$74.25
|
| Rate for Payer: Wellcare Medicare |
$20.81
|
| Rate for Payer: WMAP Medicaid |
$21.50
|
| Rate for Payer: WPS Commercial |
$99.99
|
|
|
CABLE 1.0 DBL NEEDLE W CRIMP 498.821S
|
Facility
IP
|
$4,961.00
|
|
| Hospital Charge Code |
2966154
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,430.89 |
| Max. Negotiated Rate |
$4,564.12 |
| Rate for Payer: Aetna Commercial |
$4,464.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,629.33
|
| Rate for Payer: Cash Price |
$1,488.30
|
| Rate for Payer: Cigna Commercial |
$4,564.12
|
| Rate for Payer: Health EOS Commercial |
$4,415.29
|
| Rate for Payer: HFN Commercial |
$4,564.12
|
| Rate for Payer: Multiplan Commercial |
$3,968.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,976.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,564.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,430.89
|
| Rate for Payer: Quartz Commercial |
$2,976.60
|
| Rate for Payer: WEA Trust Commercial |
$2,728.55
|
| Rate for Payer: WPS Commercial |
$3,674.61
|
|
|
CABLE 1.0 DBL NEEDLE W CRIMP 498.821S
|
Facility
OP
|
$4,961.00
|
|
| Hospital Charge Code |
2966154
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,389.08 |
| Max. Negotiated Rate |
$19,844.00 |
| Rate for Payer: Aetna Commercial |
$4,464.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,266.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,389.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,224.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,480.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,381.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,629.33
|
| Rate for Payer: Cash Price |
$1,488.30
|
| Rate for Payer: Cigna Commercial |
$4,564.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,776.18
|
| Rate for Payer: Health EOS Commercial |
$4,415.29
|
| Rate for Payer: HFN Commercial |
$4,564.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,720.75
|
| Rate for Payer: Multiplan Commercial |
$3,968.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,976.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,564.12
|
| Rate for Payer: Quartz Beloit One Network |
$2,430.89
|
| Rate for Payer: Quartz Commercial |
$3,224.65
|
| Rate for Payer: Quartz Medicare Advantage |
$2,976.60
|
| Rate for Payer: The Alliance Commercial |
$19,844.00
|
| Rate for Payer: WEA Trust Commercial |
$2,728.55
|
| Rate for Payer: WPS Commercial |
$3,674.61
|
|
|
CABLE 1.6 BEADED VITALLIUM 6704-0-420
|
Facility
OP
|
$1,168.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
4520353
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$327.04 |
| Max. Negotiated Rate |
$1,196.24 |
| Rate for Payer: Aetna Commercial |
$1,051.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,004.48
|
| Rate for Payer: Aetna Managed Medicare |
$327.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$759.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$584.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$560.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$619.04
|
| Rate for Payer: Cash Price |
$350.40
|
| Rate for Payer: Cash Price |
$350.40
|
| Rate for Payer: Cigna Commercial |
$1,074.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$653.61
|
| Rate for Payer: Health EOS Commercial |
$1,039.52
|
| Rate for Payer: HFN Commercial |
$1,074.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$876.00
|
| Rate for Payer: Multiplan Commercial |
$934.40
|
| Rate for Payer: NAPHCARE Commercial |
$700.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,074.56
|
| Rate for Payer: Quartz Beloit One Network |
$572.32
|
| Rate for Payer: Quartz Commercial |
$759.20
|
| Rate for Payer: Quartz Medicare Advantage |
$700.80
|
| Rate for Payer: The Alliance Commercial |
$1,196.24
|
| Rate for Payer: WEA Trust Commercial |
$642.40
|
| Rate for Payer: WPS Commercial |
$865.14
|
|
|
CABLE 1.6 BEADED VITALLIUM 6704-0-420
|
Facility
IP
|
$1,168.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
4520353
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$572.32 |
| Max. Negotiated Rate |
$1,074.56 |
| Rate for Payer: Aetna Commercial |
$1,051.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$619.04
|
| Rate for Payer: Cash Price |
$350.40
|
| Rate for Payer: Cigna Commercial |
$1,074.56
|
| Rate for Payer: Health EOS Commercial |
$1,039.52
|
| Rate for Payer: HFN Commercial |
$1,074.56
|
| Rate for Payer: Multiplan Commercial |
$934.40
|
| Rate for Payer: NAPHCARE Commercial |
$700.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,074.56
|
| Rate for Payer: Quartz Beloit One Network |
$572.32
|
| Rate for Payer: Quartz Commercial |
$700.80
|
| Rate for Payer: WEA Trust Commercial |
$642.40
|
| Rate for Payer: WPS Commercial |
$865.14
|
|
|
CABLE 1.6MM X 750MM 6704-8-016
|
Facility
IP
|
$2,564.00
|
|
| Hospital Charge Code |
2966072
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,256.36 |
| Max. Negotiated Rate |
$2,358.88 |
| Rate for Payer: Aetna Commercial |
$2,307.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,358.92
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cigna Commercial |
$2,358.88
|
| Rate for Payer: Health EOS Commercial |
$2,281.96
|
| Rate for Payer: HFN Commercial |
$2,358.88
|
| Rate for Payer: Multiplan Commercial |
$2,051.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,538.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,358.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,256.36
|
| Rate for Payer: Quartz Commercial |
$1,538.40
|
| Rate for Payer: WEA Trust Commercial |
$1,410.20
|
| Rate for Payer: WPS Commercial |
$1,899.15
|
|
|
CABLE 1.6MM X 750MM 6704-8-016
|
Facility
OP
|
$2,564.00
|
|
| Hospital Charge Code |
2966072
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$717.92 |
| Max. Negotiated Rate |
$10,256.00 |
| Rate for Payer: Aetna Commercial |
$2,307.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,205.04
|
| Rate for Payer: Aetna Managed Medicare |
$717.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,666.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,282.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,230.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,358.92
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cigna Commercial |
$2,358.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,434.81
|
| Rate for Payer: Health EOS Commercial |
$2,281.96
|
| Rate for Payer: HFN Commercial |
$2,358.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,923.00
|
| Rate for Payer: Multiplan Commercial |
$2,051.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,538.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,358.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,256.36
|
| Rate for Payer: Quartz Commercial |
$1,666.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,538.40
|
| Rate for Payer: The Alliance Commercial |
$10,256.00
|
| Rate for Payer: WEA Trust Commercial |
$1,410.20
|
| Rate for Payer: WPS Commercial |
$1,899.15
|
|
|
CABLE 1.8 X 635MM GTR CABLE-READY 2232-05-18
|
Facility
IP
|
$3,660.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
3687501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,793.40 |
| Max. Negotiated Rate |
$3,367.20 |
| Rate for Payer: Aetna Commercial |
$3,294.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,939.80
|
| Rate for Payer: Cash Price |
$1,098.00
|
| Rate for Payer: Cigna Commercial |
$3,367.20
|
| Rate for Payer: Health EOS Commercial |
$3,257.40
|
| Rate for Payer: HFN Commercial |
$3,367.20
|
| Rate for Payer: Multiplan Commercial |
$2,928.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,196.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,367.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,793.40
|
| Rate for Payer: Quartz Commercial |
$2,196.00
|
| Rate for Payer: WEA Trust Commercial |
$2,013.00
|
| Rate for Payer: WPS Commercial |
$2,710.96
|
|
|
CABLE 1.8 X 635MM GTR CABLE-READY 2232-05-18
|
Facility
OP
|
$3,660.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
3687501
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,024.80 |
| Max. Negotiated Rate |
$3,367.20 |
| Rate for Payer: Aetna Commercial |
$3,294.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,147.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,024.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,379.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,830.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,756.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,939.80
|
| Rate for Payer: Cash Price |
$1,098.00
|
| Rate for Payer: Cash Price |
$1,098.00
|
| Rate for Payer: Cigna Commercial |
$3,367.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,048.14
|
| Rate for Payer: Health EOS Commercial |
$3,257.40
|
| Rate for Payer: HFN Commercial |
$3,367.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,745.00
|
| Rate for Payer: Multiplan Commercial |
$2,928.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,196.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,367.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,793.40
|
| Rate for Payer: Quartz Commercial |
$2,379.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,196.00
|
| Rate for Payer: The Alliance Commercial |
$1,196.24
|
| Rate for Payer: WEA Trust Commercial |
$2,013.00
|
| Rate for Payer: WPS Commercial |
$2,710.96
|
|
|
CABLE 2.0MM BEADED & SLEEVE VITALLIUM 6704-0-520
|
Facility
OP
|
$4,180.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
4520355
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,170.40 |
| Max. Negotiated Rate |
$3,845.60 |
| Rate for Payer: Aetna Commercial |
$3,762.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,594.80
|
| Rate for Payer: Aetna Managed Medicare |
$1,170.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,717.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,090.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,006.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,215.40
|
| Rate for Payer: Cash Price |
$1,254.00
|
| Rate for Payer: Cash Price |
$1,254.00
|
| Rate for Payer: Cigna Commercial |
$3,845.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,339.13
|
| Rate for Payer: Health EOS Commercial |
$3,720.20
|
| Rate for Payer: HFN Commercial |
$3,845.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,135.00
|
| Rate for Payer: Multiplan Commercial |
$3,344.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,508.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,845.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,048.20
|
| Rate for Payer: Quartz Commercial |
$2,717.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,508.00
|
| Rate for Payer: The Alliance Commercial |
$1,196.24
|
| Rate for Payer: WEA Trust Commercial |
$2,299.00
|
| Rate for Payer: WPS Commercial |
$3,096.13
|
|
|
CABLE 2.0MM BEADED & SLEEVE VITALLIUM 6704-0-520
|
Facility
IP
|
$4,180.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
4520355
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,048.20 |
| Max. Negotiated Rate |
$3,845.60 |
| Rate for Payer: Aetna Commercial |
$3,762.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,215.40
|
| Rate for Payer: Cash Price |
$1,254.00
|
| Rate for Payer: Cigna Commercial |
$3,845.60
|
| Rate for Payer: Health EOS Commercial |
$3,720.20
|
| Rate for Payer: HFN Commercial |
$3,845.60
|
| Rate for Payer: Multiplan Commercial |
$3,344.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,508.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,845.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,048.20
|
| Rate for Payer: Quartz Commercial |
$2,508.00
|
| Rate for Payer: WEA Trust Commercial |
$2,299.00
|
| Rate for Payer: WPS Commercial |
$3,096.13
|
|
|
CABLE 2.0MM X 750MM 6704-8-240
|
Facility
IP
|
$2,564.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2966073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,256.36 |
| Max. Negotiated Rate |
$2,358.88 |
| Rate for Payer: Aetna Commercial |
$2,307.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,358.92
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cigna Commercial |
$2,358.88
|
| Rate for Payer: Health EOS Commercial |
$2,281.96
|
| Rate for Payer: HFN Commercial |
$2,358.88
|
| Rate for Payer: Multiplan Commercial |
$2,051.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,538.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,358.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,256.36
|
| Rate for Payer: Quartz Commercial |
$1,538.40
|
| Rate for Payer: WEA Trust Commercial |
$1,410.20
|
| Rate for Payer: WPS Commercial |
$1,899.15
|
|
|
CABLE 2.0MM X 750MM 6704-8-240
|
Facility
OP
|
$2,564.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2966073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$717.92 |
| Max. Negotiated Rate |
$2,358.88 |
| Rate for Payer: Aetna Commercial |
$2,307.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,205.04
|
| Rate for Payer: Aetna Managed Medicare |
$717.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,666.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,282.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,230.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,358.92
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cigna Commercial |
$2,358.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,434.81
|
| Rate for Payer: Health EOS Commercial |
$2,281.96
|
| Rate for Payer: HFN Commercial |
$2,358.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,923.00
|
| Rate for Payer: Multiplan Commercial |
$2,051.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,538.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,358.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,256.36
|
| Rate for Payer: Quartz Commercial |
$1,666.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,538.40
|
| Rate for Payer: The Alliance Commercial |
$1,196.24
|
| Rate for Payer: WEA Trust Commercial |
$1,410.20
|
| Rate for Payer: WPS Commercial |
$1,899.15
|
|
|
CABLE/CRIMP 1.7MM SYNTHES 298.801.01S
|
Facility
OP
|
$4,957.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2966155
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,196.24 |
| Max. Negotiated Rate |
$4,560.44 |
| Rate for Payer: Aetna Commercial |
$4,461.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,263.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,387.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,222.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,478.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,379.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,627.21
|
| Rate for Payer: Cash Price |
$1,487.10
|
| Rate for Payer: Cash Price |
$1,487.10
|
| Rate for Payer: Cigna Commercial |
$4,560.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,773.94
|
| Rate for Payer: Health EOS Commercial |
$4,411.73
|
| Rate for Payer: HFN Commercial |
$4,560.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,717.75
|
| Rate for Payer: Multiplan Commercial |
$3,965.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,974.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,560.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,428.93
|
| Rate for Payer: Quartz Commercial |
$3,222.05
|
| Rate for Payer: Quartz Medicare Advantage |
$2,974.20
|
| Rate for Payer: The Alliance Commercial |
$1,196.24
|
| Rate for Payer: WEA Trust Commercial |
$2,726.35
|
| Rate for Payer: WPS Commercial |
$3,671.65
|
|
|
CABLE/CRIMP 1.7MM SYNTHES 298.801.01S
|
Facility
IP
|
$4,957.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2966155
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,428.93 |
| Max. Negotiated Rate |
$4,560.44 |
| Rate for Payer: Aetna Commercial |
$4,461.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,627.21
|
| Rate for Payer: Cash Price |
$1,487.10
|
| Rate for Payer: Cigna Commercial |
$4,560.44
|
| Rate for Payer: Health EOS Commercial |
$4,411.73
|
| Rate for Payer: HFN Commercial |
$4,560.44
|
| Rate for Payer: Multiplan Commercial |
$3,965.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,974.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,560.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,428.93
|
| Rate for Payer: Quartz Commercial |
$2,974.20
|
| Rate for Payer: WEA Trust Commercial |
$2,726.35
|
| Rate for Payer: WPS Commercial |
$3,671.65
|
|
|
CABLE INTEGRAL LONG GTR W/4 23 X 121MM 2232-02-05
|
Facility
IP
|
$13,052.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
4147200
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,395.48 |
| Max. Negotiated Rate |
$12,007.84 |
| Rate for Payer: Aetna Commercial |
$11,746.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,917.56
|
| Rate for Payer: Cash Price |
$3,915.60
|
| Rate for Payer: Cigna Commercial |
$12,007.84
|
| Rate for Payer: Health EOS Commercial |
$11,616.28
|
| Rate for Payer: HFN Commercial |
$12,007.84
|
| Rate for Payer: Multiplan Commercial |
$10,441.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,831.20
|
| Rate for Payer: Preferred Network Access Commercial |
$12,007.84
|
| Rate for Payer: Quartz Beloit One Network |
$6,395.48
|
| Rate for Payer: Quartz Commercial |
$7,831.20
|
| Rate for Payer: WEA Trust Commercial |
$7,178.60
|
| Rate for Payer: WPS Commercial |
$9,667.62
|
|
|
CABLE INTEGRAL LONG GTR W/4 23 X 121MM 2232-02-05
|
Facility
OP
|
$13,052.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
4147200
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,196.24 |
| Max. Negotiated Rate |
$12,007.84 |
| Rate for Payer: Aetna Commercial |
$11,746.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,224.72
|
| Rate for Payer: Aetna Managed Medicare |
$3,654.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,483.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,526.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,264.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,917.56
|
| Rate for Payer: Cash Price |
$3,915.60
|
| Rate for Payer: Cash Price |
$3,915.60
|
| Rate for Payer: Cigna Commercial |
$12,007.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,303.90
|
| Rate for Payer: Health EOS Commercial |
$11,616.28
|
| Rate for Payer: HFN Commercial |
$12,007.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,789.00
|
| Rate for Payer: Multiplan Commercial |
$10,441.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,831.20
|
| Rate for Payer: Preferred Network Access Commercial |
$12,007.84
|
| Rate for Payer: Quartz Beloit One Network |
$6,395.48
|
| Rate for Payer: Quartz Commercial |
$8,483.80
|
| Rate for Payer: Quartz Medicare Advantage |
$7,831.20
|
| Rate for Payer: The Alliance Commercial |
$1,196.24
|
| Rate for Payer: WEA Trust Commercial |
$7,178.60
|
| Rate for Payer: WPS Commercial |
$9,667.62
|
|
|
CABLE INTEGRAL LONG GTR W/4 23 X 232MM 2232-02-06
|
Facility
IP
|
$20,359.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
3697509
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,975.91 |
| Max. Negotiated Rate |
$18,730.28 |
| Rate for Payer: Aetna Commercial |
$18,323.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,790.27
|
| Rate for Payer: Cash Price |
$6,107.70
|
| Rate for Payer: Cigna Commercial |
$18,730.28
|
| Rate for Payer: Health EOS Commercial |
$18,119.51
|
| Rate for Payer: HFN Commercial |
$18,730.28
|
| Rate for Payer: Multiplan Commercial |
$16,287.20
|
| Rate for Payer: NAPHCARE Commercial |
$12,215.40
|
| Rate for Payer: Preferred Network Access Commercial |
$18,730.28
|
| Rate for Payer: Quartz Beloit One Network |
$9,975.91
|
| Rate for Payer: Quartz Commercial |
$12,215.40
|
| Rate for Payer: WEA Trust Commercial |
$11,197.45
|
| Rate for Payer: WPS Commercial |
$15,079.91
|
|
