|
Brucella IgM
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT 86622
|
| Hospital Charge Code |
5383344
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.29 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Aetna Managed Medicare |
$9.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.25
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.42
|
| Rate for Payer: Anthem Medicare Advantage |
$9.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.29
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9.29
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.29
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9.29
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9.29
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: NAPHCARE Commercial |
$13.93
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$60.16
|
| Rate for Payer: Quartz Medicare Advantage |
$9.29
|
| Rate for Payer: The Alliance Commercial |
$37.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.29
|
| Rate for Payer: United Healthcare PPO |
$69.42
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: Wellcare Medicare |
$9.29
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
|
Brucella IgM
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
CPT 86622
|
| Hospital Charge Code |
5383344
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.29 |
| Max. Negotiated Rate |
$87.93 |
| Rate for Payer: Aetna Commercial |
$87.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Aetna Managed Medicare |
$9.29
|
| Rate for Payer: Anthem Medicare Advantage |
$9.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.29
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$87.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$46.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.29
|
| Rate for Payer: Health EOS Commercial |
$84.23
|
| Rate for Payer: HFN Commercial |
$87.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$32.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.29
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: NAPHCARE Commercial |
$13.93
|
| Rate for Payer: Preferred Network Access Commercial |
$87.93
|
| Rate for Payer: Quartz Beloit One Network |
$40.73
|
| Rate for Payer: Quartz Commercial |
$52.76
|
| Rate for Payer: Quartz Medicare Advantage |
$9.29
|
| Rate for Payer: The Alliance Commercial |
$36.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.29
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$40.86
|
|
|
Brucella IgM
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 86622
|
| Hospital Charge Code |
5383344
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$45.35 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$55.54
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
|
BRUSH CHANNEL CLEANING
|
Facility
|
OP
|
$63.00
|
|
| Hospital Charge Code |
2972557
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$18.35 |
| Max. Negotiated Rate |
$60.28 |
| Rate for Payer: Aetna Commercial |
$58.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.35
|
| Rate for Payer: Aetna Managed Medicare |
$18.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$42.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.73
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$60.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.67
|
| Rate for Payer: Health EOS Commercial |
$58.31
|
| Rate for Payer: HFN Commercial |
$60.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.14
|
| Rate for Payer: Multiplan Commercial |
$52.42
|
| Rate for Payer: NAPHCARE Commercial |
$39.31
|
| Rate for Payer: Preferred Network Access Commercial |
$60.28
|
| Rate for Payer: Quartz Beloit One Network |
$32.10
|
| Rate for Payer: Quartz Commercial |
$42.59
|
| Rate for Payer: Quartz Medicare Advantage |
$39.31
|
| Rate for Payer: The Alliance Commercial |
$32.76
|
| Rate for Payer: WEA Trust Commercial |
$36.04
|
| Rate for Payer: WPS Commercial |
$48.53
|
|
|
BRUSH CHANNEL CLEANING
|
Facility
|
IP
|
$63.00
|
|
| Hospital Charge Code |
2972557
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$32.10 |
| Max. Negotiated Rate |
$60.28 |
| Rate for Payer: Aetna Commercial |
$58.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.73
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$60.28
|
| Rate for Payer: Health EOS Commercial |
$58.31
|
| Rate for Payer: HFN Commercial |
$60.28
|
| Rate for Payer: Multiplan Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$60.28
|
| Rate for Payer: Quartz Beloit One Network |
$32.10
|
| Rate for Payer: Quartz Commercial |
$39.31
|
| Rate for Payer: WEA Trust Commercial |
$36.04
|
| Rate for Payer: WPS Commercial |
$48.53
|
|
|
BRUSH CYTOLOGY 3FR X 115CM CYB-3
|
Facility
|
IP
|
$2,548.00
|
|
| Hospital Charge Code |
2965411
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,298.46 |
| Max. Negotiated Rate |
$2,437.93 |
| Rate for Payer: Aetna Commercial |
$2,384.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,278.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,404.46
|
| Rate for Payer: Cash Price |
$764.40
|
| Rate for Payer: Cigna Commercial |
$2,437.93
|
| Rate for Payer: Health EOS Commercial |
$2,358.43
|
| Rate for Payer: HFN Commercial |
$2,437.93
|
| Rate for Payer: Multiplan Commercial |
$2,119.94
|
| Rate for Payer: Preferred Network Access Commercial |
$2,437.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,298.46
|
| Rate for Payer: Quartz Commercial |
$1,589.95
|
| Rate for Payer: WEA Trust Commercial |
$1,457.46
|
| Rate for Payer: WPS Commercial |
$1,962.72
|
|
|
BRUSH CYTOLOGY 3FR X 115CM CYB-3
|
Facility
|
OP
|
$2,548.00
|
|
| Hospital Charge Code |
2965411
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$741.98 |
| Max. Negotiated Rate |
$2,437.93 |
| Rate for Payer: Aetna Commercial |
$2,384.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,278.93
|
| Rate for Payer: Aetna Managed Medicare |
$741.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,722.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,324.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,271.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,404.46
|
| Rate for Payer: Cash Price |
$764.40
|
| Rate for Payer: Cigna Commercial |
$2,437.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,482.94
|
| Rate for Payer: Health EOS Commercial |
$2,358.43
|
| Rate for Payer: HFN Commercial |
$2,437.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,987.44
|
| Rate for Payer: Multiplan Commercial |
$2,119.94
|
| Rate for Payer: NAPHCARE Commercial |
$1,589.95
|
| Rate for Payer: Preferred Network Access Commercial |
$2,437.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,298.46
|
| Rate for Payer: Quartz Commercial |
$1,722.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,589.95
|
| Rate for Payer: The Alliance Commercial |
$1,324.96
|
| Rate for Payer: WEA Trust Commercial |
$1,457.46
|
| Rate for Payer: WPS Commercial |
$1,962.72
|
|
|
BRUSH CYTOLOGY RX 4500
|
Facility
|
OP
|
$1,631.00
|
|
| Hospital Charge Code |
2972568
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$474.95 |
| Max. Negotiated Rate |
$1,560.54 |
| Rate for Payer: Aetna Commercial |
$1,526.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,458.77
|
| Rate for Payer: Aetna Managed Medicare |
$474.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,102.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$848.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$814.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$899.01
|
| Rate for Payer: Cash Price |
$489.30
|
| Rate for Payer: Cigna Commercial |
$1,560.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$949.24
|
| Rate for Payer: Health EOS Commercial |
$1,509.65
|
| Rate for Payer: HFN Commercial |
$1,560.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,272.18
|
| Rate for Payer: Multiplan Commercial |
$1,356.99
|
| Rate for Payer: NAPHCARE Commercial |
$1,017.74
|
| Rate for Payer: Preferred Network Access Commercial |
$1,560.54
|
| Rate for Payer: Quartz Beloit One Network |
$831.16
|
| Rate for Payer: Quartz Commercial |
$1,102.56
|
| Rate for Payer: Quartz Medicare Advantage |
$1,017.74
|
| Rate for Payer: The Alliance Commercial |
$848.12
|
| Rate for Payer: WEA Trust Commercial |
$932.93
|
| Rate for Payer: WPS Commercial |
$1,256.36
|
|
|
BRUSH CYTOLOGY RX 4500
|
Facility
|
IP
|
$1,631.00
|
|
| Hospital Charge Code |
2972568
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$831.16 |
| Max. Negotiated Rate |
$1,560.54 |
| Rate for Payer: Aetna Commercial |
$1,526.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,458.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$899.01
|
| Rate for Payer: Cash Price |
$489.30
|
| Rate for Payer: Cigna Commercial |
$1,560.54
|
| Rate for Payer: Health EOS Commercial |
$1,509.65
|
| Rate for Payer: HFN Commercial |
$1,560.54
|
| Rate for Payer: Multiplan Commercial |
$1,356.99
|
| Rate for Payer: Preferred Network Access Commercial |
$1,560.54
|
| Rate for Payer: Quartz Beloit One Network |
$831.16
|
| Rate for Payer: Quartz Commercial |
$1,017.74
|
| Rate for Payer: WEA Trust Commercial |
$932.93
|
| Rate for Payer: WPS Commercial |
$1,256.36
|
|
|
BRUSH ENDO CYTOLOGY G22409
|
Facility
|
OP
|
$400.00
|
|
| Hospital Charge Code |
2973004
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.48 |
| Max. Negotiated Rate |
$382.72 |
| Rate for Payer: Aetna Commercial |
$374.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$357.76
|
| Rate for Payer: Aetna Managed Medicare |
$116.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$270.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$208.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$199.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$220.48
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$382.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$232.80
|
| Rate for Payer: Health EOS Commercial |
$370.24
|
| Rate for Payer: HFN Commercial |
$382.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$312.00
|
| Rate for Payer: Multiplan Commercial |
$332.80
|
| Rate for Payer: NAPHCARE Commercial |
$249.60
|
| Rate for Payer: Preferred Network Access Commercial |
$382.72
|
| Rate for Payer: Quartz Beloit One Network |
$203.84
|
| Rate for Payer: Quartz Commercial |
$270.40
|
| Rate for Payer: Quartz Medicare Advantage |
$249.60
|
| Rate for Payer: The Alliance Commercial |
$208.00
|
| Rate for Payer: WEA Trust Commercial |
$228.80
|
| Rate for Payer: WPS Commercial |
$308.12
|
|
|
BRUSH ENDO CYTOLOGY G22409
|
Facility
|
IP
|
$400.00
|
|
| Hospital Charge Code |
2973004
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$203.84 |
| Max. Negotiated Rate |
$382.72 |
| Rate for Payer: Aetna Commercial |
$374.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$357.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$220.48
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$382.72
|
| Rate for Payer: Health EOS Commercial |
$370.24
|
| Rate for Payer: HFN Commercial |
$382.72
|
| Rate for Payer: Multiplan Commercial |
$332.80
|
| Rate for Payer: Preferred Network Access Commercial |
$382.72
|
| Rate for Payer: Quartz Beloit One Network |
$203.84
|
| Rate for Payer: Quartz Commercial |
$249.60
|
| Rate for Payer: WEA Trust Commercial |
$228.80
|
| Rate for Payer: WPS Commercial |
$308.12
|
|
|
BRUSH GI CYTOLOGY G22108
|
Facility
|
IP
|
$405.00
|
|
| Hospital Charge Code |
2973043
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$206.39 |
| Max. Negotiated Rate |
$387.50 |
| Rate for Payer: Aetna Commercial |
$379.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.24
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$387.50
|
| Rate for Payer: Health EOS Commercial |
$374.87
|
| Rate for Payer: HFN Commercial |
$387.50
|
| Rate for Payer: Multiplan Commercial |
$336.96
|
| Rate for Payer: Preferred Network Access Commercial |
$387.50
|
| Rate for Payer: Quartz Beloit One Network |
$206.39
|
| Rate for Payer: Quartz Commercial |
$252.72
|
| Rate for Payer: WEA Trust Commercial |
$231.66
|
| Rate for Payer: WPS Commercial |
$311.97
|
|
|
BRUSH GI CYTOLOGY G22108
|
Facility
|
OP
|
$405.00
|
|
| Hospital Charge Code |
2973043
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$117.94 |
| Max. Negotiated Rate |
$387.50 |
| Rate for Payer: Aetna Commercial |
$379.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.23
|
| Rate for Payer: Aetna Managed Medicare |
$117.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$273.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$210.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$202.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.24
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$387.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$235.71
|
| Rate for Payer: Health EOS Commercial |
$374.87
|
| Rate for Payer: HFN Commercial |
$387.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$315.90
|
| Rate for Payer: Multiplan Commercial |
$336.96
|
| Rate for Payer: NAPHCARE Commercial |
$252.72
|
| Rate for Payer: Preferred Network Access Commercial |
$387.50
|
| Rate for Payer: Quartz Beloit One Network |
$206.39
|
| Rate for Payer: Quartz Commercial |
$273.78
|
| Rate for Payer: Quartz Medicare Advantage |
$252.72
|
| Rate for Payer: The Alliance Commercial |
$210.60
|
| Rate for Payer: WEA Trust Commercial |
$231.66
|
| Rate for Payer: WPS Commercial |
$311.97
|
|
|
BRUSH TIP FEMORAL CANAL 0210-004-000
|
Facility
|
OP
|
$456.00
|
|
| Hospital Charge Code |
2963164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.79 |
| Max. Negotiated Rate |
$436.30 |
| Rate for Payer: Aetna Commercial |
$426.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$407.85
|
| Rate for Payer: Aetna Managed Medicare |
$132.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$308.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$237.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$227.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.35
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$436.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$265.39
|
| Rate for Payer: Health EOS Commercial |
$422.07
|
| Rate for Payer: HFN Commercial |
$436.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$355.68
|
| Rate for Payer: Multiplan Commercial |
$379.39
|
| Rate for Payer: NAPHCARE Commercial |
$284.54
|
| Rate for Payer: Preferred Network Access Commercial |
$436.30
|
| Rate for Payer: Quartz Beloit One Network |
$232.38
|
| Rate for Payer: Quartz Commercial |
$308.26
|
| Rate for Payer: Quartz Medicare Advantage |
$284.54
|
| Rate for Payer: The Alliance Commercial |
$237.12
|
| Rate for Payer: WEA Trust Commercial |
$260.83
|
| Rate for Payer: WPS Commercial |
$351.26
|
|
|
BRUSH TIP FEMORAL CANAL 0210-004-000
|
Facility
|
IP
|
$456.00
|
|
| Hospital Charge Code |
2963164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$232.38 |
| Max. Negotiated Rate |
$436.30 |
| Rate for Payer: Aetna Commercial |
$426.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$407.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.35
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna Commercial |
$436.30
|
| Rate for Payer: Health EOS Commercial |
$422.07
|
| Rate for Payer: HFN Commercial |
$436.30
|
| Rate for Payer: Multiplan Commercial |
$379.39
|
| Rate for Payer: Preferred Network Access Commercial |
$436.30
|
| Rate for Payer: Quartz Beloit One Network |
$232.38
|
| Rate for Payer: Quartz Commercial |
$284.54
|
| Rate for Payer: WEA Trust Commercial |
$260.83
|
| Rate for Payer: WPS Commercial |
$351.26
|
|
|
BRUSH ULTRADEX SCRUB
|
Facility
|
IP
|
$22.00
|
|
| Hospital Charge Code |
2963141
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$13.73
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
BRUSH ULTRADEX SCRUB
|
Facility
|
OP
|
$22.00
|
|
| Hospital Charge Code |
2963141
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.13
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna Commercial |
$21.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.80
|
| Rate for Payer: Health EOS Commercial |
$20.36
|
| Rate for Payer: HFN Commercial |
$21.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.16
|
| Rate for Payer: Multiplan Commercial |
$18.30
|
| Rate for Payer: NAPHCARE Commercial |
$13.73
|
| Rate for Payer: Preferred Network Access Commercial |
$21.05
|
| Rate for Payer: Quartz Beloit One Network |
$11.21
|
| Rate for Payer: Quartz Commercial |
$14.87
|
| Rate for Payer: Quartz Medicare Advantage |
$13.73
|
| Rate for Payer: The Alliance Commercial |
$11.44
|
| Rate for Payer: WEA Trust Commercial |
$12.58
|
| Rate for Payer: WPS Commercial |
$16.95
|
|
|
B-SCAN, OPH US DX 76512
|
Professional
|
Both
|
$508.00
|
|
|
Service Code
|
CPT 76512
|
| Hospital Charge Code |
6180170
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$48.93 |
| Max. Negotiated Rate |
$501.90 |
| Rate for Payer: Aetna Commercial |
$501.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$454.36
|
| Rate for Payer: Aetna Managed Medicare |
$48.93
|
| Rate for Payer: Anthem Medicare Advantage |
$48.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$48.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$48.93
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$501.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$264.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.93
|
| Rate for Payer: Health EOS Commercial |
$480.77
|
| Rate for Payer: HFN Commercial |
$501.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$175.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$175.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$48.93
|
| Rate for Payer: Multiplan Commercial |
$422.66
|
| Rate for Payer: NAPHCARE Commercial |
$73.40
|
| Rate for Payer: Preferred Network Access Commercial |
$501.90
|
| Rate for Payer: Quartz Beloit One Network |
$232.46
|
| Rate for Payer: Quartz Commercial |
$301.14
|
| Rate for Payer: Quartz Medicare Advantage |
$48.93
|
| Rate for Payer: The Alliance Commercial |
$185.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.93
|
| Rate for Payer: WEA Trust Commercial |
$290.58
|
| Rate for Payer: WPS Commercial |
$244.66
|
|
|
B-SCAN, OPH US DX 76512-26
|
Professional
|
Both
|
$508.00
|
|
|
Service Code
|
CPT 76512 26
|
| Hospital Charge Code |
6194961
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.86 |
| Max. Negotiated Rate |
$501.90 |
| Rate for Payer: Aetna Commercial |
$501.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$454.36
|
| Rate for Payer: Aetna Managed Medicare |
$30.86
|
| Rate for Payer: Anthem Medicare Advantage |
$30.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.86
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cash Price |
$152.40
|
| Rate for Payer: Cigna Commercial |
$501.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$264.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.86
|
| Rate for Payer: Health EOS Commercial |
$480.77
|
| Rate for Payer: HFN Commercial |
$501.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$110.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$110.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.86
|
| Rate for Payer: Multiplan Commercial |
$422.66
|
| Rate for Payer: NAPHCARE Commercial |
$46.29
|
| Rate for Payer: Preferred Network Access Commercial |
$501.90
|
| Rate for Payer: Quartz Beloit One Network |
$232.46
|
| Rate for Payer: Quartz Commercial |
$301.14
|
| Rate for Payer: Quartz Medicare Advantage |
$30.86
|
| Rate for Payer: The Alliance Commercial |
$117.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.86
|
| Rate for Payer: WEA Trust Commercial |
$290.58
|
| Rate for Payer: WPS Commercial |
$154.28
|
|
|
B-SCAN, OPH US DX, BILAT 76512-50
|
Professional
|
Both
|
$1,014.00
|
|
|
Service Code
|
CPT 76512 50
|
| Hospital Charge Code |
6210132
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$175.08 |
| Max. Negotiated Rate |
$1,001.83 |
| Rate for Payer: Aetna Commercial |
$1,001.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$906.92
|
| Rate for Payer: Cash Price |
$304.20
|
| Rate for Payer: Cash Price |
$304.20
|
| Rate for Payer: Cash Price |
$304.20
|
| Rate for Payer: Cigna Commercial |
$1,001.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$527.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$632.74
|
| Rate for Payer: Health EOS Commercial |
$959.65
|
| Rate for Payer: HFN Commercial |
$1,001.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$175.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$175.08
|
| Rate for Payer: Multiplan Commercial |
$843.65
|
| Rate for Payer: Preferred Network Access Commercial |
$1,001.83
|
| Rate for Payer: Quartz Beloit One Network |
$464.01
|
| Rate for Payer: Quartz Commercial |
$601.10
|
| Rate for Payer: The Alliance Commercial |
$527.28
|
| Rate for Payer: WEA Trust Commercial |
$580.01
|
| Rate for Payer: WPS Commercial |
$781.08
|
|
|
BUDDY LOOPS 1 BLACK #9272-78
|
Facility
|
IP
|
$82.00
|
|
| Hospital Charge Code |
2970950
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$41.79 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.20
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$78.46
|
| Rate for Payer: Health EOS Commercial |
$75.90
|
| Rate for Payer: HFN Commercial |
$78.46
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: Preferred Network Access Commercial |
$78.46
|
| Rate for Payer: Quartz Beloit One Network |
$41.79
|
| Rate for Payer: Quartz Commercial |
$51.17
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$63.16
|
|
|
BUDDY LOOPS 1 BLACK #9272-78
|
Facility
|
OP
|
$82.00
|
|
| Hospital Charge Code |
2970950
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$23.88 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Aetna Managed Medicare |
$23.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.20
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$78.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.72
|
| Rate for Payer: Health EOS Commercial |
$75.90
|
| Rate for Payer: HFN Commercial |
$78.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.96
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: NAPHCARE Commercial |
$51.17
|
| Rate for Payer: Preferred Network Access Commercial |
$78.46
|
| Rate for Payer: Quartz Beloit One Network |
$41.79
|
| Rate for Payer: Quartz Commercial |
$55.43
|
| Rate for Payer: Quartz Medicare Advantage |
$51.17
|
| Rate for Payer: The Alliance Commercial |
$42.64
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$63.16
|
|
|
BUDDY STRAP BLACK #927277
|
Facility
|
OP
|
$66.00
|
|
| Hospital Charge Code |
2970857
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$19.22 |
| Max. Negotiated Rate |
$63.15 |
| Rate for Payer: Aetna Commercial |
$61.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.03
|
| Rate for Payer: Aetna Managed Medicare |
$19.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.38
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$63.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.41
|
| Rate for Payer: Health EOS Commercial |
$61.09
|
| Rate for Payer: HFN Commercial |
$63.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.48
|
| Rate for Payer: Multiplan Commercial |
$54.91
|
| Rate for Payer: NAPHCARE Commercial |
$41.18
|
| Rate for Payer: Preferred Network Access Commercial |
$63.15
|
| Rate for Payer: Quartz Beloit One Network |
$33.63
|
| Rate for Payer: Quartz Commercial |
$44.62
|
| Rate for Payer: Quartz Medicare Advantage |
$41.18
|
| Rate for Payer: The Alliance Commercial |
$34.32
|
| Rate for Payer: WEA Trust Commercial |
$37.75
|
| Rate for Payer: WPS Commercial |
$50.84
|
|
|
BUDDY STRAP BLACK #927277
|
Facility
|
IP
|
$66.00
|
|
| Hospital Charge Code |
2970857
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$33.63 |
| Max. Negotiated Rate |
$63.15 |
| Rate for Payer: Aetna Commercial |
$61.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.38
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$63.15
|
| Rate for Payer: Health EOS Commercial |
$61.09
|
| Rate for Payer: HFN Commercial |
$63.15
|
| Rate for Payer: Multiplan Commercial |
$54.91
|
| Rate for Payer: Preferred Network Access Commercial |
$63.15
|
| Rate for Payer: Quartz Beloit One Network |
$33.63
|
| Rate for Payer: Quartz Commercial |
$41.18
|
| Rate for Payer: WEA Trust Commercial |
$37.75
|
| Rate for Payer: WPS Commercial |
$50.84
|
|
|
BULB ESOPHAGEAL INTUBATION EID200
|
Facility
|
OP
|
$148.00
|
|
| Hospital Charge Code |
2963256
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.10 |
| Max. Negotiated Rate |
$141.61 |
| Rate for Payer: Aetna Commercial |
$138.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.37
|
| Rate for Payer: Aetna Managed Medicare |
$43.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$100.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$76.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$73.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.58
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$141.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$86.14
|
| Rate for Payer: Health EOS Commercial |
$136.99
|
| Rate for Payer: HFN Commercial |
$141.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.44
|
| Rate for Payer: Multiplan Commercial |
$123.14
|
| Rate for Payer: NAPHCARE Commercial |
$92.35
|
| Rate for Payer: Preferred Network Access Commercial |
$141.61
|
| Rate for Payer: Quartz Beloit One Network |
$75.42
|
| Rate for Payer: Quartz Commercial |
$100.05
|
| Rate for Payer: Quartz Medicare Advantage |
$92.35
|
| Rate for Payer: The Alliance Commercial |
$76.96
|
| Rate for Payer: WEA Trust Commercial |
$84.66
|
| Rate for Payer: WPS Commercial |
$114.00
|
|
