|
Bupivicaine 0.5% 50ml MDV [Med]
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
2974898
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$3.74
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
Bupivicaine 0.5% 50ml MDV [Med]
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
2974898
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Aetna Managed Medicare |
$1.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.49
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: NAPHCARE Commercial |
$3.74
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$4.06
|
| Rate for Payer: Quartz Medicare Advantage |
$3.74
|
| Rate for Payer: The Alliance Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
Bupivicaine 0.5% with Epi 50ml MDV [Med]
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
2974899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Aetna Managed Medicare |
$1.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.49
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: NAPHCARE Commercial |
$3.74
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$4.06
|
| Rate for Payer: Quartz Medicare Advantage |
$3.74
|
| Rate for Payer: The Alliance Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
Bupivicaine 0.5% with Epi 50ml MDV [Med]
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
2974899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$3.74
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
Bupivicaine 0.75% 10ml SDV [Med]
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
5286885
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.78 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna Commercial |
$27.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.98
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$27.75
|
| Rate for Payer: Health EOS Commercial |
$26.84
|
| Rate for Payer: HFN Commercial |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$24.13
|
| Rate for Payer: Preferred Network Access Commercial |
$27.75
|
| Rate for Payer: Quartz Beloit One Network |
$14.78
|
| Rate for Payer: Quartz Commercial |
$18.10
|
| Rate for Payer: WEA Trust Commercial |
$16.59
|
| Rate for Payer: WPS Commercial |
$22.34
|
|
|
Bupivicaine 0.75% 10ml SDV [Med]
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
5286885
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna Commercial |
$27.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.94
|
| Rate for Payer: Aetna Managed Medicare |
$8.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.98
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$27.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.02
|
| Rate for Payer: Health EOS Commercial |
$26.84
|
| Rate for Payer: HFN Commercial |
$27.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.62
|
| Rate for Payer: Multiplan Commercial |
$24.13
|
| Rate for Payer: NAPHCARE Commercial |
$18.10
|
| Rate for Payer: Preferred Network Access Commercial |
$27.75
|
| Rate for Payer: Quartz Beloit One Network |
$14.78
|
| Rate for Payer: Quartz Commercial |
$19.60
|
| Rate for Payer: Quartz Medicare Advantage |
$18.10
|
| Rate for Payer: The Alliance Commercial |
$0.04
|
| Rate for Payer: WEA Trust Commercial |
$16.59
|
| Rate for Payer: WPS Commercial |
$0.04
|
|
|
Buprenorphine and Naloxone Urine
|
Professional
|
Both
|
$185.00
|
|
|
Service Code
|
CPT 80348
|
| Hospital Charge Code |
4578606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$60.06 |
| Max. Negotiated Rate |
$182.78 |
| Rate for Payer: Aetna Commercial |
$182.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.46
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cigna Commercial |
$182.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$96.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.44
|
| Rate for Payer: Health EOS Commercial |
$175.08
|
| Rate for Payer: HFN Commercial |
$182.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.06
|
| Rate for Payer: Multiplan Commercial |
$153.92
|
| Rate for Payer: Preferred Network Access Commercial |
$182.78
|
| Rate for Payer: Quartz Beloit One Network |
$84.66
|
| Rate for Payer: Quartz Commercial |
$109.67
|
| Rate for Payer: The Alliance Commercial |
$96.20
|
| Rate for Payer: WEA Trust Commercial |
$105.82
|
| Rate for Payer: WPS Commercial |
$142.51
|
|
|
Buprenorphine and Naloxone Urine
|
Facility
|
IP
|
$185.00
|
|
|
Service Code
|
CPT 80348
|
| Hospital Charge Code |
4578606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$94.28 |
| Max. Negotiated Rate |
$177.01 |
| Rate for Payer: Aetna Commercial |
$173.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.97
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cigna Commercial |
$177.01
|
| Rate for Payer: Health EOS Commercial |
$171.24
|
| Rate for Payer: HFN Commercial |
$177.01
|
| Rate for Payer: Multiplan Commercial |
$153.92
|
| Rate for Payer: Preferred Network Access Commercial |
$177.01
|
| Rate for Payer: Quartz Beloit One Network |
$94.28
|
| Rate for Payer: Quartz Commercial |
$115.44
|
| Rate for Payer: WEA Trust Commercial |
$105.82
|
| Rate for Payer: WPS Commercial |
$142.51
|
|
|
Buprenorphine and Naloxone Urine
|
Facility
|
OP
|
$185.00
|
|
|
Service Code
|
CPT 80348
|
| Hospital Charge Code |
4578606
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.87 |
| Max. Negotiated Rate |
$177.01 |
| Rate for Payer: Aetna Commercial |
$173.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.46
|
| Rate for Payer: Aetna Managed Medicare |
$53.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$125.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$96.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$92.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.97
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cigna Commercial |
$177.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$107.67
|
| Rate for Payer: Health EOS Commercial |
$171.24
|
| Rate for Payer: HFN Commercial |
$177.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$144.30
|
| Rate for Payer: Multiplan Commercial |
$153.92
|
| Rate for Payer: NAPHCARE Commercial |
$115.44
|
| Rate for Payer: Preferred Network Access Commercial |
$177.01
|
| Rate for Payer: Quartz Beloit One Network |
$94.28
|
| Rate for Payer: Quartz Commercial |
$125.06
|
| Rate for Payer: Quartz Medicare Advantage |
$115.44
|
| Rate for Payer: The Alliance Commercial |
$96.20
|
| Rate for Payer: United Healthcare PPO |
$144.30
|
| Rate for Payer: WEA Trust Commercial |
$105.82
|
| Rate for Payer: WPS Commercial |
$142.51
|
|
|
Buprenorphine Serum / 93031
|
Facility
|
IP
|
$269.00
|
|
|
Service Code
|
CPT 80348
|
| Hospital Charge Code |
4075697
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.08 |
| Max. Negotiated Rate |
$257.38 |
| Rate for Payer: Aetna Commercial |
$251.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$240.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.27
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$257.38
|
| Rate for Payer: Health EOS Commercial |
$248.99
|
| Rate for Payer: HFN Commercial |
$257.38
|
| Rate for Payer: Multiplan Commercial |
$223.81
|
| Rate for Payer: Preferred Network Access Commercial |
$257.38
|
| Rate for Payer: Quartz Beloit One Network |
$137.08
|
| Rate for Payer: Quartz Commercial |
$167.86
|
| Rate for Payer: WEA Trust Commercial |
$153.87
|
| Rate for Payer: WPS Commercial |
$207.21
|
|
|
Buprenorphine Serum / 93031
|
Professional
|
Both
|
$269.00
|
|
|
Service Code
|
CPT 80348
|
| Hospital Charge Code |
4075697
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$60.06 |
| Max. Negotiated Rate |
$265.77 |
| Rate for Payer: Aetna Commercial |
$265.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$240.59
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$265.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$139.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$167.86
|
| Rate for Payer: Health EOS Commercial |
$254.58
|
| Rate for Payer: HFN Commercial |
$265.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.06
|
| Rate for Payer: Multiplan Commercial |
$223.81
|
| Rate for Payer: Preferred Network Access Commercial |
$265.77
|
| Rate for Payer: Quartz Beloit One Network |
$123.09
|
| Rate for Payer: Quartz Commercial |
$159.46
|
| Rate for Payer: The Alliance Commercial |
$139.88
|
| Rate for Payer: WEA Trust Commercial |
$153.87
|
| Rate for Payer: WPS Commercial |
$207.21
|
|
|
Buprenorphine Serum / 93031
|
Facility
|
OP
|
$269.00
|
|
|
Service Code
|
CPT 80348
|
| Hospital Charge Code |
4075697
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$78.33 |
| Max. Negotiated Rate |
$257.38 |
| Rate for Payer: Aetna Commercial |
$251.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$240.59
|
| Rate for Payer: Aetna Managed Medicare |
$78.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$181.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$139.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$134.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.27
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$257.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$156.56
|
| Rate for Payer: Health EOS Commercial |
$248.99
|
| Rate for Payer: HFN Commercial |
$257.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$209.82
|
| Rate for Payer: Multiplan Commercial |
$223.81
|
| Rate for Payer: NAPHCARE Commercial |
$167.86
|
| Rate for Payer: Preferred Network Access Commercial |
$257.38
|
| Rate for Payer: Quartz Beloit One Network |
$137.08
|
| Rate for Payer: Quartz Commercial |
$181.84
|
| Rate for Payer: Quartz Medicare Advantage |
$167.86
|
| Rate for Payer: The Alliance Commercial |
$139.88
|
| Rate for Payer: United Healthcare PPO |
$209.82
|
| Rate for Payer: WEA Trust Commercial |
$153.87
|
| Rate for Payer: WPS Commercial |
$207.21
|
|
|
Bupropion and Metabolite, Blood
|
Facility
|
OP
|
$265.00
|
|
|
Service Code
|
CPT 80338
|
| Hospital Charge Code |
3256223
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$77.17 |
| Max. Negotiated Rate |
$253.55 |
| Rate for Payer: Aetna Commercial |
$248.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$237.02
|
| Rate for Payer: Aetna Managed Medicare |
$77.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$179.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$137.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$132.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.07
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$253.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$154.23
|
| Rate for Payer: Health EOS Commercial |
$245.28
|
| Rate for Payer: HFN Commercial |
$253.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$206.70
|
| Rate for Payer: Multiplan Commercial |
$220.48
|
| Rate for Payer: NAPHCARE Commercial |
$165.36
|
| Rate for Payer: Preferred Network Access Commercial |
$253.55
|
| Rate for Payer: Quartz Beloit One Network |
$135.04
|
| Rate for Payer: Quartz Commercial |
$179.14
|
| Rate for Payer: Quartz Medicare Advantage |
$165.36
|
| Rate for Payer: The Alliance Commercial |
$137.80
|
| Rate for Payer: United Healthcare PPO |
$206.70
|
| Rate for Payer: WEA Trust Commercial |
$151.58
|
| Rate for Payer: WPS Commercial |
$204.13
|
|
|
Bupropion and Metabolite, Blood
|
Facility
|
IP
|
$265.00
|
|
|
Service Code
|
CPT 80338
|
| Hospital Charge Code |
3256223
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$135.04 |
| Max. Negotiated Rate |
$253.55 |
| Rate for Payer: Aetna Commercial |
$248.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$237.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.07
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$253.55
|
| Rate for Payer: Health EOS Commercial |
$245.28
|
| Rate for Payer: HFN Commercial |
$253.55
|
| Rate for Payer: Multiplan Commercial |
$220.48
|
| Rate for Payer: Preferred Network Access Commercial |
$253.55
|
| Rate for Payer: Quartz Beloit One Network |
$135.04
|
| Rate for Payer: Quartz Commercial |
$165.36
|
| Rate for Payer: WEA Trust Commercial |
$151.58
|
| Rate for Payer: WPS Commercial |
$204.13
|
|
|
Bupropion and Metabolite, Blood
|
Professional
|
Both
|
$265.00
|
|
|
Service Code
|
CPT 80338
|
| Hospital Charge Code |
3256223
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$46.81 |
| Max. Negotiated Rate |
$261.82 |
| Rate for Payer: Aetna Commercial |
$261.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$237.02
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$261.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$137.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$165.36
|
| Rate for Payer: Health EOS Commercial |
$250.80
|
| Rate for Payer: HFN Commercial |
$261.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.81
|
| Rate for Payer: Multiplan Commercial |
$220.48
|
| Rate for Payer: Preferred Network Access Commercial |
$261.82
|
| Rate for Payer: Quartz Beloit One Network |
$121.26
|
| Rate for Payer: Quartz Commercial |
$157.09
|
| Rate for Payer: The Alliance Commercial |
$137.80
|
| Rate for Payer: WEA Trust Commercial |
$151.58
|
| Rate for Payer: WPS Commercial |
$204.13
|
|
|
BUR 1.2 SIDE CUT 1607-002-105
|
Facility
|
IP
|
$248.00
|
|
| Hospital Charge Code |
2966108
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$126.38 |
| Max. Negotiated Rate |
$237.29 |
| Rate for Payer: Aetna Commercial |
$232.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.70
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$237.29
|
| Rate for Payer: Health EOS Commercial |
$229.55
|
| Rate for Payer: HFN Commercial |
$237.29
|
| Rate for Payer: Multiplan Commercial |
$206.34
|
| Rate for Payer: Preferred Network Access Commercial |
$237.29
|
| Rate for Payer: Quartz Beloit One Network |
$126.38
|
| Rate for Payer: Quartz Commercial |
$154.75
|
| Rate for Payer: WEA Trust Commercial |
$141.86
|
| Rate for Payer: WPS Commercial |
$191.03
|
|
|
BUR 1.2 SIDE CUT 1607-002-105
|
Facility
|
OP
|
$248.00
|
|
| Hospital Charge Code |
2966108
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$72.22 |
| Max. Negotiated Rate |
$237.29 |
| Rate for Payer: Aetna Commercial |
$232.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.81
|
| Rate for Payer: Aetna Managed Medicare |
$72.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$167.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$128.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$123.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.70
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$237.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.34
|
| Rate for Payer: Health EOS Commercial |
$229.55
|
| Rate for Payer: HFN Commercial |
$237.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$193.44
|
| Rate for Payer: Multiplan Commercial |
$206.34
|
| Rate for Payer: NAPHCARE Commercial |
$154.75
|
| Rate for Payer: Preferred Network Access Commercial |
$237.29
|
| Rate for Payer: Quartz Beloit One Network |
$126.38
|
| Rate for Payer: Quartz Commercial |
$167.65
|
| Rate for Payer: Quartz Medicare Advantage |
$154.75
|
| Rate for Payer: The Alliance Commercial |
$128.96
|
| Rate for Payer: WEA Trust Commercial |
$141.86
|
| Rate for Payer: WPS Commercial |
$191.03
|
|
|
BUR 1.6 CARBIDE 1607-002-107
|
Facility
|
IP
|
$246.00
|
|
| Hospital Charge Code |
2966109
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$125.36 |
| Max. Negotiated Rate |
$235.37 |
| Rate for Payer: Aetna Commercial |
$230.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$220.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.60
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$235.37
|
| Rate for Payer: Health EOS Commercial |
$227.70
|
| Rate for Payer: HFN Commercial |
$235.37
|
| Rate for Payer: Multiplan Commercial |
$204.67
|
| Rate for Payer: Preferred Network Access Commercial |
$235.37
|
| Rate for Payer: Quartz Beloit One Network |
$125.36
|
| Rate for Payer: Quartz Commercial |
$153.50
|
| Rate for Payer: WEA Trust Commercial |
$140.71
|
| Rate for Payer: WPS Commercial |
$189.49
|
|
|
BUR 1.6 CARBIDE 1607-002-107
|
Facility
|
OP
|
$246.00
|
|
| Hospital Charge Code |
2966109
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.64 |
| Max. Negotiated Rate |
$235.37 |
| Rate for Payer: Aetna Commercial |
$230.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$220.02
|
| Rate for Payer: Aetna Managed Medicare |
$71.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$166.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$127.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$122.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.60
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$235.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$143.17
|
| Rate for Payer: Health EOS Commercial |
$227.70
|
| Rate for Payer: HFN Commercial |
$235.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$191.88
|
| Rate for Payer: Multiplan Commercial |
$204.67
|
| Rate for Payer: NAPHCARE Commercial |
$153.50
|
| Rate for Payer: Preferred Network Access Commercial |
$235.37
|
| Rate for Payer: Quartz Beloit One Network |
$125.36
|
| Rate for Payer: Quartz Commercial |
$166.30
|
| Rate for Payer: Quartz Medicare Advantage |
$153.50
|
| Rate for Payer: The Alliance Commercial |
$127.92
|
| Rate for Payer: WEA Trust Commercial |
$140.71
|
| Rate for Payer: WPS Commercial |
$189.49
|
|
|
BUR 2.1 SIDE CUT 1607-002-109
|
Facility
|
IP
|
$248.00
|
|
| Hospital Charge Code |
3072523
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$126.38 |
| Max. Negotiated Rate |
$237.29 |
| Rate for Payer: Aetna Commercial |
$232.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.70
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$237.29
|
| Rate for Payer: Health EOS Commercial |
$229.55
|
| Rate for Payer: HFN Commercial |
$237.29
|
| Rate for Payer: Multiplan Commercial |
$206.34
|
| Rate for Payer: Preferred Network Access Commercial |
$237.29
|
| Rate for Payer: Quartz Beloit One Network |
$126.38
|
| Rate for Payer: Quartz Commercial |
$154.75
|
| Rate for Payer: WEA Trust Commercial |
$141.86
|
| Rate for Payer: WPS Commercial |
$191.03
|
|
|
BUR 2.1 SIDE CUT 1607-002-109
|
Facility
|
OP
|
$248.00
|
|
| Hospital Charge Code |
3072523
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$72.22 |
| Max. Negotiated Rate |
$237.29 |
| Rate for Payer: Aetna Commercial |
$232.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.81
|
| Rate for Payer: Aetna Managed Medicare |
$72.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$167.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$128.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$123.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.70
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$237.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.34
|
| Rate for Payer: Health EOS Commercial |
$229.55
|
| Rate for Payer: HFN Commercial |
$237.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$193.44
|
| Rate for Payer: Multiplan Commercial |
$206.34
|
| Rate for Payer: NAPHCARE Commercial |
$154.75
|
| Rate for Payer: Preferred Network Access Commercial |
$237.29
|
| Rate for Payer: Quartz Beloit One Network |
$126.38
|
| Rate for Payer: Quartz Commercial |
$167.65
|
| Rate for Payer: Quartz Medicare Advantage |
$154.75
|
| Rate for Payer: The Alliance Commercial |
$128.96
|
| Rate for Payer: WEA Trust Commercial |
$141.86
|
| Rate for Payer: WPS Commercial |
$191.03
|
|
|
BUR 2 X 30MM ROUND STEEL
|
Facility
|
OP
|
$1,602.00
|
|
| Hospital Charge Code |
2964895
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$466.50 |
| Max. Negotiated Rate |
$1,532.79 |
| Rate for Payer: Aetna Commercial |
$1,499.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,432.83
|
| Rate for Payer: Aetna Managed Medicare |
$466.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,082.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$833.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$799.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$883.02
|
| Rate for Payer: Cash Price |
$480.60
|
| Rate for Payer: Cigna Commercial |
$1,532.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$932.36
|
| Rate for Payer: Health EOS Commercial |
$1,482.81
|
| Rate for Payer: HFN Commercial |
$1,532.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,249.56
|
| Rate for Payer: Multiplan Commercial |
$1,332.86
|
| Rate for Payer: NAPHCARE Commercial |
$999.65
|
| Rate for Payer: Preferred Network Access Commercial |
$1,532.79
|
| Rate for Payer: Quartz Beloit One Network |
$816.38
|
| Rate for Payer: Quartz Commercial |
$1,082.95
|
| Rate for Payer: Quartz Medicare Advantage |
$999.65
|
| Rate for Payer: The Alliance Commercial |
$833.04
|
| Rate for Payer: WEA Trust Commercial |
$916.34
|
| Rate for Payer: WPS Commercial |
$1,234.02
|
|
|
BUR 2 X 30MM ROUND STEEL
|
Facility
|
IP
|
$1,602.00
|
|
| Hospital Charge Code |
2964895
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$816.38 |
| Max. Negotiated Rate |
$1,532.79 |
| Rate for Payer: Aetna Commercial |
$1,499.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,432.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$883.02
|
| Rate for Payer: Cash Price |
$480.60
|
| Rate for Payer: Cigna Commercial |
$1,532.79
|
| Rate for Payer: Health EOS Commercial |
$1,482.81
|
| Rate for Payer: HFN Commercial |
$1,532.79
|
| Rate for Payer: Multiplan Commercial |
$1,332.86
|
| Rate for Payer: Preferred Network Access Commercial |
$1,532.79
|
| Rate for Payer: Quartz Beloit One Network |
$816.38
|
| Rate for Payer: Quartz Commercial |
$999.65
|
| Rate for Payer: WEA Trust Commercial |
$916.34
|
| Rate for Payer: WPS Commercial |
$1,234.02
|
|
|
BUR 2 X 48MM #E8220
|
Facility
|
OP
|
$1,484.00
|
|
| Hospital Charge Code |
2964896
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$432.14 |
| Max. Negotiated Rate |
$1,419.89 |
| Rate for Payer: Aetna Commercial |
$1,389.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,327.29
|
| Rate for Payer: Aetna Managed Medicare |
$432.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,003.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$771.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$740.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$817.98
|
| Rate for Payer: Cash Price |
$445.20
|
| Rate for Payer: Cigna Commercial |
$1,419.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$863.69
|
| Rate for Payer: Health EOS Commercial |
$1,373.59
|
| Rate for Payer: HFN Commercial |
$1,419.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,157.52
|
| Rate for Payer: Multiplan Commercial |
$1,234.69
|
| Rate for Payer: NAPHCARE Commercial |
$926.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,419.89
|
| Rate for Payer: Quartz Beloit One Network |
$756.25
|
| Rate for Payer: Quartz Commercial |
$1,003.18
|
| Rate for Payer: Quartz Medicare Advantage |
$926.02
|
| Rate for Payer: The Alliance Commercial |
$771.68
|
| Rate for Payer: WEA Trust Commercial |
$848.85
|
| Rate for Payer: WPS Commercial |
$1,143.13
|
|
|
BUR 2 X 48MM #E8220
|
Facility
|
IP
|
$1,484.00
|
|
| Hospital Charge Code |
2964896
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$756.25 |
| Max. Negotiated Rate |
$1,419.89 |
| Rate for Payer: Aetna Commercial |
$1,389.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,327.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$817.98
|
| Rate for Payer: Cash Price |
$445.20
|
| Rate for Payer: Cigna Commercial |
$1,419.89
|
| Rate for Payer: Health EOS Commercial |
$1,373.59
|
| Rate for Payer: HFN Commercial |
$1,419.89
|
| Rate for Payer: Multiplan Commercial |
$1,234.69
|
| Rate for Payer: Preferred Network Access Commercial |
$1,419.89
|
| Rate for Payer: Quartz Beloit One Network |
$756.25
|
| Rate for Payer: Quartz Commercial |
$926.02
|
| Rate for Payer: WEA Trust Commercial |
$848.85
|
| Rate for Payer: WPS Commercial |
$1,143.13
|
|
