|
C4 Complement
|
Facility
|
OP
|
$238.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
633685
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$227.72 |
| Rate for Payer: Aetna Commercial |
$222.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$212.87
|
| Rate for Payer: Aetna Managed Medicare |
$12.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.72
|
| Rate for Payer: Anthem Medicare Advantage |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.48
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$227.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$138.52
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.48
|
| Rate for Payer: Health EOS Commercial |
$220.29
|
| Rate for Payer: HFN Commercial |
$227.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$198.02
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$227.72
|
| Rate for Payer: Quartz Beloit One Network |
$121.28
|
| Rate for Payer: Quartz Commercial |
$160.89
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$49.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.48
|
| Rate for Payer: United Healthcare PPO |
$185.64
|
| Rate for Payer: WEA Trust Commercial |
$136.14
|
| Rate for Payer: Wellcare Medicare |
$12.48
|
| Rate for Payer: WPS Commercial |
$183.33
|
|
|
C4 Complement
|
Professional
|
Both
|
$220.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
3403544
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$217.36 |
| Rate for Payer: Aetna Commercial |
$217.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.77
|
| Rate for Payer: Aetna Managed Medicare |
$12.48
|
| Rate for Payer: Anthem Medicare Advantage |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.48
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$217.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$114.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.48
|
| Rate for Payer: Health EOS Commercial |
$208.21
|
| Rate for Payer: HFN Commercial |
$217.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$183.04
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$217.36
|
| Rate for Payer: Quartz Beloit One Network |
$100.67
|
| Rate for Payer: Quartz Commercial |
$130.42
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$49.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.48
|
| Rate for Payer: WEA Trust Commercial |
$125.84
|
| Rate for Payer: WPS Commercial |
$54.91
|
|
|
C4 Complement
|
Facility
|
IP
|
$238.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
633685
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$121.28 |
| Max. Negotiated Rate |
$227.72 |
| Rate for Payer: Aetna Commercial |
$222.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$212.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.19
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$227.72
|
| Rate for Payer: Health EOS Commercial |
$220.29
|
| Rate for Payer: HFN Commercial |
$227.72
|
| Rate for Payer: Multiplan Commercial |
$198.02
|
| Rate for Payer: Preferred Network Access Commercial |
$227.72
|
| Rate for Payer: Quartz Beloit One Network |
$121.28
|
| Rate for Payer: Quartz Commercial |
$148.51
|
| Rate for Payer: WEA Trust Commercial |
$136.14
|
| Rate for Payer: WPS Commercial |
$183.33
|
|
|
C4 Complement
|
Professional
|
Both
|
$238.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
633685
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$235.14 |
| Rate for Payer: Aetna Commercial |
$235.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$212.87
|
| Rate for Payer: Aetna Managed Medicare |
$12.48
|
| Rate for Payer: Anthem Medicare Advantage |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.48
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$235.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$123.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.48
|
| Rate for Payer: Health EOS Commercial |
$225.24
|
| Rate for Payer: HFN Commercial |
$235.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$198.02
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$235.14
|
| Rate for Payer: Quartz Beloit One Network |
$108.91
|
| Rate for Payer: Quartz Commercial |
$141.09
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$49.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.48
|
| Rate for Payer: WEA Trust Commercial |
$136.14
|
| Rate for Payer: WPS Commercial |
$54.91
|
|
|
C4 Complement
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
3403544
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$112.11 |
| Max. Negotiated Rate |
$210.50 |
| Rate for Payer: Aetna Commercial |
$205.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$121.26
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$210.50
|
| Rate for Payer: Health EOS Commercial |
$203.63
|
| Rate for Payer: HFN Commercial |
$210.50
|
| Rate for Payer: Multiplan Commercial |
$183.04
|
| Rate for Payer: Preferred Network Access Commercial |
$210.50
|
| Rate for Payer: Quartz Beloit One Network |
$112.11
|
| Rate for Payer: Quartz Commercial |
$137.28
|
| Rate for Payer: WEA Trust Commercial |
$125.84
|
| Rate for Payer: WPS Commercial |
$169.47
|
|
|
C4 Complement
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
3403544
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$210.50 |
| Rate for Payer: Aetna Commercial |
$205.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.77
|
| Rate for Payer: Aetna Managed Medicare |
$12.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.72
|
| Rate for Payer: Anthem Medicare Advantage |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$121.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.48
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$210.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$128.04
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.48
|
| Rate for Payer: Health EOS Commercial |
$203.63
|
| Rate for Payer: HFN Commercial |
$210.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$183.04
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$210.50
|
| Rate for Payer: Quartz Beloit One Network |
$112.11
|
| Rate for Payer: Quartz Commercial |
$148.72
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$49.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.48
|
| Rate for Payer: United Healthcare PPO |
$171.60
|
| Rate for Payer: WEA Trust Commercial |
$125.84
|
| Rate for Payer: Wellcare Medicare |
$12.48
|
| Rate for Payer: WPS Commercial |
$169.47
|
|
|
CA 19-9, Peritoneal Fluid
|
Professional
|
Both
|
$135.00
|
|
|
Service Code
|
CPT 86301
|
| Hospital Charge Code |
5791655
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.64 |
| Max. Negotiated Rate |
$133.38 |
| Rate for Payer: Aetna Commercial |
$133.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.74
|
| Rate for Payer: Aetna Managed Medicare |
$21.64
|
| Rate for Payer: Anthem Medicare Advantage |
$21.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.64
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$133.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$70.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.64
|
| Rate for Payer: Health EOS Commercial |
$127.76
|
| Rate for Payer: HFN Commercial |
$133.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$76.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.64
|
| Rate for Payer: Multiplan Commercial |
$112.32
|
| Rate for Payer: NAPHCARE Commercial |
$32.46
|
| Rate for Payer: Preferred Network Access Commercial |
$133.38
|
| Rate for Payer: Quartz Beloit One Network |
$61.78
|
| Rate for Payer: Quartz Commercial |
$80.03
|
| Rate for Payer: Quartz Medicare Advantage |
$21.64
|
| Rate for Payer: The Alliance Commercial |
$85.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.64
|
| Rate for Payer: WEA Trust Commercial |
$77.22
|
| Rate for Payer: WPS Commercial |
$95.23
|
|
|
CA 19-9, Peritoneal Fluid
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
CPT 86301
|
| Hospital Charge Code |
5791655
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.64 |
| Max. Negotiated Rate |
$129.17 |
| Rate for Payer: Aetna Commercial |
$126.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.74
|
| Rate for Payer: Aetna Managed Medicare |
$21.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37.87
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.93
|
| Rate for Payer: Anthem Medicare Advantage |
$21.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.64
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$129.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$21.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$78.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$21.64
|
| Rate for Payer: Health EOS Commercial |
$124.96
|
| Rate for Payer: HFN Commercial |
$129.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$21.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$21.64
|
| Rate for Payer: Multiplan Commercial |
$112.32
|
| Rate for Payer: NAPHCARE Commercial |
$32.46
|
| Rate for Payer: Preferred Network Access Commercial |
$129.17
|
| Rate for Payer: Quartz Beloit One Network |
$68.80
|
| Rate for Payer: Quartz Commercial |
$91.26
|
| Rate for Payer: Quartz Medicare Advantage |
$21.64
|
| Rate for Payer: The Alliance Commercial |
$86.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.64
|
| Rate for Payer: United Healthcare PPO |
$105.30
|
| Rate for Payer: WEA Trust Commercial |
$77.22
|
| Rate for Payer: Wellcare Medicare |
$21.64
|
| Rate for Payer: WPS Commercial |
$103.99
|
|
|
CA 19-9, Peritoneal Fluid
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
CPT 86301
|
| Hospital Charge Code |
5791655
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$68.80 |
| Max. Negotiated Rate |
$129.17 |
| Rate for Payer: Aetna Commercial |
$126.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.41
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$129.17
|
| Rate for Payer: Health EOS Commercial |
$124.96
|
| Rate for Payer: HFN Commercial |
$129.17
|
| Rate for Payer: Multiplan Commercial |
$112.32
|
| Rate for Payer: Preferred Network Access Commercial |
$129.17
|
| Rate for Payer: Quartz Beloit One Network |
$68.80
|
| Rate for Payer: Quartz Commercial |
$84.24
|
| Rate for Payer: WEA Trust Commercial |
$77.22
|
| Rate for Payer: WPS Commercial |
$103.99
|
|
|
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 |
$2,528.13 |
| Max. Negotiated Rate |
$4,746.68 |
| Rate for Payer: Aetna Commercial |
$4,643.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,437.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,734.50
|
| Rate for Payer: Cash Price |
$1,488.30
|
| Rate for Payer: Cigna Commercial |
$4,746.68
|
| Rate for Payer: Health EOS Commercial |
$4,591.90
|
| Rate for Payer: HFN Commercial |
$4,746.68
|
| Rate for Payer: Multiplan Commercial |
$4,127.55
|
| Rate for Payer: Preferred Network Access Commercial |
$4,746.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,528.13
|
| Rate for Payer: Quartz Commercial |
$3,095.66
|
| Rate for Payer: WEA Trust Commercial |
$2,837.69
|
| Rate for Payer: WPS Commercial |
$3,821.46
|
|
|
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 |
$1,444.64 |
| Max. Negotiated Rate |
$4,746.68 |
| Rate for Payer: Aetna Commercial |
$4,643.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,437.12
|
| Rate for Payer: Aetna Managed Medicare |
$1,444.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,353.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,579.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,476.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,734.50
|
| Rate for Payer: Cash Price |
$1,488.30
|
| Rate for Payer: Cigna Commercial |
$4,746.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,887.30
|
| Rate for Payer: Health EOS Commercial |
$4,591.90
|
| Rate for Payer: HFN Commercial |
$4,746.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,869.58
|
| Rate for Payer: Multiplan Commercial |
$4,127.55
|
| Rate for Payer: NAPHCARE Commercial |
$3,095.66
|
| Rate for Payer: Preferred Network Access Commercial |
$4,746.68
|
| Rate for Payer: Quartz Beloit One Network |
$2,528.13
|
| Rate for Payer: Quartz Commercial |
$3,353.64
|
| Rate for Payer: Quartz Medicare Advantage |
$3,095.66
|
| Rate for Payer: The Alliance Commercial |
$2,579.72
|
| Rate for Payer: WEA Trust Commercial |
$2,837.69
|
| Rate for Payer: WPS Commercial |
$3,821.46
|
|
|
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 |
$595.21 |
| Max. Negotiated Rate |
$1,117.54 |
| Rate for Payer: Aetna Commercial |
$1,093.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,044.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$643.80
|
| Rate for Payer: Cash Price |
$350.40
|
| Rate for Payer: Cigna Commercial |
$1,117.54
|
| Rate for Payer: Health EOS Commercial |
$1,081.10
|
| Rate for Payer: HFN Commercial |
$1,117.54
|
| Rate for Payer: Multiplan Commercial |
$971.78
|
| Rate for Payer: Preferred Network Access Commercial |
$1,117.54
|
| Rate for Payer: Quartz Beloit One Network |
$595.21
|
| Rate for Payer: Quartz Commercial |
$728.83
|
| Rate for Payer: WEA Trust Commercial |
$668.10
|
| Rate for Payer: WPS Commercial |
$899.71
|
|
|
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 |
$340.12 |
| Max. Negotiated Rate |
$1,117.54 |
| Rate for Payer: Aetna Commercial |
$1,093.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,044.66
|
| Rate for Payer: Aetna Managed Medicare |
$340.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$789.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$607.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$583.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$643.80
|
| Rate for Payer: Cash Price |
$350.40
|
| Rate for Payer: Cigna Commercial |
$1,117.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$679.78
|
| Rate for Payer: Health EOS Commercial |
$1,081.10
|
| Rate for Payer: HFN Commercial |
$1,117.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$911.04
|
| Rate for Payer: Multiplan Commercial |
$971.78
|
| Rate for Payer: NAPHCARE Commercial |
$728.83
|
| Rate for Payer: Preferred Network Access Commercial |
$1,117.54
|
| Rate for Payer: Quartz Beloit One Network |
$595.21
|
| Rate for Payer: Quartz Commercial |
$789.57
|
| Rate for Payer: Quartz Medicare Advantage |
$728.83
|
| Rate for Payer: The Alliance Commercial |
$607.36
|
| Rate for Payer: WEA Trust Commercial |
$668.10
|
| Rate for Payer: WPS Commercial |
$899.71
|
|
|
CABLE 1.6MM X 750MM 6704-8-016
|
Facility
|
IP
|
$2,564.00
|
|
| Hospital Charge Code |
2966072
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,306.61 |
| Max. Negotiated Rate |
$2,453.24 |
| Rate for Payer: Aetna Commercial |
$2,399.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,293.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,413.28
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cigna Commercial |
$2,453.24
|
| Rate for Payer: Health EOS Commercial |
$2,373.24
|
| Rate for Payer: HFN Commercial |
$2,453.24
|
| Rate for Payer: Multiplan Commercial |
$2,133.25
|
| Rate for Payer: Preferred Network Access Commercial |
$2,453.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,306.61
|
| Rate for Payer: Quartz Commercial |
$1,599.94
|
| Rate for Payer: WEA Trust Commercial |
$1,466.61
|
| Rate for Payer: WPS Commercial |
$1,975.05
|
|
|
CABLE 1.6MM X 750MM 6704-8-016
|
Facility
|
OP
|
$2,564.00
|
|
| Hospital Charge Code |
2966072
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$746.64 |
| Max. Negotiated Rate |
$2,453.24 |
| Rate for Payer: Aetna Commercial |
$2,399.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,293.24
|
| Rate for Payer: Aetna Managed Medicare |
$746.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,733.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,333.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,279.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,413.28
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cigna Commercial |
$2,453.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,492.25
|
| Rate for Payer: Health EOS Commercial |
$2,373.24
|
| Rate for Payer: HFN Commercial |
$2,453.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,999.92
|
| Rate for Payer: Multiplan Commercial |
$2,133.25
|
| Rate for Payer: NAPHCARE Commercial |
$1,599.94
|
| Rate for Payer: Preferred Network Access Commercial |
$2,453.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,306.61
|
| Rate for Payer: Quartz Commercial |
$1,733.26
|
| Rate for Payer: Quartz Medicare Advantage |
$1,599.94
|
| Rate for Payer: The Alliance Commercial |
$1,333.28
|
| Rate for Payer: WEA Trust Commercial |
$1,466.61
|
| Rate for Payer: WPS Commercial |
$1,975.05
|
|
|
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 |
$1,065.79 |
| Max. Negotiated Rate |
$3,501.89 |
| Rate for Payer: Aetna Commercial |
$3,425.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,273.50
|
| Rate for Payer: Aetna Managed Medicare |
$1,065.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,474.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,903.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,827.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,017.39
|
| Rate for Payer: Cash Price |
$1,098.00
|
| Rate for Payer: Cigna Commercial |
$3,501.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,130.12
|
| Rate for Payer: Health EOS Commercial |
$3,387.70
|
| Rate for Payer: HFN Commercial |
$3,501.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,854.80
|
| Rate for Payer: Multiplan Commercial |
$3,045.12
|
| Rate for Payer: NAPHCARE Commercial |
$2,283.84
|
| Rate for Payer: Preferred Network Access Commercial |
$3,501.89
|
| Rate for Payer: Quartz Beloit One Network |
$1,865.14
|
| Rate for Payer: Quartz Commercial |
$2,474.16
|
| Rate for Payer: Quartz Medicare Advantage |
$2,283.84
|
| Rate for Payer: The Alliance Commercial |
$1,903.20
|
| Rate for Payer: WEA Trust Commercial |
$2,093.52
|
| Rate for Payer: WPS Commercial |
$2,819.30
|
|
|
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 |
$1,865.14 |
| Max. Negotiated Rate |
$3,501.89 |
| Rate for Payer: Aetna Commercial |
$3,425.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,273.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,017.39
|
| Rate for Payer: Cash Price |
$1,098.00
|
| Rate for Payer: Cigna Commercial |
$3,501.89
|
| Rate for Payer: Health EOS Commercial |
$3,387.70
|
| Rate for Payer: HFN Commercial |
$3,501.89
|
| Rate for Payer: Multiplan Commercial |
$3,045.12
|
| Rate for Payer: Preferred Network Access Commercial |
$3,501.89
|
| Rate for Payer: Quartz Beloit One Network |
$1,865.14
|
| Rate for Payer: Quartz Commercial |
$2,283.84
|
| Rate for Payer: WEA Trust Commercial |
$2,093.52
|
| Rate for Payer: WPS Commercial |
$2,819.30
|
|
|
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 |
$1,217.22 |
| Max. Negotiated Rate |
$3,999.42 |
| Rate for Payer: Aetna Commercial |
$3,912.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,738.59
|
| Rate for Payer: Aetna Managed Medicare |
$1,217.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,825.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,173.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,086.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,304.02
|
| Rate for Payer: Cash Price |
$1,254.00
|
| Rate for Payer: Cigna Commercial |
$3,999.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,432.76
|
| Rate for Payer: Health EOS Commercial |
$3,869.01
|
| Rate for Payer: HFN Commercial |
$3,999.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,260.40
|
| Rate for Payer: Multiplan Commercial |
$3,477.76
|
| Rate for Payer: NAPHCARE Commercial |
$2,608.32
|
| Rate for Payer: Preferred Network Access Commercial |
$3,999.42
|
| Rate for Payer: Quartz Beloit One Network |
$2,130.13
|
| Rate for Payer: Quartz Commercial |
$2,825.68
|
| Rate for Payer: Quartz Medicare Advantage |
$2,608.32
|
| Rate for Payer: The Alliance Commercial |
$2,173.60
|
| Rate for Payer: WEA Trust Commercial |
$2,390.96
|
| Rate for Payer: WPS Commercial |
$3,219.85
|
|
|
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 |
$2,130.13 |
| Max. Negotiated Rate |
$3,999.42 |
| Rate for Payer: Aetna Commercial |
$3,912.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,738.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,304.02
|
| Rate for Payer: Cash Price |
$1,254.00
|
| Rate for Payer: Cigna Commercial |
$3,999.42
|
| Rate for Payer: Health EOS Commercial |
$3,869.01
|
| Rate for Payer: HFN Commercial |
$3,999.42
|
| Rate for Payer: Multiplan Commercial |
$3,477.76
|
| Rate for Payer: Preferred Network Access Commercial |
$3,999.42
|
| Rate for Payer: Quartz Beloit One Network |
$2,130.13
|
| Rate for Payer: Quartz Commercial |
$2,608.32
|
| Rate for Payer: WEA Trust Commercial |
$2,390.96
|
| Rate for Payer: WPS Commercial |
$3,219.85
|
|
|
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 |
$746.64 |
| Max. Negotiated Rate |
$2,453.24 |
| Rate for Payer: Aetna Commercial |
$2,399.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,293.24
|
| Rate for Payer: Aetna Managed Medicare |
$746.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,733.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,333.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,279.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,413.28
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cigna Commercial |
$2,453.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,492.25
|
| Rate for Payer: Health EOS Commercial |
$2,373.24
|
| Rate for Payer: HFN Commercial |
$2,453.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,999.92
|
| Rate for Payer: Multiplan Commercial |
$2,133.25
|
| Rate for Payer: NAPHCARE Commercial |
$1,599.94
|
| Rate for Payer: Preferred Network Access Commercial |
$2,453.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,306.61
|
| Rate for Payer: Quartz Commercial |
$1,733.26
|
| Rate for Payer: Quartz Medicare Advantage |
$1,599.94
|
| Rate for Payer: The Alliance Commercial |
$1,333.28
|
| Rate for Payer: WEA Trust Commercial |
$1,466.61
|
| Rate for Payer: WPS Commercial |
$1,975.05
|
|
|
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 |
$1,306.61 |
| Max. Negotiated Rate |
$2,453.24 |
| Rate for Payer: Aetna Commercial |
$2,399.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,293.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,413.28
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cigna Commercial |
$2,453.24
|
| Rate for Payer: Health EOS Commercial |
$2,373.24
|
| Rate for Payer: HFN Commercial |
$2,453.24
|
| Rate for Payer: Multiplan Commercial |
$2,133.25
|
| Rate for Payer: Preferred Network Access Commercial |
$2,453.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,306.61
|
| Rate for Payer: Quartz Commercial |
$1,599.94
|
| Rate for Payer: WEA Trust Commercial |
$1,466.61
|
| Rate for Payer: WPS Commercial |
$1,975.05
|
|
|
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 |
$1,443.48 |
| Max. Negotiated Rate |
$4,742.86 |
| Rate for Payer: Aetna Commercial |
$4,639.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,433.54
|
| Rate for Payer: Aetna Managed Medicare |
$1,443.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,350.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,577.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,474.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,732.30
|
| Rate for Payer: Cash Price |
$1,487.10
|
| Rate for Payer: Cigna Commercial |
$4,742.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,884.97
|
| Rate for Payer: Health EOS Commercial |
$4,588.20
|
| Rate for Payer: HFN Commercial |
$4,742.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,866.46
|
| Rate for Payer: Multiplan Commercial |
$4,124.22
|
| Rate for Payer: NAPHCARE Commercial |
$3,093.17
|
| Rate for Payer: Preferred Network Access Commercial |
$4,742.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,526.09
|
| Rate for Payer: Quartz Commercial |
$3,350.93
|
| Rate for Payer: Quartz Medicare Advantage |
$3,093.17
|
| Rate for Payer: The Alliance Commercial |
$2,577.64
|
| Rate for Payer: WEA Trust Commercial |
$2,835.40
|
| Rate for Payer: WPS Commercial |
$3,818.38
|
|
|
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 |
$2,526.09 |
| Max. Negotiated Rate |
$4,742.86 |
| Rate for Payer: Aetna Commercial |
$4,639.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,433.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,732.30
|
| Rate for Payer: Cash Price |
$1,487.10
|
| Rate for Payer: Cigna Commercial |
$4,742.86
|
| Rate for Payer: Health EOS Commercial |
$4,588.20
|
| Rate for Payer: HFN Commercial |
$4,742.86
|
| Rate for Payer: Multiplan Commercial |
$4,124.22
|
| Rate for Payer: Preferred Network Access Commercial |
$4,742.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,526.09
|
| Rate for Payer: Quartz Commercial |
$3,093.17
|
| Rate for Payer: WEA Trust Commercial |
$2,835.40
|
| Rate for Payer: WPS Commercial |
$3,818.38
|
|
|
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 |
$3,800.74 |
| Max. Negotiated Rate |
$12,488.15 |
| Rate for Payer: Aetna Commercial |
$12,216.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,673.71
|
| Rate for Payer: Aetna Managed Medicare |
$3,800.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,823.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,787.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,515.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,194.26
|
| Rate for Payer: Cash Price |
$3,915.60
|
| Rate for Payer: Cigna Commercial |
$12,488.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,596.26
|
| Rate for Payer: Health EOS Commercial |
$12,080.93
|
| Rate for Payer: HFN Commercial |
$12,488.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,180.56
|
| Rate for Payer: Multiplan Commercial |
$10,859.26
|
| Rate for Payer: NAPHCARE Commercial |
$8,144.45
|
| Rate for Payer: Preferred Network Access Commercial |
$12,488.15
|
| Rate for Payer: Quartz Beloit One Network |
$6,651.30
|
| Rate for Payer: Quartz Commercial |
$8,823.15
|
| Rate for Payer: Quartz Medicare Advantage |
$8,144.45
|
| Rate for Payer: The Alliance Commercial |
$6,787.04
|
| Rate for Payer: WEA Trust Commercial |
$7,465.74
|
| Rate for Payer: WPS Commercial |
$10,053.96
|
|
|
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 |
$6,651.30 |
| Max. Negotiated Rate |
$12,488.15 |
| Rate for Payer: Aetna Commercial |
$12,216.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$11,673.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,194.26
|
| Rate for Payer: Cash Price |
$3,915.60
|
| Rate for Payer: Cigna Commercial |
$12,488.15
|
| Rate for Payer: Health EOS Commercial |
$12,080.93
|
| Rate for Payer: HFN Commercial |
$12,488.15
|
| Rate for Payer: Multiplan Commercial |
$10,859.26
|
| Rate for Payer: Preferred Network Access Commercial |
$12,488.15
|
| Rate for Payer: Quartz Beloit One Network |
$6,651.30
|
| Rate for Payer: Quartz Commercial |
$8,144.45
|
| Rate for Payer: WEA Trust Commercial |
$7,465.74
|
| Rate for Payer: WPS Commercial |
$10,053.96
|
|
