|
CARTILAGE GRAFT; NASAL SEPTUM
|
Facility
OP
|
$13,191.23
|
|
|
Service Code
|
CPT 20912
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,472.92 |
| Max. Negotiated Rate |
$13,191.23 |
| Rate for Payer: Aetna Managed Medicare |
$3,546.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,546.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,546.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,546.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,546.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,546.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,191.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,546.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,546.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,546.03
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,546.03
|
| Rate for Payer: NAPHCARE Commercial |
$5,319.04
|
| Rate for Payer: Quartz Medicare Advantage |
$3,546.03
|
| Rate for Payer: The Alliance Commercial |
$3,472.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,546.03
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: Wellcare Medicare |
$3,546.03
|
|
|
CARTRIDGE BLOOD LINE CS3 #1010256035461
|
Facility
OP
|
$111.00
|
|
| Hospital Charge Code |
2971907
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$31.08 |
| Max. Negotiated Rate |
$444.00 |
| Rate for Payer: Aetna Commercial |
$99.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.46
|
| Rate for Payer: Aetna Managed Medicare |
$31.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$55.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$53.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.83
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$102.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.12
|
| Rate for Payer: Health EOS Commercial |
$98.79
|
| Rate for Payer: HFN Commercial |
$102.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.25
|
| Rate for Payer: Multiplan Commercial |
$88.80
|
| Rate for Payer: NAPHCARE Commercial |
$66.60
|
| Rate for Payer: Preferred Network Access Commercial |
$102.12
|
| Rate for Payer: Quartz Beloit One Network |
$54.39
|
| Rate for Payer: Quartz Commercial |
$72.15
|
| Rate for Payer: Quartz Medicare Advantage |
$66.60
|
| Rate for Payer: The Alliance Commercial |
$444.00
|
| Rate for Payer: WEA Trust Commercial |
$61.05
|
| Rate for Payer: WPS Commercial |
$82.22
|
|
|
CARTRIDGE BLOOD LINE CS3 #1010256035461
|
Facility
IP
|
$111.00
|
|
| Hospital Charge Code |
2971907
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$54.39 |
| Max. Negotiated Rate |
$102.12 |
| Rate for Payer: Aetna Commercial |
$99.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.83
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$102.12
|
| Rate for Payer: Health EOS Commercial |
$98.79
|
| Rate for Payer: HFN Commercial |
$102.12
|
| Rate for Payer: Multiplan Commercial |
$88.80
|
| Rate for Payer: NAPHCARE Commercial |
$66.60
|
| Rate for Payer: Preferred Network Access Commercial |
$102.12
|
| Rate for Payer: Quartz Beloit One Network |
$54.39
|
| Rate for Payer: Quartz Commercial |
$66.60
|
| Rate for Payer: WEA Trust Commercial |
$61.05
|
| Rate for Payer: WPS Commercial |
$82.22
|
|
|
CARTRIDGE B MONARCH III
|
Facility
IP
|
$50.00
|
|
| Hospital Charge Code |
2964183
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$46.00 |
| Rate for Payer: Aetna Commercial |
$45.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.50
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$46.00
|
| Rate for Payer: Health EOS Commercial |
$44.50
|
| Rate for Payer: HFN Commercial |
$46.00
|
| Rate for Payer: Multiplan Commercial |
$40.00
|
| Rate for Payer: NAPHCARE Commercial |
$30.00
|
| Rate for Payer: Preferred Network Access Commercial |
$46.00
|
| Rate for Payer: Quartz Beloit One Network |
$24.50
|
| Rate for Payer: Quartz Commercial |
$30.00
|
| Rate for Payer: WEA Trust Commercial |
$27.50
|
| Rate for Payer: WPS Commercial |
$37.04
|
|
|
CARTRIDGE B MONARCH III
|
Facility
OP
|
$50.00
|
|
| Hospital Charge Code |
2964183
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$45.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.00
|
| Rate for Payer: Aetna Managed Medicare |
$14.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.50
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$46.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.98
|
| Rate for Payer: Health EOS Commercial |
$44.50
|
| Rate for Payer: HFN Commercial |
$46.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.50
|
| Rate for Payer: Multiplan Commercial |
$40.00
|
| Rate for Payer: NAPHCARE Commercial |
$30.00
|
| Rate for Payer: Preferred Network Access Commercial |
$46.00
|
| Rate for Payer: Quartz Beloit One Network |
$24.50
|
| Rate for Payer: Quartz Commercial |
$32.50
|
| Rate for Payer: Quartz Medicare Advantage |
$30.00
|
| Rate for Payer: The Alliance Commercial |
$200.00
|
| Rate for Payer: WEA Trust Commercial |
$27.50
|
| Rate for Payer: WPS Commercial |
$37.04
|
|
|
CARTRIDGE LIGACLIP BLUE SMALL 6 CLIPS LT100
|
Facility
OP
|
$480.00
|
|
| Hospital Charge Code |
2965762
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$134.40 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: Aetna Commercial |
$432.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.80
|
| Rate for Payer: Aetna Managed Medicare |
$134.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$312.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$240.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$230.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.40
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$441.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.61
|
| Rate for Payer: Health EOS Commercial |
$427.20
|
| Rate for Payer: HFN Commercial |
$441.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$360.00
|
| Rate for Payer: Multiplan Commercial |
$384.00
|
| Rate for Payer: NAPHCARE Commercial |
$288.00
|
| Rate for Payer: Preferred Network Access Commercial |
$441.60
|
| Rate for Payer: Quartz Beloit One Network |
$235.20
|
| Rate for Payer: Quartz Commercial |
$312.00
|
| Rate for Payer: Quartz Medicare Advantage |
$288.00
|
| Rate for Payer: The Alliance Commercial |
$1,920.00
|
| Rate for Payer: WEA Trust Commercial |
$264.00
|
| Rate for Payer: WPS Commercial |
$355.54
|
|
|
CARTRIDGE LIGACLIP BLUE SMALL 6 CLIPS LT100
|
Facility
IP
|
$480.00
|
|
| Hospital Charge Code |
2965762
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$235.20 |
| Max. Negotiated Rate |
$441.60 |
| Rate for Payer: Aetna Commercial |
$432.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.40
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$441.60
|
| Rate for Payer: Health EOS Commercial |
$427.20
|
| Rate for Payer: HFN Commercial |
$441.60
|
| Rate for Payer: Multiplan Commercial |
$384.00
|
| Rate for Payer: NAPHCARE Commercial |
$288.00
|
| Rate for Payer: Preferred Network Access Commercial |
$441.60
|
| Rate for Payer: Quartz Beloit One Network |
$235.20
|
| Rate for Payer: Quartz Commercial |
$288.00
|
| Rate for Payer: WEA Trust Commercial |
$264.00
|
| Rate for Payer: WPS Commercial |
$355.54
|
|
|
CARTRIDGE LIGACLIP GREEN MED/LG 6 CLIPS LT300
|
Facility
OP
|
$480.00
|
|
| Hospital Charge Code |
2965764
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$134.40 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: Aetna Commercial |
$432.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.80
|
| Rate for Payer: Aetna Managed Medicare |
$134.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$312.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$240.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$230.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.40
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$441.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.61
|
| Rate for Payer: Health EOS Commercial |
$427.20
|
| Rate for Payer: HFN Commercial |
$441.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$360.00
|
| Rate for Payer: Multiplan Commercial |
$384.00
|
| Rate for Payer: NAPHCARE Commercial |
$288.00
|
| Rate for Payer: Preferred Network Access Commercial |
$441.60
|
| Rate for Payer: Quartz Beloit One Network |
$235.20
|
| Rate for Payer: Quartz Commercial |
$312.00
|
| Rate for Payer: Quartz Medicare Advantage |
$288.00
|
| Rate for Payer: The Alliance Commercial |
$1,920.00
|
| Rate for Payer: WEA Trust Commercial |
$264.00
|
| Rate for Payer: WPS Commercial |
$355.54
|
|
|
CARTRIDGE LIGACLIP GREEN MED/LG 6 CLIPS LT300
|
Facility
IP
|
$480.00
|
|
| Hospital Charge Code |
2965764
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$235.20 |
| Max. Negotiated Rate |
$441.60 |
| Rate for Payer: Aetna Commercial |
$432.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.40
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$441.60
|
| Rate for Payer: Health EOS Commercial |
$427.20
|
| Rate for Payer: HFN Commercial |
$441.60
|
| Rate for Payer: Multiplan Commercial |
$384.00
|
| Rate for Payer: NAPHCARE Commercial |
$288.00
|
| Rate for Payer: Preferred Network Access Commercial |
$441.60
|
| Rate for Payer: Quartz Beloit One Network |
$235.20
|
| Rate for Payer: Quartz Commercial |
$288.00
|
| Rate for Payer: WEA Trust Commercial |
$264.00
|
| Rate for Payer: WPS Commercial |
$355.54
|
|
|
CARTRIDGE LIGACLIP SILVER MEDIUM 20 CLIPS LT202
|
Facility
OP
|
$480.00
|
|
| Hospital Charge Code |
2965763
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$134.40 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: Aetna Commercial |
$432.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.80
|
| Rate for Payer: Aetna Managed Medicare |
$134.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$312.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$240.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$230.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.40
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$441.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.61
|
| Rate for Payer: Health EOS Commercial |
$427.20
|
| Rate for Payer: HFN Commercial |
$441.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$360.00
|
| Rate for Payer: Multiplan Commercial |
$384.00
|
| Rate for Payer: NAPHCARE Commercial |
$288.00
|
| Rate for Payer: Preferred Network Access Commercial |
$441.60
|
| Rate for Payer: Quartz Beloit One Network |
$235.20
|
| Rate for Payer: Quartz Commercial |
$312.00
|
| Rate for Payer: Quartz Medicare Advantage |
$288.00
|
| Rate for Payer: The Alliance Commercial |
$1,920.00
|
| Rate for Payer: WEA Trust Commercial |
$264.00
|
| Rate for Payer: WPS Commercial |
$355.54
|
|
|
CARTRIDGE LIGACLIP SILVER MEDIUM 20 CLIPS LT202
|
Facility
IP
|
$480.00
|
|
| Hospital Charge Code |
2965763
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$235.20 |
| Max. Negotiated Rate |
$441.60 |
| Rate for Payer: Aetna Commercial |
$432.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.40
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$441.60
|
| Rate for Payer: Health EOS Commercial |
$427.20
|
| Rate for Payer: HFN Commercial |
$441.60
|
| Rate for Payer: Multiplan Commercial |
$384.00
|
| Rate for Payer: NAPHCARE Commercial |
$288.00
|
| Rate for Payer: Preferred Network Access Commercial |
$441.60
|
| Rate for Payer: Quartz Beloit One Network |
$235.20
|
| Rate for Payer: Quartz Commercial |
$288.00
|
| Rate for Payer: WEA Trust Commercial |
$264.00
|
| Rate for Payer: WPS Commercial |
$355.54
|
|
|
CARTRIDGE LIGACLIP YELLOW LARGE 6 CLIPS LT400
|
Facility
IP
|
$480.00
|
|
| Hospital Charge Code |
2965765
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$235.20 |
| Max. Negotiated Rate |
$441.60 |
| Rate for Payer: Aetna Commercial |
$432.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.40
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$441.60
|
| Rate for Payer: Health EOS Commercial |
$427.20
|
| Rate for Payer: HFN Commercial |
$441.60
|
| Rate for Payer: Multiplan Commercial |
$384.00
|
| Rate for Payer: NAPHCARE Commercial |
$288.00
|
| Rate for Payer: Preferred Network Access Commercial |
$441.60
|
| Rate for Payer: Quartz Beloit One Network |
$235.20
|
| Rate for Payer: Quartz Commercial |
$288.00
|
| Rate for Payer: WEA Trust Commercial |
$264.00
|
| Rate for Payer: WPS Commercial |
$355.54
|
|
|
CARTRIDGE LIGACLIP YELLOW LARGE 6 CLIPS LT400
|
Facility
OP
|
$480.00
|
|
| Hospital Charge Code |
2965765
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$134.40 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: Aetna Commercial |
$432.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.80
|
| Rate for Payer: Aetna Managed Medicare |
$134.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$312.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$240.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$230.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.40
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$441.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.61
|
| Rate for Payer: Health EOS Commercial |
$427.20
|
| Rate for Payer: HFN Commercial |
$441.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$360.00
|
| Rate for Payer: Multiplan Commercial |
$384.00
|
| Rate for Payer: NAPHCARE Commercial |
$288.00
|
| Rate for Payer: Preferred Network Access Commercial |
$441.60
|
| Rate for Payer: Quartz Beloit One Network |
$235.20
|
| Rate for Payer: Quartz Commercial |
$312.00
|
| Rate for Payer: Quartz Medicare Advantage |
$288.00
|
| Rate for Payer: The Alliance Commercial |
$1,920.00
|
| Rate for Payer: WEA Trust Commercial |
$264.00
|
| Rate for Payer: WPS Commercial |
$355.54
|
|
|
Cartridges-V-Vac Suction Rplmt
|
Facility
IP
|
$81.00
|
|
| Hospital Charge Code |
3040350
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$48.60
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Cartridges-V-Vac Suction Rplmt
|
Facility
OP
|
$81.00
|
|
| Hospital Charge Code |
3040350
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.68 |
| Max. Negotiated Rate |
$324.00 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Aetna Managed Medicare |
$22.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.33
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.75
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$52.65
|
| Rate for Payer: Quartz Medicare Advantage |
$48.60
|
| Rate for Payer: The Alliance Commercial |
$324.00
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
CARTRIDGE V-VAC SUCTION
|
Facility
OP
|
$298.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2963615
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$83.44 |
| Max. Negotiated Rate |
$274.16 |
| Rate for Payer: Aetna Commercial |
$268.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$256.28
|
| Rate for Payer: Aetna Managed Medicare |
$83.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$193.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$149.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$143.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.94
|
| Rate for Payer: Cash Price |
$89.40
|
| Rate for Payer: Cigna Commercial |
$274.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$166.76
|
| Rate for Payer: Health EOS Commercial |
$265.22
|
| Rate for Payer: HFN Commercial |
$274.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$223.50
|
| Rate for Payer: Multiplan Commercial |
$238.40
|
| Rate for Payer: NAPHCARE Commercial |
$178.80
|
| Rate for Payer: Preferred Network Access Commercial |
$274.16
|
| Rate for Payer: Quartz Beloit One Network |
$146.02
|
| Rate for Payer: Quartz Commercial |
$193.70
|
| Rate for Payer: Quartz Medicare Advantage |
$178.80
|
| Rate for Payer: WEA Trust Commercial |
$163.90
|
| Rate for Payer: WPS Commercial |
$220.73
|
|
|
CARTRIDGE V-VAC SUCTION
|
Facility
IP
|
$298.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2963615
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$146.02 |
| Max. Negotiated Rate |
$274.16 |
| Rate for Payer: Aetna Commercial |
$268.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.94
|
| Rate for Payer: Cash Price |
$89.40
|
| Rate for Payer: Cigna Commercial |
$274.16
|
| Rate for Payer: Health EOS Commercial |
$265.22
|
| Rate for Payer: HFN Commercial |
$274.16
|
| Rate for Payer: Multiplan Commercial |
$238.40
|
| Rate for Payer: NAPHCARE Commercial |
$178.80
|
| Rate for Payer: Preferred Network Access Commercial |
$274.16
|
| Rate for Payer: Quartz Beloit One Network |
$146.02
|
| Rate for Payer: Quartz Commercial |
$178.80
|
| Rate for Payer: WEA Trust Commercial |
$163.90
|
| Rate for Payer: WPS Commercial |
$220.73
|
|
|
CASE CONTACT LENS FLIP TOP
|
Facility
IP
|
$27.00
|
|
| Hospital Charge Code |
2962972
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$13.23 |
| Max. Negotiated Rate |
$24.84 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$16.20
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
CASE CONTACT LENS FLIP TOP
|
Facility
OP
|
$27.00
|
|
| Hospital Charge Code |
2962972
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Aetna Managed Medicare |
$7.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.11
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.25
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$17.55
|
| Rate for Payer: Quartz Medicare Advantage |
$16.20
|
| Rate for Payer: The Alliance Commercial |
$108.00
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
CASH Brace - PT Equipment Issued Rehab
|
Facility
IP
|
$1,654.00
|
|
|
Service Code
|
HCPCS L0472
|
| Hospital Charge Code |
2989878
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$810.46 |
| Max. Negotiated Rate |
$1,521.68 |
| Rate for Payer: Aetna Commercial |
$1,488.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$876.62
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cigna Commercial |
$1,521.68
|
| Rate for Payer: Health EOS Commercial |
$1,472.06
|
| Rate for Payer: HFN Commercial |
$1,521.68
|
| Rate for Payer: Multiplan Commercial |
$1,323.20
|
| Rate for Payer: NAPHCARE Commercial |
$992.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,521.68
|
| Rate for Payer: Quartz Beloit One Network |
$810.46
|
| Rate for Payer: Quartz Commercial |
$992.40
|
| Rate for Payer: WEA Trust Commercial |
$909.70
|
| Rate for Payer: WPS Commercial |
$1,225.12
|
|
|
CASH Brace - PT Equipment Issued Rehab
|
Facility
OP
|
$1,654.00
|
|
|
Service Code
|
HCPCS L0472
|
| Hospital Charge Code |
2989878
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$329.19 |
| Max. Negotiated Rate |
$6,616.00 |
| Rate for Payer: Aetna Commercial |
$1,488.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,422.44
|
| Rate for Payer: Aetna Managed Medicare |
$463.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$329.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$329.19
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$329.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$876.62
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cigna Commercial |
$1,521.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$925.58
|
| Rate for Payer: Health EOS Commercial |
$1,472.06
|
| Rate for Payer: HFN Commercial |
$1,521.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,240.50
|
| Rate for Payer: Multiplan Commercial |
$1,323.20
|
| Rate for Payer: NAPHCARE Commercial |
$992.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,521.68
|
| Rate for Payer: Quartz Beloit One Network |
$810.46
|
| Rate for Payer: Quartz Commercial |
$1,075.10
|
| Rate for Payer: Quartz Medicare Advantage |
$992.40
|
| Rate for Payer: The Alliance Commercial |
$6,616.00
|
| Rate for Payer: WEA Trust Commercial |
$909.70
|
| Rate for Payer: WPS Commercial |
$1,225.12
|
|
|
CASH Brace - PT Equipment Issued Rehab
|
Professional
|
$1,654.00
|
|
|
Service Code
|
HCPCS L0472
|
| Hospital Charge Code |
2989878
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$727.76 |
| Max. Negotiated Rate |
$1,571.30 |
| Rate for Payer: Aetna Commercial |
$1,571.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,422.44
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cash Price |
$496.20
|
| Rate for Payer: Cigna Commercial |
$1,571.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$827.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$992.40
|
| Rate for Payer: Health EOS Commercial |
$1,505.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,434.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,434.63
|
| Rate for Payer: Multiplan Commercial |
$1,323.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,571.30
|
| Rate for Payer: Quartz Beloit One Network |
$727.76
|
| Rate for Payer: Quartz Commercial |
$942.78
|
| Rate for Payer: The Alliance Commercial |
$827.00
|
| Rate for Payer: WEA Trust Commercial |
$909.70
|
| Rate for Payer: WPS Commercial |
$1,225.12
|
|
|
CASSETTE LIPID PRFL GLU 10-991
|
Facility
OP
|
$270.00
|
|
| Hospital Charge Code |
2969763
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.20
|
| Rate for Payer: Aetna Managed Medicare |
$75.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$175.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$129.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.10
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$248.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.09
|
| Rate for Payer: Health EOS Commercial |
$240.30
|
| Rate for Payer: HFN Commercial |
$248.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.50
|
| Rate for Payer: Multiplan Commercial |
$216.00
|
| Rate for Payer: NAPHCARE Commercial |
$162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$248.40
|
| Rate for Payer: Quartz Beloit One Network |
$132.30
|
| Rate for Payer: Quartz Commercial |
$175.50
|
| Rate for Payer: Quartz Medicare Advantage |
$162.00
|
| Rate for Payer: The Alliance Commercial |
$1,080.00
|
| Rate for Payer: WEA Trust Commercial |
$148.50
|
| Rate for Payer: WPS Commercial |
$199.99
|
|
|
CASSETTE LIPID PRFL GLU 10-991
|
Facility
IP
|
$270.00
|
|
| Hospital Charge Code |
2969763
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$248.40 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.10
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$248.40
|
| Rate for Payer: Health EOS Commercial |
$240.30
|
| Rate for Payer: HFN Commercial |
$248.40
|
| Rate for Payer: Multiplan Commercial |
$216.00
|
| Rate for Payer: NAPHCARE Commercial |
$162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$248.40
|
| Rate for Payer: Quartz Beloit One Network |
$132.30
|
| Rate for Payer: Quartz Commercial |
$162.00
|
| Rate for Payer: WEA Trust Commercial |
$148.50
|
| Rate for Payer: WPS Commercial |
$199.99
|
|
|
CASSETTE V.A.C. VERALINK WITH ADAPTOR (VERAFLO) ULTLNK0500
|
Facility
IP
|
$861.00
|
|
| Hospital Charge Code |
5583408
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$421.89 |
| Max. Negotiated Rate |
$792.12 |
| Rate for Payer: Aetna Commercial |
$774.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$456.33
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$792.12
|
| Rate for Payer: Health EOS Commercial |
$766.29
|
| Rate for Payer: HFN Commercial |
$792.12
|
| Rate for Payer: Multiplan Commercial |
$688.80
|
| Rate for Payer: NAPHCARE Commercial |
$516.60
|
| Rate for Payer: Preferred Network Access Commercial |
$792.12
|
| Rate for Payer: Quartz Beloit One Network |
$421.89
|
| Rate for Payer: Quartz Commercial |
$516.60
|
| Rate for Payer: WEA Trust Commercial |
$473.55
|
| Rate for Payer: WPS Commercial |
$637.74
|
|
