|
CANISTER INFOV.A.C. 500ML WITH GEL M8275063/10
|
Facility
|
IP
|
$853.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
3785556
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$434.69 |
| Max. Negotiated Rate |
$816.15 |
| Rate for Payer: Aetna Commercial |
$798.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$762.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.17
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cigna Commercial |
$816.15
|
| Rate for Payer: Health EOS Commercial |
$789.54
|
| Rate for Payer: HFN Commercial |
$816.15
|
| Rate for Payer: Multiplan Commercial |
$709.70
|
| Rate for Payer: Preferred Network Access Commercial |
$816.15
|
| Rate for Payer: Quartz Beloit One Network |
$434.69
|
| Rate for Payer: Quartz Commercial |
$532.27
|
| Rate for Payer: WEA Trust Commercial |
$487.92
|
| Rate for Payer: WPS Commercial |
$657.07
|
|
|
CANISTER INFOV.A.C. 500ML WITH GEL M8275063/10
|
Facility
|
OP
|
$853.00
|
|
|
Service Code
|
HCPCS A6550
|
| Hospital Charge Code |
3785556
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.79 |
| Max. Negotiated Rate |
$816.15 |
| Rate for Payer: Aetna Commercial |
$798.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$762.92
|
| Rate for Payer: Aetna Managed Medicare |
$248.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$576.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$443.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$425.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.17
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cigna Commercial |
$816.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$496.45
|
| Rate for Payer: Health EOS Commercial |
$789.54
|
| Rate for Payer: HFN Commercial |
$816.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$665.34
|
| Rate for Payer: Multiplan Commercial |
$709.70
|
| Rate for Payer: NAPHCARE Commercial |
$532.27
|
| Rate for Payer: Preferred Network Access Commercial |
$816.15
|
| Rate for Payer: Quartz Beloit One Network |
$434.69
|
| Rate for Payer: Quartz Commercial |
$576.63
|
| Rate for Payer: Quartz Medicare Advantage |
$532.27
|
| Rate for Payer: The Alliance Commercial |
$132.79
|
| Rate for Payer: WEA Trust Commercial |
$487.92
|
| Rate for Payer: WPS Commercial |
$657.07
|
|
|
CANISTER KIT W/ISOLYZER #M6275063-10
|
Facility
|
IP
|
$800.00
|
|
| Hospital Charge Code |
2974089
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$407.68 |
| Max. Negotiated Rate |
$765.44 |
| Rate for Payer: Aetna Commercial |
$748.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$715.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$440.96
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Cigna Commercial |
$765.44
|
| Rate for Payer: Health EOS Commercial |
$740.48
|
| Rate for Payer: HFN Commercial |
$765.44
|
| Rate for Payer: Multiplan Commercial |
$665.60
|
| Rate for Payer: Preferred Network Access Commercial |
$765.44
|
| Rate for Payer: Quartz Beloit One Network |
$407.68
|
| Rate for Payer: Quartz Commercial |
$499.20
|
| Rate for Payer: WEA Trust Commercial |
$457.60
|
| Rate for Payer: WPS Commercial |
$616.24
|
|
|
CANISTER KIT W/ISOLYZER #M6275063-10
|
Facility
|
OP
|
$800.00
|
|
| Hospital Charge Code |
2974089
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$232.96 |
| Max. Negotiated Rate |
$765.44 |
| Rate for Payer: Aetna Commercial |
$748.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$715.52
|
| Rate for Payer: Aetna Managed Medicare |
$232.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$540.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$416.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$399.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$440.96
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Cigna Commercial |
$765.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$465.60
|
| Rate for Payer: Health EOS Commercial |
$740.48
|
| Rate for Payer: HFN Commercial |
$765.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$624.00
|
| Rate for Payer: Multiplan Commercial |
$665.60
|
| Rate for Payer: NAPHCARE Commercial |
$499.20
|
| Rate for Payer: Preferred Network Access Commercial |
$765.44
|
| Rate for Payer: Quartz Beloit One Network |
$407.68
|
| Rate for Payer: Quartz Commercial |
$540.80
|
| Rate for Payer: Quartz Medicare Advantage |
$499.20
|
| Rate for Payer: The Alliance Commercial |
$416.00
|
| Rate for Payer: WEA Trust Commercial |
$457.60
|
| Rate for Payer: WPS Commercial |
$616.24
|
|
|
CANISTER PREVENA 150ML PRE4095
|
Facility
|
IP
|
$556.00
|
|
|
Service Code
|
HCPCS A7000
|
| Hospital Charge Code |
5074885
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$283.34 |
| Max. Negotiated Rate |
$531.98 |
| Rate for Payer: Aetna Commercial |
$520.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$497.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$306.47
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$531.98
|
| Rate for Payer: Health EOS Commercial |
$514.63
|
| Rate for Payer: HFN Commercial |
$531.98
|
| Rate for Payer: Multiplan Commercial |
$462.59
|
| Rate for Payer: Preferred Network Access Commercial |
$531.98
|
| Rate for Payer: Quartz Beloit One Network |
$283.34
|
| Rate for Payer: Quartz Commercial |
$346.94
|
| Rate for Payer: WEA Trust Commercial |
$318.03
|
| Rate for Payer: WPS Commercial |
$428.29
|
|
|
CANISTER PREVENA 150ML PRE4095
|
Facility
|
OP
|
$556.00
|
|
|
Service Code
|
HCPCS A7000
|
| Hospital Charge Code |
5074885
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$161.91 |
| Max. Negotiated Rate |
$531.98 |
| Rate for Payer: Aetna Commercial |
$520.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$497.29
|
| Rate for Payer: Aetna Managed Medicare |
$161.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$375.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$289.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$277.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$306.47
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$531.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$323.59
|
| Rate for Payer: Health EOS Commercial |
$514.63
|
| Rate for Payer: HFN Commercial |
$531.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$433.68
|
| Rate for Payer: Multiplan Commercial |
$462.59
|
| Rate for Payer: NAPHCARE Commercial |
$346.94
|
| Rate for Payer: Preferred Network Access Commercial |
$531.98
|
| Rate for Payer: Quartz Beloit One Network |
$283.34
|
| Rate for Payer: Quartz Commercial |
$375.86
|
| Rate for Payer: Quartz Medicare Advantage |
$346.94
|
| Rate for Payer: The Alliance Commercial |
$289.12
|
| Rate for Payer: WEA Trust Commercial |
$318.03
|
| Rate for Payer: WPS Commercial |
$428.29
|
|
|
CANISTER PREVENA 45ML PRE1095.S
|
Facility
|
OP
|
$505.00
|
|
|
Service Code
|
HCPCS A7000
|
| Hospital Charge Code |
4595761
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$147.06 |
| Max. Negotiated Rate |
$483.18 |
| Rate for Payer: Aetna Commercial |
$472.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$451.67
|
| Rate for Payer: Aetna Managed Medicare |
$147.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$341.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$262.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$252.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$278.36
|
| Rate for Payer: Cash Price |
$151.50
|
| Rate for Payer: Cigna Commercial |
$483.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$293.91
|
| Rate for Payer: Health EOS Commercial |
$467.43
|
| Rate for Payer: HFN Commercial |
$483.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$393.90
|
| Rate for Payer: Multiplan Commercial |
$420.16
|
| Rate for Payer: NAPHCARE Commercial |
$315.12
|
| Rate for Payer: Preferred Network Access Commercial |
$483.18
|
| Rate for Payer: Quartz Beloit One Network |
$257.35
|
| Rate for Payer: Quartz Commercial |
$341.38
|
| Rate for Payer: Quartz Medicare Advantage |
$315.12
|
| Rate for Payer: The Alliance Commercial |
$262.60
|
| Rate for Payer: WEA Trust Commercial |
$288.86
|
| Rate for Payer: WPS Commercial |
$389.00
|
|
|
CANISTER PREVENA 45ML PRE1095.S
|
Facility
|
IP
|
$505.00
|
|
|
Service Code
|
HCPCS A7000
|
| Hospital Charge Code |
4595761
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$257.35 |
| Max. Negotiated Rate |
$483.18 |
| Rate for Payer: Aetna Commercial |
$472.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$451.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$278.36
|
| Rate for Payer: Cash Price |
$151.50
|
| Rate for Payer: Cigna Commercial |
$483.18
|
| Rate for Payer: Health EOS Commercial |
$467.43
|
| Rate for Payer: HFN Commercial |
$483.18
|
| Rate for Payer: Multiplan Commercial |
$420.16
|
| Rate for Payer: Preferred Network Access Commercial |
$483.18
|
| Rate for Payer: Quartz Beloit One Network |
$257.35
|
| Rate for Payer: Quartz Commercial |
$315.12
|
| Rate for Payer: WEA Trust Commercial |
$288.86
|
| Rate for Payer: WPS Commercial |
$389.00
|
|
|
CANISTER TRUCLEAR HI-FLOW 72200024
|
Facility
|
OP
|
$128.00
|
|
| Hospital Charge Code |
5074777
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$37.27 |
| Max. Negotiated Rate |
$122.47 |
| Rate for Payer: Aetna Commercial |
$119.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Aetna Managed Medicare |
$37.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$86.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$66.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$63.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$70.55
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$122.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.50
|
| Rate for Payer: Health EOS Commercial |
$118.48
|
| Rate for Payer: HFN Commercial |
$122.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$99.84
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: NAPHCARE Commercial |
$79.87
|
| Rate for Payer: Preferred Network Access Commercial |
$122.47
|
| Rate for Payer: Quartz Beloit One Network |
$65.23
|
| Rate for Payer: Quartz Commercial |
$86.53
|
| Rate for Payer: Quartz Medicare Advantage |
$79.87
|
| Rate for Payer: The Alliance Commercial |
$66.56
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: WPS Commercial |
$98.60
|
|
|
CANISTER TRUCLEAR HI-FLOW 72200024
|
Facility
|
IP
|
$128.00
|
|
| Hospital Charge Code |
5074777
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$65.23 |
| Max. Negotiated Rate |
$122.47 |
| Rate for Payer: Aetna Commercial |
$119.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$70.55
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$122.47
|
| Rate for Payer: Health EOS Commercial |
$118.48
|
| Rate for Payer: HFN Commercial |
$122.47
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: Preferred Network Access Commercial |
$122.47
|
| Rate for Payer: Quartz Beloit One Network |
$65.23
|
| Rate for Payer: Quartz Commercial |
$79.87
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: WPS Commercial |
$98.60
|
|
|
Cannabinoids, Pnl Serum
|
Facility
|
OP
|
$263.00
|
|
|
Service Code
|
CPT 80349
|
| Hospital Charge Code |
5812130
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$76.59 |
| Max. Negotiated Rate |
$251.64 |
| Rate for Payer: Aetna Commercial |
$246.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$235.23
|
| Rate for Payer: Aetna Managed Medicare |
$76.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$177.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$136.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$131.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.97
|
| Rate for Payer: Cash Price |
$78.90
|
| Rate for Payer: Cigna Commercial |
$251.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$153.07
|
| Rate for Payer: Health EOS Commercial |
$243.43
|
| Rate for Payer: HFN Commercial |
$251.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$205.14
|
| Rate for Payer: Multiplan Commercial |
$218.82
|
| Rate for Payer: NAPHCARE Commercial |
$164.11
|
| Rate for Payer: Preferred Network Access Commercial |
$251.64
|
| Rate for Payer: Quartz Beloit One Network |
$134.02
|
| Rate for Payer: Quartz Commercial |
$177.79
|
| Rate for Payer: Quartz Medicare Advantage |
$164.11
|
| Rate for Payer: The Alliance Commercial |
$136.76
|
| Rate for Payer: United Healthcare PPO |
$205.14
|
| Rate for Payer: WEA Trust Commercial |
$150.44
|
| Rate for Payer: WPS Commercial |
$202.59
|
|
|
Cannabinoids, Pnl Serum
|
Professional
|
Both
|
$263.00
|
|
|
Service Code
|
CPT 80349
|
| Hospital Charge Code |
5812130
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$259.84 |
| Rate for Payer: Aetna Commercial |
$259.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$235.23
|
| Rate for Payer: Cash Price |
$78.90
|
| Rate for Payer: Cash Price |
$78.90
|
| Rate for Payer: Cigna Commercial |
$259.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$136.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$164.11
|
| Rate for Payer: Health EOS Commercial |
$248.90
|
| Rate for Payer: HFN Commercial |
$259.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$218.82
|
| Rate for Payer: Preferred Network Access Commercial |
$259.84
|
| Rate for Payer: Quartz Beloit One Network |
$120.35
|
| Rate for Payer: Quartz Commercial |
$155.91
|
| Rate for Payer: The Alliance Commercial |
$136.76
|
| Rate for Payer: WEA Trust Commercial |
$150.44
|
| Rate for Payer: WPS Commercial |
$202.59
|
|
|
Cannabinoids, Pnl Serum
|
Facility
|
IP
|
$263.00
|
|
|
Service Code
|
CPT 80349
|
| Hospital Charge Code |
5812130
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$134.02 |
| Max. Negotiated Rate |
$251.64 |
| Rate for Payer: Aetna Commercial |
$246.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$235.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.97
|
| Rate for Payer: Cash Price |
$78.90
|
| Rate for Payer: Cigna Commercial |
$251.64
|
| Rate for Payer: Health EOS Commercial |
$243.43
|
| Rate for Payer: HFN Commercial |
$251.64
|
| Rate for Payer: Multiplan Commercial |
$218.82
|
| Rate for Payer: Preferred Network Access Commercial |
$251.64
|
| Rate for Payer: Quartz Beloit One Network |
$134.02
|
| Rate for Payer: Quartz Commercial |
$164.11
|
| Rate for Payer: WEA Trust Commercial |
$150.44
|
| Rate for Payer: WPS Commercial |
$202.59
|
|
|
CANN.SCREW 6.5 X 115MM #121643
|
Facility
|
OP
|
$2,674.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2975001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$778.67 |
| Max. Negotiated Rate |
$2,558.48 |
| Rate for Payer: Aetna Commercial |
$2,502.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,391.63
|
| Rate for Payer: Aetna Managed Medicare |
$778.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,807.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,390.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,334.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,473.91
|
| Rate for Payer: Cash Price |
$802.20
|
| Rate for Payer: Cigna Commercial |
$2,558.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,556.27
|
| Rate for Payer: Health EOS Commercial |
$2,475.05
|
| Rate for Payer: HFN Commercial |
$2,558.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,085.72
|
| Rate for Payer: Multiplan Commercial |
$2,224.77
|
| Rate for Payer: NAPHCARE Commercial |
$1,668.58
|
| Rate for Payer: Preferred Network Access Commercial |
$2,558.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,362.67
|
| Rate for Payer: Quartz Commercial |
$1,807.62
|
| Rate for Payer: Quartz Medicare Advantage |
$1,668.58
|
| Rate for Payer: The Alliance Commercial |
$1,390.48
|
| Rate for Payer: WEA Trust Commercial |
$1,529.53
|
| Rate for Payer: WPS Commercial |
$2,059.78
|
|
|
CANN.SCREW 6.5 X 115MM #121643
|
Facility
|
IP
|
$2,674.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2975001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.67 |
| Max. Negotiated Rate |
$2,558.48 |
| Rate for Payer: Aetna Commercial |
$2,502.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,391.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,473.91
|
| Rate for Payer: Cash Price |
$802.20
|
| Rate for Payer: Cigna Commercial |
$2,558.48
|
| Rate for Payer: Health EOS Commercial |
$2,475.05
|
| Rate for Payer: HFN Commercial |
$2,558.48
|
| Rate for Payer: Multiplan Commercial |
$2,224.77
|
| Rate for Payer: Preferred Network Access Commercial |
$2,558.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,362.67
|
| Rate for Payer: Quartz Commercial |
$1,668.58
|
| Rate for Payer: WEA Trust Commercial |
$1,529.53
|
| Rate for Payer: WPS Commercial |
$2,059.78
|
|
|
CANN.SCREW 6.5 X 120MM #121644
|
Facility
|
OP
|
$2,674.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2975068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$778.67 |
| Max. Negotiated Rate |
$2,558.48 |
| Rate for Payer: Aetna Commercial |
$2,502.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,391.63
|
| Rate for Payer: Aetna Managed Medicare |
$778.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,807.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,390.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,334.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,473.91
|
| Rate for Payer: Cash Price |
$802.20
|
| Rate for Payer: Cigna Commercial |
$2,558.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,556.27
|
| Rate for Payer: Health EOS Commercial |
$2,475.05
|
| Rate for Payer: HFN Commercial |
$2,558.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,085.72
|
| Rate for Payer: Multiplan Commercial |
$2,224.77
|
| Rate for Payer: NAPHCARE Commercial |
$1,668.58
|
| Rate for Payer: Preferred Network Access Commercial |
$2,558.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,362.67
|
| Rate for Payer: Quartz Commercial |
$1,807.62
|
| Rate for Payer: Quartz Medicare Advantage |
$1,668.58
|
| Rate for Payer: The Alliance Commercial |
$1,390.48
|
| Rate for Payer: WEA Trust Commercial |
$1,529.53
|
| Rate for Payer: WPS Commercial |
$2,059.78
|
|
|
CANN.SCREW 6.5 X 120MM #121644
|
Facility
|
IP
|
$2,674.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
2975068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.67 |
| Max. Negotiated Rate |
$2,558.48 |
| Rate for Payer: Aetna Commercial |
$2,502.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,391.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,473.91
|
| Rate for Payer: Cash Price |
$802.20
|
| Rate for Payer: Cigna Commercial |
$2,558.48
|
| Rate for Payer: Health EOS Commercial |
$2,475.05
|
| Rate for Payer: HFN Commercial |
$2,558.48
|
| Rate for Payer: Multiplan Commercial |
$2,224.77
|
| Rate for Payer: Preferred Network Access Commercial |
$2,558.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,362.67
|
| Rate for Payer: Quartz Commercial |
$1,668.58
|
| Rate for Payer: WEA Trust Commercial |
$1,529.53
|
| Rate for Payer: WPS Commercial |
$2,059.78
|
|
|
CANNULA 02 NASAL 1867
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
HCPCS A4615
|
| Hospital Charge Code |
2974614
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.97 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$30.58
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
CANNULA 02 NASAL 1867
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
HCPCS A4615
|
| Hospital Charge Code |
2974614
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.33 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Aetna Managed Medicare |
$14.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.52
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.22
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: NAPHCARE Commercial |
$30.58
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$33.12
|
| Rate for Payer: Quartz Medicare Advantage |
$30.58
|
| Rate for Payer: The Alliance Commercial |
$4.33
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
CANNULA 12FR CORONARY 30012
|
Facility
|
IP
|
$558.00
|
|
| Hospital Charge Code |
2965774
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$284.36 |
| Max. Negotiated Rate |
$533.89 |
| Rate for Payer: Aetna Commercial |
$522.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$499.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.57
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$533.89
|
| Rate for Payer: Health EOS Commercial |
$516.48
|
| Rate for Payer: HFN Commercial |
$533.89
|
| Rate for Payer: Multiplan Commercial |
$464.26
|
| Rate for Payer: Preferred Network Access Commercial |
$533.89
|
| Rate for Payer: Quartz Beloit One Network |
$284.36
|
| Rate for Payer: Quartz Commercial |
$348.19
|
| Rate for Payer: WEA Trust Commercial |
$319.18
|
| Rate for Payer: WPS Commercial |
$429.83
|
|
|
CANNULA 12FR CORONARY 30012
|
Facility
|
OP
|
$558.00
|
|
| Hospital Charge Code |
2965774
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$162.49 |
| Max. Negotiated Rate |
$533.89 |
| Rate for Payer: Aetna Commercial |
$522.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$499.08
|
| Rate for Payer: Aetna Managed Medicare |
$162.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$377.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$290.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$278.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.57
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$533.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$324.76
|
| Rate for Payer: Health EOS Commercial |
$516.48
|
| Rate for Payer: HFN Commercial |
$533.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$435.24
|
| Rate for Payer: Multiplan Commercial |
$464.26
|
| Rate for Payer: NAPHCARE Commercial |
$348.19
|
| Rate for Payer: Preferred Network Access Commercial |
$533.89
|
| Rate for Payer: Quartz Beloit One Network |
$284.36
|
| Rate for Payer: Quartz Commercial |
$377.21
|
| Rate for Payer: Quartz Medicare Advantage |
$348.19
|
| Rate for Payer: The Alliance Commercial |
$290.16
|
| Rate for Payer: WEA Trust Commercial |
$319.18
|
| Rate for Payer: WPS Commercial |
$429.83
|
|
|
CANNULA 13FR RETROGRADE 94113T
|
Facility
|
OP
|
$1,184.00
|
|
| Hospital Charge Code |
2965372
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$344.78 |
| Max. Negotiated Rate |
$1,132.85 |
| Rate for Payer: Aetna Commercial |
$1,108.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,058.97
|
| Rate for Payer: Aetna Managed Medicare |
$344.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$800.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$615.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$591.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$652.62
|
| Rate for Payer: Cash Price |
$355.20
|
| Rate for Payer: Cigna Commercial |
$1,132.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$689.09
|
| Rate for Payer: Health EOS Commercial |
$1,095.91
|
| Rate for Payer: HFN Commercial |
$1,132.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$923.52
|
| Rate for Payer: Multiplan Commercial |
$985.09
|
| Rate for Payer: NAPHCARE Commercial |
$738.82
|
| Rate for Payer: Preferred Network Access Commercial |
$1,132.85
|
| Rate for Payer: Quartz Beloit One Network |
$603.37
|
| Rate for Payer: Quartz Commercial |
$800.38
|
| Rate for Payer: Quartz Medicare Advantage |
$738.82
|
| Rate for Payer: The Alliance Commercial |
$615.68
|
| Rate for Payer: WEA Trust Commercial |
$677.25
|
| Rate for Payer: WPS Commercial |
$912.04
|
|
|
CANNULA 13FR RETROGRADE 94113T
|
Facility
|
IP
|
$1,184.00
|
|
| Hospital Charge Code |
2965372
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$603.37 |
| Max. Negotiated Rate |
$1,132.85 |
| Rate for Payer: Aetna Commercial |
$1,108.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,058.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$652.62
|
| Rate for Payer: Cash Price |
$355.20
|
| Rate for Payer: Cigna Commercial |
$1,132.85
|
| Rate for Payer: Health EOS Commercial |
$1,095.91
|
| Rate for Payer: HFN Commercial |
$1,132.85
|
| Rate for Payer: Multiplan Commercial |
$985.09
|
| Rate for Payer: Preferred Network Access Commercial |
$1,132.85
|
| Rate for Payer: Quartz Beloit One Network |
$603.37
|
| Rate for Payer: Quartz Commercial |
$738.82
|
| Rate for Payer: WEA Trust Commercial |
$677.25
|
| Rate for Payer: WPS Commercial |
$912.04
|
|
|
CANNULA 15FR RETROGRADE 94115T
|
Facility
|
IP
|
$1,535.00
|
|
| Hospital Charge Code |
2965341
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$782.24 |
| Max. Negotiated Rate |
$1,468.69 |
| Rate for Payer: Aetna Commercial |
$1,436.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,372.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$846.09
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cigna Commercial |
$1,468.69
|
| Rate for Payer: Health EOS Commercial |
$1,420.80
|
| Rate for Payer: HFN Commercial |
$1,468.69
|
| Rate for Payer: Multiplan Commercial |
$1,277.12
|
| Rate for Payer: Preferred Network Access Commercial |
$1,468.69
|
| Rate for Payer: Quartz Beloit One Network |
$782.24
|
| Rate for Payer: Quartz Commercial |
$957.84
|
| Rate for Payer: WEA Trust Commercial |
$878.02
|
| Rate for Payer: WPS Commercial |
$1,182.41
|
|
|
CANNULA 15FR RETROGRADE 94115T
|
Facility
|
OP
|
$1,535.00
|
|
| Hospital Charge Code |
2965341
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$446.99 |
| Max. Negotiated Rate |
$1,468.69 |
| Rate for Payer: Aetna Commercial |
$1,436.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,372.90
|
| Rate for Payer: Aetna Managed Medicare |
$446.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,037.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$798.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$766.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$846.09
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cigna Commercial |
$1,468.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$893.37
|
| Rate for Payer: Health EOS Commercial |
$1,420.80
|
| Rate for Payer: HFN Commercial |
$1,468.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,197.30
|
| Rate for Payer: Multiplan Commercial |
$1,277.12
|
| Rate for Payer: NAPHCARE Commercial |
$957.84
|
| Rate for Payer: Preferred Network Access Commercial |
$1,468.69
|
| Rate for Payer: Quartz Beloit One Network |
$782.24
|
| Rate for Payer: Quartz Commercial |
$1,037.66
|
| Rate for Payer: Quartz Medicare Advantage |
$957.84
|
| Rate for Payer: The Alliance Commercial |
$798.20
|
| Rate for Payer: WEA Trust Commercial |
$878.02
|
| Rate for Payer: WPS Commercial |
$1,182.41
|
|
