|
CAPD Training Per Day
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
CPT 90993
|
| Hospital Charge Code |
3605556
|
|
Hospital Revenue Code
|
840
|
| Min. Negotiated Rate |
$970.28 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,188.10
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
CAPD Training Per Day
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
CPT 90993
|
| Hospital Charge Code |
3605556
|
|
Hospital Revenue Code
|
840
|
| Min. Negotiated Rate |
$554.44 |
| Max. Negotiated Rate |
$1,821.75 |
| Rate for Payer: Aetna Commercial |
$1,782.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,702.94
|
| Rate for Payer: Aetna Managed Medicare |
$554.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,287.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$990.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$950.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,049.48
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,821.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,108.13
|
| Rate for Payer: Health EOS Commercial |
$1,762.34
|
| Rate for Payer: HFN Commercial |
$1,821.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,485.12
|
| Rate for Payer: Multiplan Commercial |
$1,584.13
|
| Rate for Payer: NAPHCARE Commercial |
$1,188.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,821.75
|
| Rate for Payer: Quartz Beloit One Network |
$970.28
|
| Rate for Payer: Quartz Commercial |
$1,287.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,188.10
|
| Rate for Payer: The Alliance Commercial |
$990.08
|
| Rate for Payer: United Healthcare PPO |
$1,485.12
|
| Rate for Payer: WEA Trust Commercial |
$1,089.09
|
| Rate for Payer: WPS Commercial |
$1,466.65
|
|
|
CAP HALO MEDIUM CP-002A
|
Facility
|
OP
|
$620.00
|
|
| Hospital Charge Code |
2973371
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$180.54 |
| Max. Negotiated Rate |
$593.22 |
| Rate for Payer: Aetna Commercial |
$580.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$554.53
|
| Rate for Payer: Aetna Managed Medicare |
$180.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$419.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$322.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$309.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$341.74
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$593.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$360.84
|
| Rate for Payer: Health EOS Commercial |
$573.87
|
| Rate for Payer: HFN Commercial |
$593.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$483.60
|
| Rate for Payer: Multiplan Commercial |
$515.84
|
| Rate for Payer: NAPHCARE Commercial |
$386.88
|
| Rate for Payer: Preferred Network Access Commercial |
$593.22
|
| Rate for Payer: Quartz Beloit One Network |
$315.95
|
| Rate for Payer: Quartz Commercial |
$419.12
|
| Rate for Payer: Quartz Medicare Advantage |
$386.88
|
| Rate for Payer: The Alliance Commercial |
$322.40
|
| Rate for Payer: WEA Trust Commercial |
$354.64
|
| Rate for Payer: WPS Commercial |
$477.59
|
|
|
CAP HALO MEDIUM CP-002A
|
Facility
|
IP
|
$620.00
|
|
| Hospital Charge Code |
2973371
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$315.95 |
| Max. Negotiated Rate |
$593.22 |
| Rate for Payer: Aetna Commercial |
$580.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$554.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$341.74
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$593.22
|
| Rate for Payer: Health EOS Commercial |
$573.87
|
| Rate for Payer: HFN Commercial |
$593.22
|
| Rate for Payer: Multiplan Commercial |
$515.84
|
| Rate for Payer: Preferred Network Access Commercial |
$593.22
|
| Rate for Payer: Quartz Beloit One Network |
$315.95
|
| Rate for Payer: Quartz Commercial |
$386.88
|
| Rate for Payer: WEA Trust Commercial |
$354.64
|
| Rate for Payer: WPS Commercial |
$477.59
|
|
|
CAP HALO SMALL CP-001A
|
Facility
|
IP
|
$596.00
|
|
| Hospital Charge Code |
2973370
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$303.72 |
| Max. Negotiated Rate |
$570.25 |
| Rate for Payer: Aetna Commercial |
$557.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$533.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$328.52
|
| Rate for Payer: Cash Price |
$178.80
|
| Rate for Payer: Cigna Commercial |
$570.25
|
| Rate for Payer: Health EOS Commercial |
$551.66
|
| Rate for Payer: HFN Commercial |
$570.25
|
| Rate for Payer: Multiplan Commercial |
$495.87
|
| Rate for Payer: Preferred Network Access Commercial |
$570.25
|
| Rate for Payer: Quartz Beloit One Network |
$303.72
|
| Rate for Payer: Quartz Commercial |
$371.90
|
| Rate for Payer: WEA Trust Commercial |
$340.91
|
| Rate for Payer: WPS Commercial |
$459.10
|
|
|
CAP HALO SMALL CP-001A
|
Facility
|
OP
|
$596.00
|
|
| Hospital Charge Code |
2973370
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$173.56 |
| Max. Negotiated Rate |
$570.25 |
| Rate for Payer: Aetna Commercial |
$557.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$533.06
|
| Rate for Payer: Aetna Managed Medicare |
$173.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$402.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$309.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$297.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$328.52
|
| Rate for Payer: Cash Price |
$178.80
|
| Rate for Payer: Cigna Commercial |
$570.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$346.87
|
| Rate for Payer: Health EOS Commercial |
$551.66
|
| Rate for Payer: HFN Commercial |
$570.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$464.88
|
| Rate for Payer: Multiplan Commercial |
$495.87
|
| Rate for Payer: NAPHCARE Commercial |
$371.90
|
| Rate for Payer: Preferred Network Access Commercial |
$570.25
|
| Rate for Payer: Quartz Beloit One Network |
$303.72
|
| Rate for Payer: Quartz Commercial |
$402.90
|
| Rate for Payer: Quartz Medicare Advantage |
$371.90
|
| Rate for Payer: The Alliance Commercial |
$309.92
|
| Rate for Payer: WEA Trust Commercial |
$340.91
|
| Rate for Payer: WPS Commercial |
$459.10
|
|
|
CAP MINI 5C4466P
|
Facility
|
IP
|
$24.00
|
|
| Hospital Charge Code |
2971443
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.23 |
| Max. Negotiated Rate |
$22.96 |
| Rate for Payer: Aetna Commercial |
$22.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.23
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.96
|
| Rate for Payer: Health EOS Commercial |
$22.21
|
| Rate for Payer: HFN Commercial |
$22.96
|
| Rate for Payer: Multiplan Commercial |
$19.97
|
| Rate for Payer: Preferred Network Access Commercial |
$22.96
|
| Rate for Payer: Quartz Beloit One Network |
$12.23
|
| Rate for Payer: Quartz Commercial |
$14.98
|
| Rate for Payer: WEA Trust Commercial |
$13.73
|
| Rate for Payer: WPS Commercial |
$18.49
|
|
|
CAP MINI 5C4466P
|
Facility
|
OP
|
$24.00
|
|
| Hospital Charge Code |
2971443
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.99 |
| Max. Negotiated Rate |
$22.96 |
| Rate for Payer: Aetna Commercial |
$22.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.47
|
| Rate for Payer: Aetna Managed Medicare |
$6.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.23
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cigna Commercial |
$22.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.97
|
| Rate for Payer: Health EOS Commercial |
$22.21
|
| Rate for Payer: HFN Commercial |
$22.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.72
|
| Rate for Payer: Multiplan Commercial |
$19.97
|
| Rate for Payer: NAPHCARE Commercial |
$14.98
|
| Rate for Payer: Preferred Network Access Commercial |
$22.96
|
| Rate for Payer: Quartz Beloit One Network |
$12.23
|
| Rate for Payer: Quartz Commercial |
$16.22
|
| Rate for Payer: Quartz Medicare Advantage |
$14.98
|
| Rate for Payer: The Alliance Commercial |
$12.48
|
| Rate for Payer: WEA Trust Commercial |
$13.73
|
| Rate for Payer: WPS Commercial |
$18.49
|
|
|
CAP PROTECTIVE 1.8
|
Facility
|
IP
|
$650.00
|
|
| Hospital Charge Code |
2966159
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$331.24 |
| Max. Negotiated Rate |
$621.92 |
| Rate for Payer: Aetna Commercial |
$608.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$581.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$358.28
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$621.92
|
| Rate for Payer: Health EOS Commercial |
$601.64
|
| Rate for Payer: HFN Commercial |
$621.92
|
| Rate for Payer: Multiplan Commercial |
$540.80
|
| Rate for Payer: Preferred Network Access Commercial |
$621.92
|
| Rate for Payer: Quartz Beloit One Network |
$331.24
|
| Rate for Payer: Quartz Commercial |
$405.60
|
| Rate for Payer: WEA Trust Commercial |
$371.80
|
| Rate for Payer: WPS Commercial |
$500.69
|
|
|
CAP PROTECTIVE 1.8
|
Facility
|
OP
|
$650.00
|
|
| Hospital Charge Code |
2966159
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$189.28 |
| Max. Negotiated Rate |
$621.92 |
| Rate for Payer: Aetna Commercial |
$608.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$581.36
|
| Rate for Payer: Aetna Managed Medicare |
$189.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$439.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$338.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$324.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$358.28
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$621.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$378.30
|
| Rate for Payer: Health EOS Commercial |
$601.64
|
| Rate for Payer: HFN Commercial |
$621.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$507.00
|
| Rate for Payer: Multiplan Commercial |
$540.80
|
| Rate for Payer: NAPHCARE Commercial |
$405.60
|
| Rate for Payer: Preferred Network Access Commercial |
$621.92
|
| Rate for Payer: Quartz Beloit One Network |
$331.24
|
| Rate for Payer: Quartz Commercial |
$439.40
|
| Rate for Payer: Quartz Medicare Advantage |
$405.60
|
| Rate for Payer: The Alliance Commercial |
$338.00
|
| Rate for Payer: WEA Trust Commercial |
$371.80
|
| Rate for Payer: WPS Commercial |
$500.69
|
|
|
CAP RIBBED KNIT DIGITAL XXL #0815-41-150
|
Facility
|
OP
|
$538.00
|
|
|
Service Code
|
HCPCS A6457
|
| Hospital Charge Code |
2969887
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$6.74 |
| Max. Negotiated Rate |
$514.76 |
| Rate for Payer: Aetna Commercial |
$503.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$481.19
|
| Rate for Payer: Aetna Managed Medicare |
$156.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$363.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$279.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$268.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$296.55
|
| Rate for Payer: Cash Price |
$161.40
|
| Rate for Payer: Cash Price |
$161.40
|
| Rate for Payer: Cigna Commercial |
$514.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$313.12
|
| Rate for Payer: Health EOS Commercial |
$497.97
|
| Rate for Payer: HFN Commercial |
$514.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$419.64
|
| Rate for Payer: Multiplan Commercial |
$447.62
|
| Rate for Payer: NAPHCARE Commercial |
$335.71
|
| Rate for Payer: Preferred Network Access Commercial |
$514.76
|
| Rate for Payer: Quartz Beloit One Network |
$274.16
|
| Rate for Payer: Quartz Commercial |
$363.69
|
| Rate for Payer: Quartz Medicare Advantage |
$335.71
|
| Rate for Payer: The Alliance Commercial |
$6.74
|
| Rate for Payer: WEA Trust Commercial |
$307.74
|
| Rate for Payer: WPS Commercial |
$414.42
|
|
|
CAP RIBBED KNIT DIGITAL XXL #0815-41-150
|
Facility
|
IP
|
$538.00
|
|
|
Service Code
|
HCPCS A6457
|
| Hospital Charge Code |
2969887
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$274.16 |
| Max. Negotiated Rate |
$514.76 |
| Rate for Payer: Aetna Commercial |
$503.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$481.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$296.55
|
| Rate for Payer: Cash Price |
$161.40
|
| Rate for Payer: Cigna Commercial |
$514.76
|
| Rate for Payer: Health EOS Commercial |
$497.97
|
| Rate for Payer: HFN Commercial |
$514.76
|
| Rate for Payer: Multiplan Commercial |
$447.62
|
| Rate for Payer: Preferred Network Access Commercial |
$514.76
|
| Rate for Payer: Quartz Beloit One Network |
$274.16
|
| Rate for Payer: Quartz Commercial |
$335.71
|
| Rate for Payer: WEA Trust Commercial |
$307.74
|
| Rate for Payer: WPS Commercial |
$414.42
|
|
|
CAP RIBBED KNIT L/XL #5506-10
|
Facility
|
OP
|
$488.00
|
|
|
Service Code
|
HCPCS A6457
|
| Hospital Charge Code |
2969687
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$6.74 |
| Max. Negotiated Rate |
$466.92 |
| Rate for Payer: Aetna Commercial |
$456.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$436.47
|
| Rate for Payer: Aetna Managed Medicare |
$142.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$329.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$253.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$243.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$268.99
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cigna Commercial |
$466.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$284.02
|
| Rate for Payer: Health EOS Commercial |
$451.69
|
| Rate for Payer: HFN Commercial |
$466.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$380.64
|
| Rate for Payer: Multiplan Commercial |
$406.02
|
| Rate for Payer: NAPHCARE Commercial |
$304.51
|
| Rate for Payer: Preferred Network Access Commercial |
$466.92
|
| Rate for Payer: Quartz Beloit One Network |
$248.68
|
| Rate for Payer: Quartz Commercial |
$329.89
|
| Rate for Payer: Quartz Medicare Advantage |
$304.51
|
| Rate for Payer: The Alliance Commercial |
$6.74
|
| Rate for Payer: WEA Trust Commercial |
$279.14
|
| Rate for Payer: WPS Commercial |
$375.91
|
|
|
CAP RIBBED KNIT L/XL #5506-10
|
Facility
|
IP
|
$488.00
|
|
|
Service Code
|
HCPCS A6457
|
| Hospital Charge Code |
2969687
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$248.68 |
| Max. Negotiated Rate |
$466.92 |
| Rate for Payer: Aetna Commercial |
$456.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$436.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$268.99
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cigna Commercial |
$466.92
|
| Rate for Payer: Health EOS Commercial |
$451.69
|
| Rate for Payer: HFN Commercial |
$466.92
|
| Rate for Payer: Multiplan Commercial |
$406.02
|
| Rate for Payer: Preferred Network Access Commercial |
$466.92
|
| Rate for Payer: Quartz Beloit One Network |
$248.68
|
| Rate for Payer: Quartz Commercial |
$304.51
|
| Rate for Payer: WEA Trust Commercial |
$279.14
|
| Rate for Payer: WPS Commercial |
$375.91
|
|
|
CAPS DIGITAL GEL LG/XLG MESH #56095302
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
HCPCS A6457
|
| Hospital Charge Code |
2971286
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$6.74 |
| Max. Negotiated Rate |
$109.08 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Aetna Managed Medicare |
$33.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$59.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$56.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.84
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$109.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.35
|
| Rate for Payer: Health EOS Commercial |
$105.52
|
| Rate for Payer: HFN Commercial |
$109.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.92
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: NAPHCARE Commercial |
$71.14
|
| Rate for Payer: Preferred Network Access Commercial |
$109.08
|
| Rate for Payer: Quartz Beloit One Network |
$58.09
|
| Rate for Payer: Quartz Commercial |
$77.06
|
| Rate for Payer: Quartz Medicare Advantage |
$71.14
|
| Rate for Payer: The Alliance Commercial |
$6.74
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
|
CAPS DIGITAL GEL LG/XLG MESH #56095302
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
HCPCS A6457
|
| Hospital Charge Code |
2971286
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$58.09 |
| Max. Negotiated Rate |
$109.08 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.84
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$109.08
|
| Rate for Payer: Health EOS Commercial |
$105.52
|
| Rate for Payer: HFN Commercial |
$109.08
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: Preferred Network Access Commercial |
$109.08
|
| Rate for Payer: Quartz Beloit One Network |
$58.09
|
| Rate for Payer: Quartz Commercial |
$71.14
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
|
CAPSULECTOMY OR CAPSULOTOMY; INTERPHALANGEAL JOINT, EACH JOINT
|
Facility
|
OP
|
$6,807.99
|
|
|
Service Code
|
CPT 26525
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,692.24 |
| Max. Negotiated Rate |
$6,807.99 |
| Rate for Payer: Aetna Managed Medicare |
$1,692.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$1,692.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,692.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,692.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,692.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,807.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,692.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,295.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,692.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,692.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,692.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,692.24
|
| Rate for Payer: NAPHCARE Commercial |
$2,538.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1,692.24
|
| Rate for Payer: The Alliance Commercial |
$6,768.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,692.24
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$1,692.24
|
|
|
CAPSULE POLISHER TERRY SQUEEGEE SILICONE 8065428220
|
Facility
|
OP
|
$150.00
|
|
| Hospital Charge Code |
5415556
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.68 |
| Max. Negotiated Rate |
$143.52 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Aetna Managed Medicare |
$43.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$101.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$74.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.30
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.00
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: NAPHCARE Commercial |
$93.60
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$101.40
|
| Rate for Payer: Quartz Medicare Advantage |
$93.60
|
| Rate for Payer: The Alliance Commercial |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
|
CAPSULE POLISHER TERRY SQUEEGEE SILICONE 8065428220
|
Facility
|
IP
|
$150.00
|
|
| Hospital Charge Code |
5415556
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$76.44 |
| Max. Negotiated Rate |
$143.52 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$93.60
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
|
CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY
|
Facility
|
OP
|
$30,545.47
|
|
|
Service Code
|
CPT 25320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,807.99 |
| Max. Negotiated Rate |
$30,545.47 |
| Rate for Payer: Aetna Managed Medicare |
$7,636.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,182.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,724.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,889.12
|
| Rate for Payer: Anthem Medicare Advantage |
$7,636.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,636.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,636.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,636.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,807.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,636.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,407.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,636.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,636.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,636.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,636.37
|
| Rate for Payer: NAPHCARE Commercial |
$11,454.55
|
| Rate for Payer: Quartz Medicare Advantage |
$7,636.37
|
| Rate for Payer: The Alliance Commercial |
$30,545.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,636.37
|
| Rate for Payer: United Healthcare PPO |
$8,790.08
|
| Rate for Payer: Wellcare Medicare |
$7,636.37
|
|
|
CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$13,773.68
|
|
|
Service Code
|
CPT 28270
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,443.42 |
| Max. Negotiated Rate |
$13,773.68 |
| Rate for Payer: Aetna Managed Medicare |
$3,443.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,443.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,443.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,443.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,947.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,443.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,809.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,443.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,443.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,443.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,443.42
|
| Rate for Payer: NAPHCARE Commercial |
$5,165.13
|
| Rate for Payer: Quartz Medicare Advantage |
$3,443.42
|
| Rate for Payer: The Alliance Commercial |
$13,773.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,443.42
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,443.42
|
|
|
CAPSURE EPI 5071-53
|
Facility
|
OP
|
$4,850.00
|
|
| Hospital Charge Code |
2965344
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,412.32 |
| Max. Negotiated Rate |
$4,640.48 |
| Rate for Payer: Aetna Commercial |
$4,539.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,337.84
|
| Rate for Payer: Aetna Managed Medicare |
$1,412.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,278.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,522.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,421.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,673.32
|
| Rate for Payer: Cash Price |
$1,455.00
|
| Rate for Payer: Cigna Commercial |
$4,640.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,822.70
|
| Rate for Payer: Health EOS Commercial |
$4,489.16
|
| Rate for Payer: HFN Commercial |
$4,640.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,783.00
|
| Rate for Payer: Multiplan Commercial |
$4,035.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,026.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,640.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,471.56
|
| Rate for Payer: Quartz Commercial |
$3,278.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,026.40
|
| Rate for Payer: The Alliance Commercial |
$2,522.00
|
| Rate for Payer: WEA Trust Commercial |
$2,774.20
|
| Rate for Payer: WPS Commercial |
$3,735.95
|
|
|
CAPSURE EPI 5071-53
|
Facility
|
IP
|
$4,850.00
|
|
| Hospital Charge Code |
2965344
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,471.56 |
| Max. Negotiated Rate |
$4,640.48 |
| Rate for Payer: Aetna Commercial |
$4,539.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,337.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,673.32
|
| Rate for Payer: Cash Price |
$1,455.00
|
| Rate for Payer: Cigna Commercial |
$4,640.48
|
| Rate for Payer: Health EOS Commercial |
$4,489.16
|
| Rate for Payer: HFN Commercial |
$4,640.48
|
| Rate for Payer: Multiplan Commercial |
$4,035.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,640.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,471.56
|
| Rate for Payer: Quartz Commercial |
$3,026.40
|
| Rate for Payer: WEA Trust Commercial |
$2,774.20
|
| Rate for Payer: WPS Commercial |
$3,735.95
|
|
|
CAP TOE GELSMART S/M 1075
|
Facility
|
IP
|
$80.00
|
|
| Hospital Charge Code |
2971413
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$40.77 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
|
CAP TOE GELSMART S/M 1075
|
Facility
|
OP
|
$80.00
|
|
| Hospital Charge Code |
2971413
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$23.30 |
| Max. Negotiated Rate |
$76.54 |
| Rate for Payer: Aetna Commercial |
$74.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Aetna Managed Medicare |
$23.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.10
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.56
|
| Rate for Payer: Health EOS Commercial |
$74.05
|
| Rate for Payer: HFN Commercial |
$76.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.40
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: NAPHCARE Commercial |
$49.92
|
| Rate for Payer: Preferred Network Access Commercial |
$76.54
|
| Rate for Payer: Quartz Beloit One Network |
$40.77
|
| Rate for Payer: Quartz Commercial |
$54.08
|
| Rate for Payer: Quartz Medicare Advantage |
$49.92
|
| Rate for Payer: The Alliance Commercial |
$41.60
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$61.62
|
|
