|
CATHETER SHUTTLE SLIP 4.5 FR.
|
Facility
|
OP
|
$1,401.00
|
|
| Hospital Charge Code |
2972245
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$407.97 |
| Max. Negotiated Rate |
$1,340.48 |
| Rate for Payer: Aetna Commercial |
$1,311.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,253.05
|
| Rate for Payer: Aetna Managed Medicare |
$407.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$947.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$728.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$699.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$772.23
|
| Rate for Payer: Cash Price |
$420.30
|
| Rate for Payer: Cigna Commercial |
$1,340.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$815.38
|
| Rate for Payer: Health EOS Commercial |
$1,296.77
|
| Rate for Payer: HFN Commercial |
$1,340.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,092.78
|
| Rate for Payer: Multiplan Commercial |
$1,165.63
|
| Rate for Payer: NAPHCARE Commercial |
$874.22
|
| Rate for Payer: Preferred Network Access Commercial |
$1,340.48
|
| Rate for Payer: Quartz Beloit One Network |
$713.95
|
| Rate for Payer: Quartz Commercial |
$947.08
|
| Rate for Payer: Quartz Medicare Advantage |
$874.22
|
| Rate for Payer: The Alliance Commercial |
$728.52
|
| Rate for Payer: WEA Trust Commercial |
$801.37
|
| Rate for Payer: WPS Commercial |
$1,079.19
|
|
|
CATHETER SHUTTLE SLIP 4.5 FR.
|
Facility
|
IP
|
$1,401.00
|
|
| Hospital Charge Code |
2972245
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$713.95 |
| Max. Negotiated Rate |
$1,340.48 |
| Rate for Payer: Aetna Commercial |
$1,311.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,253.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$772.23
|
| Rate for Payer: Cash Price |
$420.30
|
| Rate for Payer: Cigna Commercial |
$1,340.48
|
| Rate for Payer: Health EOS Commercial |
$1,296.77
|
| Rate for Payer: HFN Commercial |
$1,340.48
|
| Rate for Payer: Multiplan Commercial |
$1,165.63
|
| Rate for Payer: Preferred Network Access Commercial |
$1,340.48
|
| Rate for Payer: Quartz Beloit One Network |
$713.95
|
| Rate for Payer: Quartz Commercial |
$874.22
|
| Rate for Payer: WEA Trust Commercial |
$801.37
|
| Rate for Payer: WPS Commercial |
$1,079.19
|
|
|
CATHETER SHUTTLE SLIP 5.5 FR.
|
Facility
|
OP
|
$1,647.00
|
|
| Hospital Charge Code |
2972387
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$479.61 |
| Max. Negotiated Rate |
$1,575.85 |
| Rate for Payer: Aetna Commercial |
$1,541.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,473.08
|
| Rate for Payer: Aetna Managed Medicare |
$479.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,113.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$856.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$822.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$907.83
|
| Rate for Payer: Cash Price |
$494.10
|
| Rate for Payer: Cigna Commercial |
$1,575.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$958.55
|
| Rate for Payer: Health EOS Commercial |
$1,524.46
|
| Rate for Payer: HFN Commercial |
$1,575.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,284.66
|
| Rate for Payer: Multiplan Commercial |
$1,370.30
|
| Rate for Payer: NAPHCARE Commercial |
$1,027.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,575.85
|
| Rate for Payer: Quartz Beloit One Network |
$839.31
|
| Rate for Payer: Quartz Commercial |
$1,113.37
|
| Rate for Payer: Quartz Medicare Advantage |
$1,027.73
|
| Rate for Payer: The Alliance Commercial |
$856.44
|
| Rate for Payer: WEA Trust Commercial |
$942.08
|
| Rate for Payer: WPS Commercial |
$1,268.68
|
|
|
CATHETER SHUTTLE SLIP 5.5 FR.
|
Facility
|
IP
|
$1,647.00
|
|
| Hospital Charge Code |
2972387
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$839.31 |
| Max. Negotiated Rate |
$1,575.85 |
| Rate for Payer: Aetna Commercial |
$1,541.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,473.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$907.83
|
| Rate for Payer: Cash Price |
$494.10
|
| Rate for Payer: Cigna Commercial |
$1,575.85
|
| Rate for Payer: Health EOS Commercial |
$1,524.46
|
| Rate for Payer: HFN Commercial |
$1,575.85
|
| Rate for Payer: Multiplan Commercial |
$1,370.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,575.85
|
| Rate for Payer: Quartz Beloit One Network |
$839.31
|
| Rate for Payer: Quartz Commercial |
$1,027.73
|
| Rate for Payer: WEA Trust Commercial |
$942.08
|
| Rate for Payer: WPS Commercial |
$1,268.68
|
|
|
CATHETER SINGLE LUMEN KIT AK-04301
|
Facility
|
IP
|
$375.00
|
|
| Hospital Charge Code |
2963128
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$191.10 |
| Max. Negotiated Rate |
$358.80 |
| Rate for Payer: Aetna Commercial |
$351.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$335.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.70
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$358.80
|
| Rate for Payer: Health EOS Commercial |
$347.10
|
| Rate for Payer: HFN Commercial |
$358.80
|
| Rate for Payer: Multiplan Commercial |
$312.00
|
| Rate for Payer: Preferred Network Access Commercial |
$358.80
|
| Rate for Payer: Quartz Beloit One Network |
$191.10
|
| Rate for Payer: Quartz Commercial |
$234.00
|
| Rate for Payer: WEA Trust Commercial |
$214.50
|
| Rate for Payer: WPS Commercial |
$288.86
|
|
|
CATHETER SINGLE LUMEN KIT AK-04301
|
Facility
|
OP
|
$375.00
|
|
| Hospital Charge Code |
2963128
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$109.20 |
| Max. Negotiated Rate |
$358.80 |
| Rate for Payer: Aetna Commercial |
$351.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$335.40
|
| Rate for Payer: Aetna Managed Medicare |
$109.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$253.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$195.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$187.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.70
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$358.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$218.25
|
| Rate for Payer: Health EOS Commercial |
$347.10
|
| Rate for Payer: HFN Commercial |
$358.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$292.50
|
| Rate for Payer: Multiplan Commercial |
$312.00
|
| Rate for Payer: NAPHCARE Commercial |
$234.00
|
| Rate for Payer: Preferred Network Access Commercial |
$358.80
|
| Rate for Payer: Quartz Beloit One Network |
$191.10
|
| Rate for Payer: Quartz Commercial |
$253.50
|
| Rate for Payer: Quartz Medicare Advantage |
$234.00
|
| Rate for Payer: The Alliance Commercial |
$195.00
|
| Rate for Payer: WEA Trust Commercial |
$214.50
|
| Rate for Payer: WPS Commercial |
$288.86
|
|
|
CATHETER SLIC INFUSION SINGLE ARWSS14701
|
Facility
|
OP
|
$902.00
|
|
| Hospital Charge Code |
3065499
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$262.66 |
| Max. Negotiated Rate |
$863.03 |
| Rate for Payer: Aetna Commercial |
$844.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$806.75
|
| Rate for Payer: Aetna Managed Medicare |
$262.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$609.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$469.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$450.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$497.18
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cigna Commercial |
$863.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$524.96
|
| Rate for Payer: Health EOS Commercial |
$834.89
|
| Rate for Payer: HFN Commercial |
$863.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$703.56
|
| Rate for Payer: Multiplan Commercial |
$750.46
|
| Rate for Payer: NAPHCARE Commercial |
$562.85
|
| Rate for Payer: Preferred Network Access Commercial |
$863.03
|
| Rate for Payer: Quartz Beloit One Network |
$459.66
|
| Rate for Payer: Quartz Commercial |
$609.75
|
| Rate for Payer: Quartz Medicare Advantage |
$562.85
|
| Rate for Payer: The Alliance Commercial |
$469.04
|
| Rate for Payer: WEA Trust Commercial |
$515.94
|
| Rate for Payer: WPS Commercial |
$694.81
|
|
|
CATHETER SLIC INFUSION SINGLE ARWSS14701
|
Facility
|
IP
|
$902.00
|
|
| Hospital Charge Code |
3065499
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$459.66 |
| Max. Negotiated Rate |
$863.03 |
| Rate for Payer: Aetna Commercial |
$844.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$806.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$497.18
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cigna Commercial |
$863.03
|
| Rate for Payer: Health EOS Commercial |
$834.89
|
| Rate for Payer: HFN Commercial |
$863.03
|
| Rate for Payer: Multiplan Commercial |
$750.46
|
| Rate for Payer: Preferred Network Access Commercial |
$863.03
|
| Rate for Payer: Quartz Beloit One Network |
$459.66
|
| Rate for Payer: Quartz Commercial |
$562.85
|
| Rate for Payer: WEA Trust Commercial |
$515.94
|
| Rate for Payer: WPS Commercial |
$694.81
|
|
|
CATHETERS TRAIL BLAZER 5FR
|
Facility
|
IP
|
$6,415.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2973688
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,269.08 |
| Max. Negotiated Rate |
$6,137.87 |
| Rate for Payer: Aetna Commercial |
$6,004.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,737.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,535.95
|
| Rate for Payer: Cash Price |
$1,924.50
|
| Rate for Payer: Cigna Commercial |
$6,137.87
|
| Rate for Payer: Health EOS Commercial |
$5,937.72
|
| Rate for Payer: HFN Commercial |
$6,137.87
|
| Rate for Payer: Multiplan Commercial |
$5,337.28
|
| Rate for Payer: Preferred Network Access Commercial |
$6,137.87
|
| Rate for Payer: Quartz Beloit One Network |
$3,269.08
|
| Rate for Payer: Quartz Commercial |
$4,002.96
|
| Rate for Payer: WEA Trust Commercial |
$3,669.38
|
| Rate for Payer: WPS Commercial |
$4,941.47
|
|
|
CATHETERS TRAIL BLAZER 5FR
|
Facility
|
OP
|
$6,415.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2973688
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,868.05 |
| Max. Negotiated Rate |
$6,137.87 |
| Rate for Payer: Aetna Commercial |
$6,004.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,737.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,868.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,336.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,335.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,202.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,535.95
|
| Rate for Payer: Cash Price |
$1,924.50
|
| Rate for Payer: Cigna Commercial |
$6,137.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,733.53
|
| Rate for Payer: Health EOS Commercial |
$5,937.72
|
| Rate for Payer: HFN Commercial |
$6,137.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,003.70
|
| Rate for Payer: Multiplan Commercial |
$5,337.28
|
| Rate for Payer: NAPHCARE Commercial |
$4,002.96
|
| Rate for Payer: Preferred Network Access Commercial |
$6,137.87
|
| Rate for Payer: Quartz Beloit One Network |
$3,269.08
|
| Rate for Payer: Quartz Commercial |
$4,336.54
|
| Rate for Payer: Quartz Medicare Advantage |
$4,002.96
|
| Rate for Payer: The Alliance Commercial |
$3,335.80
|
| Rate for Payer: WEA Trust Commercial |
$3,669.38
|
| Rate for Payer: WPS Commercial |
$4,941.47
|
|
|
CATHETER SUCTION KIT 10 FR
|
Facility
|
IP
|
$25.00
|
|
| Hospital Charge Code |
2963479
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$15.60
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
CATHETER SUCTION KIT 10 FR
|
Facility
|
OP
|
$25.00
|
|
| Hospital Charge Code |
2963479
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.28 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Aetna Managed Medicare |
$7.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.55
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.50
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$15.60
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$16.90
|
| Rate for Payer: Quartz Medicare Advantage |
$15.60
|
| Rate for Payer: The Alliance Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
CATHETER SUCTION KIT 12 FR
|
Facility
|
IP
|
$85.00
|
|
| Hospital Charge Code |
2963478
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.32 |
| Max. Negotiated Rate |
$81.33 |
| Rate for Payer: Aetna Commercial |
$79.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.85
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$81.33
|
| Rate for Payer: Health EOS Commercial |
$78.68
|
| Rate for Payer: HFN Commercial |
$81.33
|
| Rate for Payer: Multiplan Commercial |
$70.72
|
| Rate for Payer: Preferred Network Access Commercial |
$81.33
|
| Rate for Payer: Quartz Beloit One Network |
$43.32
|
| Rate for Payer: Quartz Commercial |
$53.04
|
| Rate for Payer: WEA Trust Commercial |
$48.62
|
| Rate for Payer: WPS Commercial |
$65.48
|
|
|
CATHETER SUCTION KIT 12 FR
|
Facility
|
OP
|
$85.00
|
|
| Hospital Charge Code |
2963478
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$81.33 |
| Rate for Payer: Aetna Commercial |
$79.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.02
|
| Rate for Payer: Aetna Managed Medicare |
$24.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.85
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$81.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.47
|
| Rate for Payer: Health EOS Commercial |
$78.68
|
| Rate for Payer: HFN Commercial |
$81.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.30
|
| Rate for Payer: Multiplan Commercial |
$70.72
|
| Rate for Payer: NAPHCARE Commercial |
$53.04
|
| Rate for Payer: Preferred Network Access Commercial |
$81.33
|
| Rate for Payer: Quartz Beloit One Network |
$43.32
|
| Rate for Payer: Quartz Commercial |
$57.46
|
| Rate for Payer: Quartz Medicare Advantage |
$53.04
|
| Rate for Payer: The Alliance Commercial |
$44.20
|
| Rate for Payer: WEA Trust Commercial |
$48.62
|
| Rate for Payer: WPS Commercial |
$65.48
|
|
|
CATHETER SUCTION KIT 14 FR 21 4864T
|
Facility
|
OP
|
$85.00
|
|
| Hospital Charge Code |
2968887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$81.33 |
| Rate for Payer: Aetna Commercial |
$79.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.02
|
| Rate for Payer: Aetna Managed Medicare |
$24.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.85
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$81.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.47
|
| Rate for Payer: Health EOS Commercial |
$78.68
|
| Rate for Payer: HFN Commercial |
$81.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.30
|
| Rate for Payer: Multiplan Commercial |
$70.72
|
| Rate for Payer: NAPHCARE Commercial |
$53.04
|
| Rate for Payer: Preferred Network Access Commercial |
$81.33
|
| Rate for Payer: Quartz Beloit One Network |
$43.32
|
| Rate for Payer: Quartz Commercial |
$57.46
|
| Rate for Payer: Quartz Medicare Advantage |
$53.04
|
| Rate for Payer: The Alliance Commercial |
$44.20
|
| Rate for Payer: WEA Trust Commercial |
$48.62
|
| Rate for Payer: WPS Commercial |
$65.48
|
|
|
CATHETER SUCTION KIT 14 FR 21 4864T
|
Facility
|
IP
|
$85.00
|
|
| Hospital Charge Code |
2968887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.32 |
| Max. Negotiated Rate |
$81.33 |
| Rate for Payer: Aetna Commercial |
$79.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.85
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$81.33
|
| Rate for Payer: Health EOS Commercial |
$78.68
|
| Rate for Payer: HFN Commercial |
$81.33
|
| Rate for Payer: Multiplan Commercial |
$70.72
|
| Rate for Payer: Preferred Network Access Commercial |
$81.33
|
| Rate for Payer: Quartz Beloit One Network |
$43.32
|
| Rate for Payer: Quartz Commercial |
$53.04
|
| Rate for Payer: WEA Trust Commercial |
$48.62
|
| Rate for Payer: WPS Commercial |
$65.48
|
|
|
CATHETER SUCTION KIT 5 FR 4863T
|
Facility
|
OP
|
$82.00
|
|
| Hospital Charge Code |
2969219
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.88 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Aetna Managed Medicare |
$23.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.20
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$78.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.72
|
| Rate for Payer: Health EOS Commercial |
$75.90
|
| Rate for Payer: HFN Commercial |
$78.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.96
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: NAPHCARE Commercial |
$51.17
|
| Rate for Payer: Preferred Network Access Commercial |
$78.46
|
| Rate for Payer: Quartz Beloit One Network |
$41.79
|
| Rate for Payer: Quartz Commercial |
$55.43
|
| Rate for Payer: Quartz Medicare Advantage |
$51.17
|
| Rate for Payer: The Alliance Commercial |
$42.64
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$63.16
|
|
|
CATHETER SUCTION KIT 5 FR 4863T
|
Facility
|
IP
|
$82.00
|
|
| Hospital Charge Code |
2969219
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.79 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.20
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$78.46
|
| Rate for Payer: Health EOS Commercial |
$75.90
|
| Rate for Payer: HFN Commercial |
$78.46
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: Preferred Network Access Commercial |
$78.46
|
| Rate for Payer: Quartz Beloit One Network |
$41.79
|
| Rate for Payer: Quartz Commercial |
$51.17
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$63.16
|
|
|
CATHETER SUCTION KIT 8 FR 4867T
|
Facility
|
OP
|
$24.00
|
|
| Hospital Charge Code |
2963486
|
|
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
|
|
|
CATHETER SUCTION KIT 8 FR 4867T
|
Facility
|
IP
|
$24.00
|
|
| Hospital Charge Code |
2963486
|
|
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
|
|
|
CATHETER SUPER-KIT MULTI LUMEN #AK-42703-SK
|
Facility
|
OP
|
$1,278.00
|
|
| Hospital Charge Code |
2973498
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$372.15 |
| Max. Negotiated Rate |
$1,222.79 |
| Rate for Payer: Aetna Commercial |
$1,196.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,143.04
|
| Rate for Payer: Aetna Managed Medicare |
$372.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$863.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$664.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$637.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$704.43
|
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cigna Commercial |
$1,222.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$743.80
|
| Rate for Payer: Health EOS Commercial |
$1,182.92
|
| Rate for Payer: HFN Commercial |
$1,222.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$996.84
|
| Rate for Payer: Multiplan Commercial |
$1,063.30
|
| Rate for Payer: NAPHCARE Commercial |
$797.47
|
| Rate for Payer: Preferred Network Access Commercial |
$1,222.79
|
| Rate for Payer: Quartz Beloit One Network |
$651.27
|
| Rate for Payer: Quartz Commercial |
$863.93
|
| Rate for Payer: Quartz Medicare Advantage |
$797.47
|
| Rate for Payer: The Alliance Commercial |
$664.56
|
| Rate for Payer: WEA Trust Commercial |
$731.02
|
| Rate for Payer: WPS Commercial |
$984.44
|
|
|
CATHETER SUPER-KIT MULTI LUMEN #AK-42703-SK
|
Facility
|
IP
|
$1,278.00
|
|
| Hospital Charge Code |
2973498
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$651.27 |
| Max. Negotiated Rate |
$1,222.79 |
| Rate for Payer: Aetna Commercial |
$1,196.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,143.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$704.43
|
| Rate for Payer: Cash Price |
$383.40
|
| Rate for Payer: Cigna Commercial |
$1,222.79
|
| Rate for Payer: Health EOS Commercial |
$1,182.92
|
| Rate for Payer: HFN Commercial |
$1,222.79
|
| Rate for Payer: Multiplan Commercial |
$1,063.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,222.79
|
| Rate for Payer: Quartz Beloit One Network |
$651.27
|
| Rate for Payer: Quartz Commercial |
$797.47
|
| Rate for Payer: WEA Trust Commercial |
$731.02
|
| Rate for Payer: WPS Commercial |
$984.44
|
|
|
CATHETER SUPRAPUBIC 14 X 25CM LOOP G30405
|
Facility
|
OP
|
$1,051.00
|
|
|
Service Code
|
HCPCS C2627
|
| Hospital Charge Code |
2969489
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$306.05 |
| Max. Negotiated Rate |
$1,005.60 |
| Rate for Payer: Aetna Commercial |
$983.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$940.01
|
| Rate for Payer: Aetna Managed Medicare |
$306.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$710.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$546.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$524.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$579.31
|
| Rate for Payer: Cash Price |
$315.30
|
| Rate for Payer: Cigna Commercial |
$1,005.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$611.68
|
| Rate for Payer: Health EOS Commercial |
$972.81
|
| Rate for Payer: HFN Commercial |
$1,005.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$819.78
|
| Rate for Payer: Multiplan Commercial |
$874.43
|
| Rate for Payer: NAPHCARE Commercial |
$655.82
|
| Rate for Payer: Preferred Network Access Commercial |
$1,005.60
|
| Rate for Payer: Quartz Beloit One Network |
$535.59
|
| Rate for Payer: Quartz Commercial |
$710.48
|
| Rate for Payer: Quartz Medicare Advantage |
$655.82
|
| Rate for Payer: The Alliance Commercial |
$546.52
|
| Rate for Payer: WEA Trust Commercial |
$601.17
|
| Rate for Payer: WPS Commercial |
$809.59
|
|
|
CATHETER SUPRAPUBIC 14 X 25CM LOOP G30405
|
Facility
|
IP
|
$1,051.00
|
|
|
Service Code
|
HCPCS C2627
|
| Hospital Charge Code |
2969489
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$535.59 |
| Max. Negotiated Rate |
$1,005.60 |
| Rate for Payer: Aetna Commercial |
$983.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$940.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$579.31
|
| Rate for Payer: Cash Price |
$315.30
|
| Rate for Payer: Cigna Commercial |
$1,005.60
|
| Rate for Payer: Health EOS Commercial |
$972.81
|
| Rate for Payer: HFN Commercial |
$1,005.60
|
| Rate for Payer: Multiplan Commercial |
$874.43
|
| Rate for Payer: Preferred Network Access Commercial |
$1,005.60
|
| Rate for Payer: Quartz Beloit One Network |
$535.59
|
| Rate for Payer: Quartz Commercial |
$655.82
|
| Rate for Payer: WEA Trust Commercial |
$601.17
|
| Rate for Payer: WPS Commercial |
$809.59
|
|
|
CATHETER SUPRAPUBIC 16FR X 22CM RUTNER BALLOON G14920
|
Facility
|
OP
|
$624.00
|
|
|
Service Code
|
HCPCS C2627
|
| Hospital Charge Code |
2965855
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$181.71 |
| Max. Negotiated Rate |
$597.04 |
| Rate for Payer: Aetna Commercial |
$584.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$558.11
|
| Rate for Payer: Aetna Managed Medicare |
$181.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$421.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$324.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$311.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$343.95
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Cigna Commercial |
$597.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$363.17
|
| Rate for Payer: Health EOS Commercial |
$577.57
|
| Rate for Payer: HFN Commercial |
$597.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$486.72
|
| Rate for Payer: Multiplan Commercial |
$519.17
|
| Rate for Payer: NAPHCARE Commercial |
$389.38
|
| Rate for Payer: Preferred Network Access Commercial |
$597.04
|
| Rate for Payer: Quartz Beloit One Network |
$317.99
|
| Rate for Payer: Quartz Commercial |
$421.82
|
| Rate for Payer: Quartz Medicare Advantage |
$389.38
|
| Rate for Payer: The Alliance Commercial |
$324.48
|
| Rate for Payer: WEA Trust Commercial |
$356.93
|
| Rate for Payer: WPS Commercial |
$480.67
|
|
