|
COIL MREYE EMBOLIZATION 5CM X 6MM .035 2.6 LOOP G20291
|
Facility
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
6200995
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$350.00 |
| Max. Negotiated Rate |
$1,150.00 |
| Rate for Payer: Aetna Commercial |
$1,125.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,075.00
|
| Rate for Payer: Aetna Managed Medicare |
$350.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$812.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$625.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$600.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$662.50
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$1,150.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$699.50
|
| Rate for Payer: Health EOS Commercial |
$1,112.50
|
| Rate for Payer: HFN Commercial |
$1,150.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$937.50
|
| Rate for Payer: Multiplan Commercial |
$1,000.00
|
| Rate for Payer: NAPHCARE Commercial |
$750.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,150.00
|
| Rate for Payer: Quartz Beloit One Network |
$612.50
|
| Rate for Payer: Quartz Commercial |
$812.50
|
| Rate for Payer: Quartz Medicare Advantage |
$750.00
|
| Rate for Payer: WEA Trust Commercial |
$687.50
|
| Rate for Payer: WPS Commercial |
$925.88
|
|
|
COIL NESTER 4mm
|
Facility
IP
|
$1,738.00
|
|
| Hospital Charge Code |
2972429
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$851.62 |
| Max. Negotiated Rate |
$1,598.96 |
| Rate for Payer: Aetna Commercial |
$1,564.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$921.14
|
| Rate for Payer: Cash Price |
$521.40
|
| Rate for Payer: Cigna Commercial |
$1,598.96
|
| Rate for Payer: Health EOS Commercial |
$1,546.82
|
| Rate for Payer: HFN Commercial |
$1,598.96
|
| Rate for Payer: Multiplan Commercial |
$1,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.96
|
| Rate for Payer: Quartz Beloit One Network |
$851.62
|
| Rate for Payer: Quartz Commercial |
$1,042.80
|
| Rate for Payer: WEA Trust Commercial |
$955.90
|
| Rate for Payer: WPS Commercial |
$1,287.34
|
|
|
COIL NESTER 4mm
|
Facility
OP
|
$1,738.00
|
|
| Hospital Charge Code |
2972429
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$486.64 |
| Max. Negotiated Rate |
$6,952.00 |
| Rate for Payer: Aetna Commercial |
$1,564.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,494.68
|
| Rate for Payer: Aetna Managed Medicare |
$486.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,129.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$869.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$834.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$921.14
|
| Rate for Payer: Cash Price |
$521.40
|
| Rate for Payer: Cigna Commercial |
$1,598.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$972.58
|
| Rate for Payer: Health EOS Commercial |
$1,546.82
|
| Rate for Payer: HFN Commercial |
$1,598.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,303.50
|
| Rate for Payer: Multiplan Commercial |
$1,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.96
|
| Rate for Payer: Quartz Beloit One Network |
$851.62
|
| Rate for Payer: Quartz Commercial |
$1,129.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,042.80
|
| Rate for Payer: The Alliance Commercial |
$6,952.00
|
| Rate for Payer: WEA Trust Commercial |
$955.90
|
| Rate for Payer: WPS Commercial |
$1,287.34
|
|
|
COIL NESTER 6mm
|
Facility
IP
|
$1,738.00
|
|
| Hospital Charge Code |
2972430
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$851.62 |
| Max. Negotiated Rate |
$1,598.96 |
| Rate for Payer: Aetna Commercial |
$1,564.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$921.14
|
| Rate for Payer: Cash Price |
$521.40
|
| Rate for Payer: Cigna Commercial |
$1,598.96
|
| Rate for Payer: Health EOS Commercial |
$1,546.82
|
| Rate for Payer: HFN Commercial |
$1,598.96
|
| Rate for Payer: Multiplan Commercial |
$1,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.96
|
| Rate for Payer: Quartz Beloit One Network |
$851.62
|
| Rate for Payer: Quartz Commercial |
$1,042.80
|
| Rate for Payer: WEA Trust Commercial |
$955.90
|
| Rate for Payer: WPS Commercial |
$1,287.34
|
|
|
COIL NESTER 6mm
|
Facility
OP
|
$1,738.00
|
|
| Hospital Charge Code |
2972430
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$486.64 |
| Max. Negotiated Rate |
$6,952.00 |
| Rate for Payer: Aetna Commercial |
$1,564.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,494.68
|
| Rate for Payer: Aetna Managed Medicare |
$486.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,129.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$869.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$834.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$921.14
|
| Rate for Payer: Cash Price |
$521.40
|
| Rate for Payer: Cigna Commercial |
$1,598.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$972.58
|
| Rate for Payer: Health EOS Commercial |
$1,546.82
|
| Rate for Payer: HFN Commercial |
$1,598.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,303.50
|
| Rate for Payer: Multiplan Commercial |
$1,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.96
|
| Rate for Payer: Quartz Beloit One Network |
$851.62
|
| Rate for Payer: Quartz Commercial |
$1,129.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,042.80
|
| Rate for Payer: The Alliance Commercial |
$6,952.00
|
| Rate for Payer: WEA Trust Commercial |
$955.90
|
| Rate for Payer: WPS Commercial |
$1,287.34
|
|
|
COIL NESTER 8mm
|
Facility
IP
|
$1,738.00
|
|
| Hospital Charge Code |
2972431
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$851.62 |
| Max. Negotiated Rate |
$1,598.96 |
| Rate for Payer: Aetna Commercial |
$1,564.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$921.14
|
| Rate for Payer: Cash Price |
$521.40
|
| Rate for Payer: Cigna Commercial |
$1,598.96
|
| Rate for Payer: Health EOS Commercial |
$1,546.82
|
| Rate for Payer: HFN Commercial |
$1,598.96
|
| Rate for Payer: Multiplan Commercial |
$1,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.96
|
| Rate for Payer: Quartz Beloit One Network |
$851.62
|
| Rate for Payer: Quartz Commercial |
$1,042.80
|
| Rate for Payer: WEA Trust Commercial |
$955.90
|
| Rate for Payer: WPS Commercial |
$1,287.34
|
|
|
COIL NESTER 8mm
|
Facility
OP
|
$1,738.00
|
|
| Hospital Charge Code |
2972431
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$486.64 |
| Max. Negotiated Rate |
$6,952.00 |
| Rate for Payer: Aetna Commercial |
$1,564.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,494.68
|
| Rate for Payer: Aetna Managed Medicare |
$486.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,129.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$869.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$834.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$921.14
|
| Rate for Payer: Cash Price |
$521.40
|
| Rate for Payer: Cigna Commercial |
$1,598.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$972.58
|
| Rate for Payer: Health EOS Commercial |
$1,546.82
|
| Rate for Payer: HFN Commercial |
$1,598.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,303.50
|
| Rate for Payer: Multiplan Commercial |
$1,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.96
|
| Rate for Payer: Quartz Beloit One Network |
$851.62
|
| Rate for Payer: Quartz Commercial |
$1,129.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,042.80
|
| Rate for Payer: The Alliance Commercial |
$6,952.00
|
| Rate for Payer: WEA Trust Commercial |
$955.90
|
| Rate for Payer: WPS Commercial |
$1,287.34
|
|
|
COL/ADP
|
Facility
OP
|
$278.00
|
|
|
Service Code
|
CPT 85576
|
| Hospital Charge Code |
4524657
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.91 |
| Max. Negotiated Rate |
$1,112.00 |
| Rate for Payer: Aetna Commercial |
$250.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$239.08
|
| Rate for Payer: Aetna Managed Medicare |
$24.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.35
|
| Rate for Payer: Anthem Medicaid |
$25.74
|
| Rate for Payer: Anthem Medicare Advantage |
$24.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$147.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24.91
|
| Rate for Payer: Cash Price |
$83.40
|
| Rate for Payer: Cash Price |
$83.40
|
| Rate for Payer: Cigna Commercial |
$255.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$24.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.74
|
| Rate for Payer: Dean Health Medicaid |
$25.74
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$24.91
|
| Rate for Payer: Health EOS Commercial |
$247.42
|
| Rate for Payer: HFN Commercial |
$255.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24.91
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$25.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24.91
|
| Rate for Payer: Managed Health Services Medicaid |
$26.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$24.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$24.91
|
| Rate for Payer: Multiplan Commercial |
$222.40
|
| Rate for Payer: NAPHCARE Commercial |
$37.36
|
| Rate for Payer: Preferred Network Access Commercial |
$255.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$25.74
|
| Rate for Payer: Quartz Beloit One Network |
$136.22
|
| Rate for Payer: Quartz Commercial |
$180.70
|
| Rate for Payer: Quartz Medicare Advantage |
$24.91
|
| Rate for Payer: The Alliance Commercial |
$1,112.00
|
| Rate for Payer: United Healthcare Medicaid |
$25.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.91
|
| Rate for Payer: United Healthcare PPO |
$208.50
|
| Rate for Payer: WEA Trust Commercial |
$152.90
|
| Rate for Payer: Wellcare Medicare |
$24.91
|
| Rate for Payer: WMAP Medicaid |
$25.74
|
| Rate for Payer: WPS Commercial |
$205.91
|
|
|
COL/ADP
|
Facility
IP
|
$278.00
|
|
|
Service Code
|
CPT 85576
|
| Hospital Charge Code |
4524657
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$136.22 |
| Max. Negotiated Rate |
$255.76 |
| Rate for Payer: Aetna Commercial |
$250.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$147.34
|
| Rate for Payer: Cash Price |
$83.40
|
| Rate for Payer: Cigna Commercial |
$255.76
|
| Rate for Payer: Health EOS Commercial |
$247.42
|
| Rate for Payer: HFN Commercial |
$255.76
|
| Rate for Payer: Multiplan Commercial |
$222.40
|
| Rate for Payer: NAPHCARE Commercial |
$166.80
|
| Rate for Payer: Preferred Network Access Commercial |
$255.76
|
| Rate for Payer: Quartz Beloit One Network |
$136.22
|
| Rate for Payer: Quartz Commercial |
$166.80
|
| Rate for Payer: WEA Trust Commercial |
$152.90
|
| Rate for Payer: WPS Commercial |
$205.91
|
|
|
COL/ADP
|
Professional
|
$278.00
|
|
|
Service Code
|
CPT 85576
|
| Hospital Charge Code |
4524657
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$264.10 |
| Rate for Payer: Aetna Commercial |
$264.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$239.08
|
| Rate for Payer: Aetna Managed Medicare |
$24.91
|
| Rate for Payer: Anthem Commercial |
$16.61
|
| Rate for Payer: Anthem Medicare Advantage |
$24.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24.91
|
| Rate for Payer: Cash Price |
$83.40
|
| Rate for Payer: Cash Price |
$83.40
|
| Rate for Payer: Cigna Commercial |
$264.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$139.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.91
|
| Rate for Payer: Health EOS Commercial |
$252.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$87.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$87.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24.91
|
| Rate for Payer: Multiplan Commercial |
$222.40
|
| Rate for Payer: Preferred Network Access Commercial |
$264.10
|
| Rate for Payer: Quartz Beloit One Network |
$122.32
|
| Rate for Payer: Quartz Commercial |
$158.46
|
| Rate for Payer: Quartz Medicare Advantage |
$24.91
|
| Rate for Payer: The Alliance Commercial |
$98.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.91
|
| Rate for Payer: WEA Trust Commercial |
$152.90
|
| Rate for Payer: WPS Commercial |
$109.60
|
|
|
Cold Agglutinins
|
Facility
OP
|
$115.00
|
|
|
Service Code
|
CPT 86157
|
| Hospital Charge Code |
633707
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.06 |
| Max. Negotiated Rate |
$460.00 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Aetna Managed Medicare |
$8.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.10
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.38
|
| Rate for Payer: Anthem Medicaid |
$8.17
|
| Rate for Payer: Anthem Medicare Advantage |
$8.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.06
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.17
|
| Rate for Payer: Dean Health Medicaid |
$8.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.06
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.06
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.06
|
| Rate for Payer: Managed Health Services Medicaid |
$8.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.06
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.06
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$12.09
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.17
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$74.75
|
| Rate for Payer: Quartz Medicare Advantage |
$8.06
|
| Rate for Payer: The Alliance Commercial |
$460.00
|
| Rate for Payer: United Healthcare Medicaid |
$8.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.06
|
| Rate for Payer: United Healthcare PPO |
$86.25
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: Wellcare Medicare |
$8.06
|
| Rate for Payer: WMAP Medicaid |
$8.17
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
Cold Agglutinins
|
Professional
|
$115.00
|
|
|
Service Code
|
CPT 86157
|
| Hospital Charge Code |
633707
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.06 |
| Max. Negotiated Rate |
$109.25 |
| Rate for Payer: Aetna Commercial |
$109.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Aetna Managed Medicare |
$8.06
|
| Rate for Payer: Anthem Medicare Advantage |
$8.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.06
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$109.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$57.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.06
|
| Rate for Payer: Health EOS Commercial |
$104.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.06
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: Preferred Network Access Commercial |
$109.25
|
| Rate for Payer: Quartz Beloit One Network |
$50.60
|
| Rate for Payer: Quartz Commercial |
$65.55
|
| Rate for Payer: Quartz Medicare Advantage |
$8.06
|
| Rate for Payer: The Alliance Commercial |
$31.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.06
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$35.46
|
|
|
Cold Agglutinins
|
Facility
IP
|
$115.00
|
|
|
Service Code
|
CPT 86157
|
| Hospital Charge Code |
633707
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.35 |
| Max. Negotiated Rate |
$105.80 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$69.00
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$69.00
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
COLD PACK NECK CONTOUR 21 L
|
Facility
IP
|
$245.00
|
|
| Hospital Charge Code |
2970826
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$120.05 |
| Max. Negotiated Rate |
$225.40 |
| Rate for Payer: Aetna Commercial |
$220.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.85
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$225.40
|
| Rate for Payer: Health EOS Commercial |
$218.05
|
| Rate for Payer: HFN Commercial |
$225.40
|
| Rate for Payer: Multiplan Commercial |
$196.00
|
| Rate for Payer: NAPHCARE Commercial |
$147.00
|
| Rate for Payer: Preferred Network Access Commercial |
$225.40
|
| Rate for Payer: Quartz Beloit One Network |
$120.05
|
| Rate for Payer: Quartz Commercial |
$147.00
|
| Rate for Payer: WEA Trust Commercial |
$134.75
|
| Rate for Payer: WPS Commercial |
$181.47
|
|
|
COLD PACK NECK CONTOUR 21 L
|
Facility
OP
|
$245.00
|
|
| Hospital Charge Code |
2970826
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$980.00 |
| Rate for Payer: Aetna Commercial |
$220.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.70
|
| Rate for Payer: Aetna Managed Medicare |
$68.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$159.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$122.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$117.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.85
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$225.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.10
|
| Rate for Payer: Health EOS Commercial |
$218.05
|
| Rate for Payer: HFN Commercial |
$225.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.75
|
| Rate for Payer: Multiplan Commercial |
$196.00
|
| Rate for Payer: NAPHCARE Commercial |
$147.00
|
| Rate for Payer: Preferred Network Access Commercial |
$225.40
|
| Rate for Payer: Quartz Beloit One Network |
$120.05
|
| Rate for Payer: Quartz Commercial |
$159.25
|
| Rate for Payer: Quartz Medicare Advantage |
$147.00
|
| Rate for Payer: The Alliance Commercial |
$980.00
|
| Rate for Payer: WEA Trust Commercial |
$134.75
|
| Rate for Payer: WPS Commercial |
$181.47
|
|
|
COLD THERAPY POLAR CARE KNEE LARGE 10706
|
Facility
OP
|
$2,804.00
|
|
| Hospital Charge Code |
3872052
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$785.12 |
| Max. Negotiated Rate |
$11,216.00 |
| Rate for Payer: Aetna Commercial |
$2,523.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,411.44
|
| Rate for Payer: Aetna Managed Medicare |
$785.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,822.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,402.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,345.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,486.12
|
| Rate for Payer: Cash Price |
$841.20
|
| Rate for Payer: Cigna Commercial |
$2,579.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,569.12
|
| Rate for Payer: Health EOS Commercial |
$2,495.56
|
| Rate for Payer: HFN Commercial |
$2,579.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,103.00
|
| Rate for Payer: Multiplan Commercial |
$2,243.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,682.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,579.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,373.96
|
| Rate for Payer: Quartz Commercial |
$1,822.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,682.40
|
| Rate for Payer: The Alliance Commercial |
$11,216.00
|
| Rate for Payer: WEA Trust Commercial |
$1,542.20
|
| Rate for Payer: WPS Commercial |
$2,076.92
|
|
|
COLD THERAPY POLAR CARE KNEE LARGE 10706
|
Facility
IP
|
$2,804.00
|
|
| Hospital Charge Code |
3872052
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,373.96 |
| Max. Negotiated Rate |
$2,579.68 |
| Rate for Payer: Aetna Commercial |
$2,523.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,486.12
|
| Rate for Payer: Cash Price |
$841.20
|
| Rate for Payer: Cigna Commercial |
$2,579.68
|
| Rate for Payer: Health EOS Commercial |
$2,495.56
|
| Rate for Payer: HFN Commercial |
$2,579.68
|
| Rate for Payer: Multiplan Commercial |
$2,243.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,682.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,579.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,373.96
|
| Rate for Payer: Quartz Commercial |
$1,682.40
|
| Rate for Payer: WEA Trust Commercial |
$1,542.20
|
| Rate for Payer: WPS Commercial |
$2,076.92
|
|
|
COLD THERAPY POLAR CARE KNEE XL 10707
|
Facility
OP
|
$2,861.00
|
|
| Hospital Charge Code |
3872050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$801.08 |
| Max. Negotiated Rate |
$11,444.00 |
| Rate for Payer: Aetna Commercial |
$2,574.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,460.46
|
| Rate for Payer: Aetna Managed Medicare |
$801.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,859.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,430.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,373.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,516.33
|
| Rate for Payer: Cash Price |
$858.30
|
| Rate for Payer: Cigna Commercial |
$2,632.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,601.02
|
| Rate for Payer: Health EOS Commercial |
$2,546.29
|
| Rate for Payer: HFN Commercial |
$2,632.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,145.75
|
| Rate for Payer: Multiplan Commercial |
$2,288.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,716.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,632.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,401.89
|
| Rate for Payer: Quartz Commercial |
$1,859.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,716.60
|
| Rate for Payer: The Alliance Commercial |
$11,444.00
|
| Rate for Payer: WEA Trust Commercial |
$1,573.55
|
| Rate for Payer: WPS Commercial |
$2,119.14
|
|
|
COLD THERAPY POLAR CARE KNEE XL 10707
|
Facility
IP
|
$2,861.00
|
|
| Hospital Charge Code |
3872050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,401.89 |
| Max. Negotiated Rate |
$2,632.12 |
| Rate for Payer: Aetna Commercial |
$2,574.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,516.33
|
| Rate for Payer: Cash Price |
$858.30
|
| Rate for Payer: Cigna Commercial |
$2,632.12
|
| Rate for Payer: Health EOS Commercial |
$2,546.29
|
| Rate for Payer: HFN Commercial |
$2,632.12
|
| Rate for Payer: Multiplan Commercial |
$2,288.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,716.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,632.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,401.89
|
| Rate for Payer: Quartz Commercial |
$1,716.60
|
| Rate for Payer: WEA Trust Commercial |
$1,573.55
|
| Rate for Payer: WPS Commercial |
$2,119.14
|
|
|
COLD THERAPY POLAR CARE SHOULDER LARGE 10711
|
Facility
IP
|
$2,363.00
|
|
| Hospital Charge Code |
3872051
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,157.87 |
| Max. Negotiated Rate |
$2,173.96 |
| Rate for Payer: Aetna Commercial |
$2,126.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,252.39
|
| Rate for Payer: Cash Price |
$708.90
|
| Rate for Payer: Cigna Commercial |
$2,173.96
|
| Rate for Payer: Health EOS Commercial |
$2,103.07
|
| Rate for Payer: HFN Commercial |
$2,173.96
|
| Rate for Payer: Multiplan Commercial |
$1,890.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,417.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,173.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,157.87
|
| Rate for Payer: Quartz Commercial |
$1,417.80
|
| Rate for Payer: WEA Trust Commercial |
$1,299.65
|
| Rate for Payer: WPS Commercial |
$1,750.27
|
|
|
COLD THERAPY POLAR CARE SHOULDER LARGE 10711
|
Facility
OP
|
$2,363.00
|
|
| Hospital Charge Code |
3872051
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$661.64 |
| Max. Negotiated Rate |
$9,452.00 |
| Rate for Payer: Aetna Commercial |
$2,126.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,032.18
|
| Rate for Payer: Aetna Managed Medicare |
$661.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,535.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,181.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,134.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,252.39
|
| Rate for Payer: Cash Price |
$708.90
|
| Rate for Payer: Cigna Commercial |
$2,173.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,322.33
|
| Rate for Payer: Health EOS Commercial |
$2,103.07
|
| Rate for Payer: HFN Commercial |
$2,173.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,772.25
|
| Rate for Payer: Multiplan Commercial |
$1,890.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,417.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,173.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,157.87
|
| Rate for Payer: Quartz Commercial |
$1,535.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,417.80
|
| Rate for Payer: The Alliance Commercial |
$9,452.00
|
| Rate for Payer: WEA Trust Commercial |
$1,299.65
|
| Rate for Payer: WPS Commercial |
$1,750.27
|
|
|
COLD THERAPY POLAR CARE SHOULDER XL 10712
|
Facility
IP
|
$2,470.00
|
|
| Hospital Charge Code |
3872049
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,210.30 |
| Max. Negotiated Rate |
$2,272.40 |
| Rate for Payer: Aetna Commercial |
$2,223.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,309.10
|
| Rate for Payer: Cash Price |
$741.00
|
| Rate for Payer: Cigna Commercial |
$2,272.40
|
| Rate for Payer: Health EOS Commercial |
$2,198.30
|
| Rate for Payer: HFN Commercial |
$2,272.40
|
| Rate for Payer: Multiplan Commercial |
$1,976.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,482.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,272.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,210.30
|
| Rate for Payer: Quartz Commercial |
$1,482.00
|
| Rate for Payer: WEA Trust Commercial |
$1,358.50
|
| Rate for Payer: WPS Commercial |
$1,829.53
|
|
|
COLD THERAPY POLAR CARE SHOULDER XL 10712
|
Facility
OP
|
$2,470.00
|
|
| Hospital Charge Code |
3872049
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$691.60 |
| Max. Negotiated Rate |
$9,880.00 |
| Rate for Payer: Aetna Commercial |
$2,223.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,124.20
|
| Rate for Payer: Aetna Managed Medicare |
$691.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,605.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,235.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,185.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,309.10
|
| Rate for Payer: Cash Price |
$741.00
|
| Rate for Payer: Cigna Commercial |
$2,272.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,382.21
|
| Rate for Payer: Health EOS Commercial |
$2,198.30
|
| Rate for Payer: HFN Commercial |
$2,272.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,852.50
|
| Rate for Payer: Multiplan Commercial |
$1,976.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,482.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,272.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,210.30
|
| Rate for Payer: Quartz Commercial |
$1,605.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,482.00
|
| Rate for Payer: The Alliance Commercial |
$9,880.00
|
| Rate for Payer: WEA Trust Commercial |
$1,358.50
|
| Rate for Payer: WPS Commercial |
$1,829.53
|
|
|
Collagen Type I C-Telopeptide
|
Facility
IP
|
$482.00
|
|
|
Service Code
|
CPT 82523
|
| Hospital Charge Code |
1038948
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$236.18 |
| Max. Negotiated Rate |
$443.44 |
| Rate for Payer: Aetna Commercial |
$433.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.46
|
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cigna Commercial |
$443.44
|
| Rate for Payer: Health EOS Commercial |
$428.98
|
| Rate for Payer: HFN Commercial |
$443.44
|
| Rate for Payer: Multiplan Commercial |
$385.60
|
| Rate for Payer: NAPHCARE Commercial |
$289.20
|
| Rate for Payer: Preferred Network Access Commercial |
$443.44
|
| Rate for Payer: Quartz Beloit One Network |
$236.18
|
| Rate for Payer: Quartz Commercial |
$289.20
|
| Rate for Payer: WEA Trust Commercial |
$265.10
|
| Rate for Payer: WPS Commercial |
$357.02
|
|
|
Collagen Type I C-Telopeptide
|
Facility
OP
|
$482.00
|
|
|
Service Code
|
CPT 82523
|
| Hospital Charge Code |
1038948
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.65 |
| Max. Negotiated Rate |
$1,928.00 |
| Rate for Payer: Aetna Commercial |
$433.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.52
|
| Rate for Payer: Aetna Managed Medicare |
$18.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.69
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.01
|
| Rate for Payer: Anthem Medicaid |
$14.65
|
| Rate for Payer: Anthem Medicare Advantage |
$18.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.68
|
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cigna Commercial |
$443.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.65
|
| Rate for Payer: Dean Health Medicaid |
$14.65
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.68
|
| Rate for Payer: Health EOS Commercial |
$428.98
|
| Rate for Payer: HFN Commercial |
$443.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.68
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.68
|
| Rate for Payer: Managed Health Services Medicaid |
$15.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.68
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.68
|
| Rate for Payer: Multiplan Commercial |
$385.60
|
| Rate for Payer: NAPHCARE Commercial |
$28.02
|
| Rate for Payer: Preferred Network Access Commercial |
$443.44
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.65
|
| Rate for Payer: Quartz Beloit One Network |
$236.18
|
| Rate for Payer: Quartz Commercial |
$313.30
|
| Rate for Payer: Quartz Medicare Advantage |
$18.68
|
| Rate for Payer: The Alliance Commercial |
$1,928.00
|
| Rate for Payer: United Healthcare Medicaid |
$14.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.68
|
| Rate for Payer: United Healthcare PPO |
$361.50
|
| Rate for Payer: WEA Trust Commercial |
$265.10
|
| Rate for Payer: Wellcare Medicare |
$18.68
|
| Rate for Payer: WMAP Medicaid |
$14.65
|
| Rate for Payer: WPS Commercial |
$357.02
|
|
