|
DETECTORS CO2 FEF END-TIDAL
|
Facility
|
IP
|
$274.00
|
|
| Hospital Charge Code |
2963009
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$139.63 |
| Max. Negotiated Rate |
$262.16 |
| Rate for Payer: Aetna Commercial |
$256.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.03
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cigna Commercial |
$262.16
|
| Rate for Payer: Health EOS Commercial |
$253.61
|
| Rate for Payer: HFN Commercial |
$262.16
|
| Rate for Payer: Multiplan Commercial |
$227.97
|
| Rate for Payer: Preferred Network Access Commercial |
$262.16
|
| Rate for Payer: Quartz Beloit One Network |
$139.63
|
| Rate for Payer: Quartz Commercial |
$170.98
|
| Rate for Payer: WEA Trust Commercial |
$156.73
|
| Rate for Payer: WPS Commercial |
$211.06
|
|
|
DEVELOPMENTAL & NEUROPSYCHOLOGICAL TESTING
|
Facility
|
OP
|
$108.75
|
|
|
Service Code
|
EAPG 00310
|
| Min. Negotiated Rate |
$104.57 |
| Max. Negotiated Rate |
$108.75 |
| Rate for Payer: Anthem Medicaid |
$104.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$104.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$104.57
|
| Rate for Payer: Dean Health Medicaid |
$104.57
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$104.57
|
| Rate for Payer: Managed Health Services Medicaid |
$108.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$104.57
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$104.57
|
| Rate for Payer: United Healthcare Medicaid |
$104.57
|
|
|
Developmental Screening 96110
|
Professional
|
Both
|
$153.00
|
|
|
Service Code
|
CPT 96110
|
| Hospital Charge Code |
2990629
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$10.32 |
| Max. Negotiated Rate |
$151.16 |
| Rate for Payer: Aetna Commercial |
$151.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$151.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.47
|
| Rate for Payer: Health EOS Commercial |
$144.80
|
| Rate for Payer: HFN Commercial |
$151.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$34.17
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: Preferred Network Access Commercial |
$151.16
|
| Rate for Payer: Quartz Beloit One Network |
$70.01
|
| Rate for Payer: Quartz Commercial |
$90.70
|
| Rate for Payer: The Alliance Commercial |
$79.56
|
| Rate for Payer: United Healthcare Medicaid |
$10.32
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
Developmental Test administration; each add 30 mins 96113
|
Professional
|
Both
|
$232.00
|
|
|
Service Code
|
CPT 96113
|
| Hospital Charge Code |
5454794
|
| Min. Negotiated Rate |
$45.94 |
| Max. Negotiated Rate |
$229.22 |
| Rate for Payer: Aetna Commercial |
$229.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.50
|
| Rate for Payer: Aetna Managed Medicare |
$45.94
|
| Rate for Payer: Anthem Medicare Advantage |
$45.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$45.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$45.94
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cigna Commercial |
$229.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$70.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.94
|
| Rate for Payer: Health EOS Commercial |
$219.56
|
| Rate for Payer: HFN Commercial |
$229.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$192.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$192.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$45.94
|
| Rate for Payer: Multiplan Commercial |
$193.02
|
| Rate for Payer: NAPHCARE Commercial |
$68.91
|
| Rate for Payer: Preferred Network Access Commercial |
$229.22
|
| Rate for Payer: Quartz Beloit One Network |
$106.16
|
| Rate for Payer: Quartz Commercial |
$137.53
|
| Rate for Payer: Quartz Medicare Advantage |
$45.94
|
| Rate for Payer: The Alliance Commercial |
$114.84
|
| Rate for Payer: United Healthcare Medicaid |
$70.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.94
|
| Rate for Payer: WEA Trust Commercial |
$132.70
|
| Rate for Payer: WPS Commercial |
$183.75
|
|
|
Developmental Test administration; first hour 96112
|
Professional
|
Both
|
$478.00
|
|
|
Service Code
|
CPT 96112
|
| Hospital Charge Code |
5454795
|
| Min. Negotiated Rate |
$107.07 |
| Max. Negotiated Rate |
$472.26 |
| Rate for Payer: Aetna Commercial |
$472.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$427.52
|
| Rate for Payer: Aetna Managed Medicare |
$107.07
|
| Rate for Payer: Anthem Medicare Advantage |
$107.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$107.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$107.07
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Cigna Commercial |
$472.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$159.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$107.07
|
| Rate for Payer: Health EOS Commercial |
$452.38
|
| Rate for Payer: HFN Commercial |
$472.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$455.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$455.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$107.07
|
| Rate for Payer: Multiplan Commercial |
$397.70
|
| Rate for Payer: NAPHCARE Commercial |
$160.60
|
| Rate for Payer: Preferred Network Access Commercial |
$472.26
|
| Rate for Payer: Quartz Beloit One Network |
$218.73
|
| Rate for Payer: Quartz Commercial |
$283.36
|
| Rate for Payer: Quartz Medicare Advantage |
$107.07
|
| Rate for Payer: The Alliance Commercial |
$267.67
|
| Rate for Payer: United Healthcare Medicaid |
$159.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$107.07
|
| Rate for Payer: WEA Trust Commercial |
$273.42
|
| Rate for Payer: WPS Commercial |
$428.27
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-030-320
|
Facility
|
IP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
3107500
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,458.33 |
| Max. Negotiated Rate |
$10,248.28 |
| Rate for Payer: Aetna Commercial |
$10,025.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.90
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$10,248.28
|
| Rate for Payer: Health EOS Commercial |
$9,914.10
|
| Rate for Payer: HFN Commercial |
$10,248.28
|
| Rate for Payer: Multiplan Commercial |
$8,911.55
|
| Rate for Payer: Preferred Network Access Commercial |
$10,248.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,458.33
|
| Rate for Payer: Quartz Commercial |
$6,683.66
|
| Rate for Payer: WEA Trust Commercial |
$6,126.69
|
| Rate for Payer: WPS Commercial |
$8,250.68
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-030-320
|
Facility
|
OP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
3107500
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,119.04 |
| Max. Negotiated Rate |
$10,248.28 |
| Rate for Payer: Aetna Commercial |
$10,025.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.92
|
| Rate for Payer: Aetna Managed Medicare |
$3,119.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,240.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,569.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,346.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.90
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$10,248.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,233.80
|
| Rate for Payer: Health EOS Commercial |
$9,914.10
|
| Rate for Payer: HFN Commercial |
$10,248.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,354.58
|
| Rate for Payer: Multiplan Commercial |
$8,911.55
|
| Rate for Payer: NAPHCARE Commercial |
$6,683.66
|
| Rate for Payer: Preferred Network Access Commercial |
$10,248.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,458.33
|
| Rate for Payer: Quartz Commercial |
$7,240.64
|
| Rate for Payer: Quartz Medicare Advantage |
$6,683.66
|
| Rate for Payer: The Alliance Commercial |
$5,569.72
|
| Rate for Payer: WEA Trust Commercial |
$6,126.69
|
| Rate for Payer: WPS Commercial |
$8,250.68
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-040-320
|
Facility
|
OP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2973738
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,119.04 |
| Max. Negotiated Rate |
$10,248.28 |
| Rate for Payer: Aetna Commercial |
$10,025.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.92
|
| Rate for Payer: Aetna Managed Medicare |
$3,119.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,240.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,569.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,346.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.90
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$10,248.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,233.80
|
| Rate for Payer: Health EOS Commercial |
$9,914.10
|
| Rate for Payer: HFN Commercial |
$10,248.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,354.58
|
| Rate for Payer: Multiplan Commercial |
$8,911.55
|
| Rate for Payer: NAPHCARE Commercial |
$6,683.66
|
| Rate for Payer: Preferred Network Access Commercial |
$10,248.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,458.33
|
| Rate for Payer: Quartz Commercial |
$7,240.64
|
| Rate for Payer: Quartz Medicare Advantage |
$6,683.66
|
| Rate for Payer: The Alliance Commercial |
$5,569.72
|
| Rate for Payer: WEA Trust Commercial |
$6,126.69
|
| Rate for Payer: WPS Commercial |
$8,250.68
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-040-320
|
Facility
|
IP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2973738
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,458.33 |
| Max. Negotiated Rate |
$10,248.28 |
| Rate for Payer: Aetna Commercial |
$10,025.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.90
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$10,248.28
|
| Rate for Payer: Health EOS Commercial |
$9,914.10
|
| Rate for Payer: HFN Commercial |
$10,248.28
|
| Rate for Payer: Multiplan Commercial |
$8,911.55
|
| Rate for Payer: Preferred Network Access Commercial |
$10,248.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,458.33
|
| Rate for Payer: Quartz Commercial |
$6,683.66
|
| Rate for Payer: WEA Trust Commercial |
$6,126.69
|
| Rate for Payer: WPS Commercial |
$8,250.68
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-050-320
|
Facility
|
IP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2973739
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,458.33 |
| Max. Negotiated Rate |
$10,248.28 |
| Rate for Payer: Aetna Commercial |
$10,025.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.90
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$10,248.28
|
| Rate for Payer: Health EOS Commercial |
$9,914.10
|
| Rate for Payer: HFN Commercial |
$10,248.28
|
| Rate for Payer: Multiplan Commercial |
$8,911.55
|
| Rate for Payer: Preferred Network Access Commercial |
$10,248.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,458.33
|
| Rate for Payer: Quartz Commercial |
$6,683.66
|
| Rate for Payer: WEA Trust Commercial |
$6,126.69
|
| Rate for Payer: WPS Commercial |
$8,250.68
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-050-320
|
Facility
|
OP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2973739
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,119.04 |
| Max. Negotiated Rate |
$10,248.28 |
| Rate for Payer: Aetna Commercial |
$10,025.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.92
|
| Rate for Payer: Aetna Managed Medicare |
$3,119.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,240.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,569.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,346.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.90
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$10,248.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,233.80
|
| Rate for Payer: Health EOS Commercial |
$9,914.10
|
| Rate for Payer: HFN Commercial |
$10,248.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,354.58
|
| Rate for Payer: Multiplan Commercial |
$8,911.55
|
| Rate for Payer: NAPHCARE Commercial |
$6,683.66
|
| Rate for Payer: Preferred Network Access Commercial |
$10,248.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,458.33
|
| Rate for Payer: Quartz Commercial |
$7,240.64
|
| Rate for Payer: Quartz Medicare Advantage |
$6,683.66
|
| Rate for Payer: The Alliance Commercial |
$5,569.72
|
| Rate for Payer: WEA Trust Commercial |
$6,126.69
|
| Rate for Payer: WPS Commercial |
$8,250.68
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-060-320
|
Facility
|
IP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2973740
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,458.33 |
| Max. Negotiated Rate |
$10,248.28 |
| Rate for Payer: Aetna Commercial |
$10,025.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.90
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$10,248.28
|
| Rate for Payer: Health EOS Commercial |
$9,914.10
|
| Rate for Payer: HFN Commercial |
$10,248.28
|
| Rate for Payer: Multiplan Commercial |
$8,911.55
|
| Rate for Payer: Preferred Network Access Commercial |
$10,248.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,458.33
|
| Rate for Payer: Quartz Commercial |
$6,683.66
|
| Rate for Payer: WEA Trust Commercial |
$6,126.69
|
| Rate for Payer: WPS Commercial |
$8,250.68
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-060-320
|
Facility
|
OP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
2973740
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,119.04 |
| Max. Negotiated Rate |
$10,248.28 |
| Rate for Payer: Aetna Commercial |
$10,025.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.92
|
| Rate for Payer: Aetna Managed Medicare |
$3,119.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,240.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,569.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,346.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.90
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$10,248.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,233.80
|
| Rate for Payer: Health EOS Commercial |
$9,914.10
|
| Rate for Payer: HFN Commercial |
$10,248.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,354.58
|
| Rate for Payer: Multiplan Commercial |
$8,911.55
|
| Rate for Payer: NAPHCARE Commercial |
$6,683.66
|
| Rate for Payer: Preferred Network Access Commercial |
$10,248.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,458.33
|
| Rate for Payer: Quartz Commercial |
$7,240.64
|
| Rate for Payer: Quartz Medicare Advantage |
$6,683.66
|
| Rate for Payer: The Alliance Commercial |
$5,569.72
|
| Rate for Payer: WEA Trust Commercial |
$6,126.69
|
| Rate for Payer: WPS Commercial |
$8,250.68
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-070-320
|
Facility
|
IP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
3107491
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,458.33 |
| Max. Negotiated Rate |
$10,248.28 |
| Rate for Payer: Aetna Commercial |
$10,025.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.90
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$10,248.28
|
| Rate for Payer: Health EOS Commercial |
$9,914.10
|
| Rate for Payer: HFN Commercial |
$10,248.28
|
| Rate for Payer: Multiplan Commercial |
$8,911.55
|
| Rate for Payer: Preferred Network Access Commercial |
$10,248.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,458.33
|
| Rate for Payer: Quartz Commercial |
$6,683.66
|
| Rate for Payer: WEA Trust Commercial |
$6,126.69
|
| Rate for Payer: WPS Commercial |
$8,250.68
|
|
|
DEVICE EMBOLIC PROTECTION SPD2-US-070-320
|
Facility
|
OP
|
$10,711.00
|
|
|
Service Code
|
HCPCS C1884
|
| Hospital Charge Code |
3107491
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,119.04 |
| Max. Negotiated Rate |
$10,248.28 |
| Rate for Payer: Aetna Commercial |
$10,025.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,579.92
|
| Rate for Payer: Aetna Managed Medicare |
$3,119.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,240.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,569.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,346.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,903.90
|
| Rate for Payer: Cash Price |
$3,213.30
|
| Rate for Payer: Cigna Commercial |
$10,248.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,233.80
|
| Rate for Payer: Health EOS Commercial |
$9,914.10
|
| Rate for Payer: HFN Commercial |
$10,248.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,354.58
|
| Rate for Payer: Multiplan Commercial |
$8,911.55
|
| Rate for Payer: NAPHCARE Commercial |
$6,683.66
|
| Rate for Payer: Preferred Network Access Commercial |
$10,248.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,458.33
|
| Rate for Payer: Quartz Commercial |
$7,240.64
|
| Rate for Payer: Quartz Medicare Advantage |
$6,683.66
|
| Rate for Payer: The Alliance Commercial |
$5,569.72
|
| Rate for Payer: WEA Trust Commercial |
$6,126.69
|
| Rate for Payer: WPS Commercial |
$8,250.68
|
|
|
DEVICE HEMIGARD ADHESIVE RETENTION SUTURE ARS HRD001
|
Facility
|
OP
|
$805.00
|
|
| Hospital Charge Code |
6153699
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$234.42 |
| Max. Negotiated Rate |
$770.22 |
| Rate for Payer: Aetna Commercial |
$753.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$719.99
|
| Rate for Payer: Aetna Managed Medicare |
$234.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$544.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$418.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$401.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$443.72
|
| Rate for Payer: Cash Price |
$241.50
|
| Rate for Payer: Cigna Commercial |
$770.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$468.51
|
| Rate for Payer: Health EOS Commercial |
$745.11
|
| Rate for Payer: HFN Commercial |
$770.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$627.90
|
| Rate for Payer: Multiplan Commercial |
$669.76
|
| Rate for Payer: NAPHCARE Commercial |
$502.32
|
| Rate for Payer: Preferred Network Access Commercial |
$770.22
|
| Rate for Payer: Quartz Beloit One Network |
$410.23
|
| Rate for Payer: Quartz Commercial |
$544.18
|
| Rate for Payer: Quartz Medicare Advantage |
$502.32
|
| Rate for Payer: The Alliance Commercial |
$418.60
|
| Rate for Payer: WEA Trust Commercial |
$460.46
|
| Rate for Payer: WPS Commercial |
$620.09
|
|
|
DEVICE HEMIGARD ADHESIVE RETENTION SUTURE ARS HRD001
|
Facility
|
IP
|
$805.00
|
|
| Hospital Charge Code |
6153699
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$410.23 |
| Max. Negotiated Rate |
$770.22 |
| Rate for Payer: Aetna Commercial |
$753.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$719.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$443.72
|
| Rate for Payer: Cash Price |
$241.50
|
| Rate for Payer: Cigna Commercial |
$770.22
|
| Rate for Payer: Health EOS Commercial |
$745.11
|
| Rate for Payer: HFN Commercial |
$770.22
|
| Rate for Payer: Multiplan Commercial |
$669.76
|
| Rate for Payer: Preferred Network Access Commercial |
$770.22
|
| Rate for Payer: Quartz Beloit One Network |
$410.23
|
| Rate for Payer: Quartz Commercial |
$502.32
|
| Rate for Payer: WEA Trust Commercial |
$460.46
|
| Rate for Payer: WPS Commercial |
$620.09
|
|
|
Devices
|
Facility
|
OP
|
$19,632.00
|
|
| Hospital Charge Code |
5102624
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$5,716.84 |
| Max. Negotiated Rate |
$18,783.90 |
| Rate for Payer: Aetna Commercial |
$18,375.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,558.86
|
| Rate for Payer: Aetna Managed Medicare |
$5,716.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,271.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,208.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,800.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,821.16
|
| Rate for Payer: Cash Price |
$5,889.60
|
| Rate for Payer: Cigna Commercial |
$18,783.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,425.82
|
| Rate for Payer: Health EOS Commercial |
$18,171.38
|
| Rate for Payer: HFN Commercial |
$18,783.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,312.96
|
| Rate for Payer: Multiplan Commercial |
$16,333.82
|
| Rate for Payer: NAPHCARE Commercial |
$12,250.37
|
| Rate for Payer: Preferred Network Access Commercial |
$18,783.90
|
| Rate for Payer: Quartz Beloit One Network |
$10,004.47
|
| Rate for Payer: Quartz Commercial |
$13,271.23
|
| Rate for Payer: Quartz Medicare Advantage |
$12,250.37
|
| Rate for Payer: The Alliance Commercial |
$10,208.64
|
| Rate for Payer: WEA Trust Commercial |
$11,229.50
|
| Rate for Payer: WPS Commercial |
$15,122.53
|
|
|
Devices
|
Facility
|
IP
|
$19,632.00
|
|
| Hospital Charge Code |
5102624
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$10,004.47 |
| Max. Negotiated Rate |
$18,783.90 |
| Rate for Payer: Aetna Commercial |
$18,375.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,558.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,821.16
|
| Rate for Payer: Cash Price |
$5,889.60
|
| Rate for Payer: Cigna Commercial |
$18,783.90
|
| Rate for Payer: Health EOS Commercial |
$18,171.38
|
| Rate for Payer: HFN Commercial |
$18,783.90
|
| Rate for Payer: Multiplan Commercial |
$16,333.82
|
| Rate for Payer: Preferred Network Access Commercial |
$18,783.90
|
| Rate for Payer: Quartz Beloit One Network |
$10,004.47
|
| Rate for Payer: Quartz Commercial |
$12,250.37
|
| Rate for Payer: WEA Trust Commercial |
$11,229.50
|
| Rate for Payer: WPS Commercial |
$15,122.53
|
|
|
DEVICE ULTRA MINI TRUCLEAR 72204064
|
Facility
|
IP
|
$6,680.00
|
|
| Hospital Charge Code |
5179377
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,404.13 |
| Max. Negotiated Rate |
$6,391.42 |
| Rate for Payer: Aetna Commercial |
$6,252.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,974.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,682.02
|
| Rate for Payer: Cash Price |
$2,004.00
|
| Rate for Payer: Cigna Commercial |
$6,391.42
|
| Rate for Payer: Health EOS Commercial |
$6,183.01
|
| Rate for Payer: HFN Commercial |
$6,391.42
|
| Rate for Payer: Multiplan Commercial |
$5,557.76
|
| Rate for Payer: Preferred Network Access Commercial |
$6,391.42
|
| Rate for Payer: Quartz Beloit One Network |
$3,404.13
|
| Rate for Payer: Quartz Commercial |
$4,168.32
|
| Rate for Payer: WEA Trust Commercial |
$3,820.96
|
| Rate for Payer: WPS Commercial |
$5,145.60
|
|
|
DEVICE ULTRA MINI TRUCLEAR 72204064
|
Facility
|
OP
|
$6,680.00
|
|
| Hospital Charge Code |
5179377
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,945.22 |
| Max. Negotiated Rate |
$6,391.42 |
| Rate for Payer: Aetna Commercial |
$6,252.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,974.59
|
| Rate for Payer: Aetna Managed Medicare |
$1,945.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,515.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,473.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,334.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,682.02
|
| Rate for Payer: Cash Price |
$2,004.00
|
| Rate for Payer: Cigna Commercial |
$6,391.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,887.76
|
| Rate for Payer: Health EOS Commercial |
$6,183.01
|
| Rate for Payer: HFN Commercial |
$6,391.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,210.40
|
| Rate for Payer: Multiplan Commercial |
$5,557.76
|
| Rate for Payer: NAPHCARE Commercial |
$4,168.32
|
| Rate for Payer: Preferred Network Access Commercial |
$6,391.42
|
| Rate for Payer: Quartz Beloit One Network |
$3,404.13
|
| Rate for Payer: Quartz Commercial |
$4,515.68
|
| Rate for Payer: Quartz Medicare Advantage |
$4,168.32
|
| Rate for Payer: The Alliance Commercial |
$3,473.60
|
| Rate for Payer: WEA Trust Commercial |
$3,820.96
|
| Rate for Payer: WPS Commercial |
$5,145.60
|
|
|
DEVICE ULTRA PLUS TRUCLEAR 72203012
|
Facility
|
IP
|
$8,212.00
|
|
| Hospital Charge Code |
5106993
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,184.84 |
| Max. Negotiated Rate |
$7,857.24 |
| Rate for Payer: Aetna Commercial |
$7,686.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,344.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,526.45
|
| Rate for Payer: Cash Price |
$2,463.60
|
| Rate for Payer: Cigna Commercial |
$7,857.24
|
| Rate for Payer: Health EOS Commercial |
$7,601.03
|
| Rate for Payer: HFN Commercial |
$7,857.24
|
| Rate for Payer: Multiplan Commercial |
$6,832.38
|
| Rate for Payer: Preferred Network Access Commercial |
$7,857.24
|
| Rate for Payer: Quartz Beloit One Network |
$4,184.84
|
| Rate for Payer: Quartz Commercial |
$5,124.29
|
| Rate for Payer: WEA Trust Commercial |
$4,697.26
|
| Rate for Payer: WPS Commercial |
$6,325.70
|
|
|
DEVICE ULTRA PLUS TRUCLEAR 72203012
|
Facility
|
OP
|
$8,212.00
|
|
| Hospital Charge Code |
5106993
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,391.33 |
| Max. Negotiated Rate |
$7,857.24 |
| Rate for Payer: Aetna Commercial |
$7,686.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,344.81
|
| Rate for Payer: Aetna Managed Medicare |
$2,391.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,551.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,270.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,099.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,526.45
|
| Rate for Payer: Cash Price |
$2,463.60
|
| Rate for Payer: Cigna Commercial |
$7,857.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,779.38
|
| Rate for Payer: Health EOS Commercial |
$7,601.03
|
| Rate for Payer: HFN Commercial |
$7,857.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,405.36
|
| Rate for Payer: Multiplan Commercial |
$6,832.38
|
| Rate for Payer: NAPHCARE Commercial |
$5,124.29
|
| Rate for Payer: Preferred Network Access Commercial |
$7,857.24
|
| Rate for Payer: Quartz Beloit One Network |
$4,184.84
|
| Rate for Payer: Quartz Commercial |
$5,551.31
|
| Rate for Payer: Quartz Medicare Advantage |
$5,124.29
|
| Rate for Payer: The Alliance Commercial |
$4,270.24
|
| Rate for Payer: WEA Trust Commercial |
$4,697.26
|
| Rate for Payer: WPS Commercial |
$6,325.70
|
|
|
DEVICE VOYANT 5MM FUSION (BLUNT) 37CM EB210
|
Facility
|
OP
|
$3,197.00
|
|
| Hospital Charge Code |
6153654
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$930.97 |
| Max. Negotiated Rate |
$3,058.89 |
| Rate for Payer: Aetna Commercial |
$2,992.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,859.40
|
| Rate for Payer: Aetna Managed Medicare |
$930.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,161.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,662.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,595.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,762.19
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$3,058.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,860.65
|
| Rate for Payer: Health EOS Commercial |
$2,959.14
|
| Rate for Payer: HFN Commercial |
$3,058.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,493.66
|
| Rate for Payer: Multiplan Commercial |
$2,659.90
|
| Rate for Payer: NAPHCARE Commercial |
$1,994.93
|
| Rate for Payer: Preferred Network Access Commercial |
$3,058.89
|
| Rate for Payer: Quartz Beloit One Network |
$1,629.19
|
| Rate for Payer: Quartz Commercial |
$2,161.17
|
| Rate for Payer: Quartz Medicare Advantage |
$1,994.93
|
| Rate for Payer: The Alliance Commercial |
$1,662.44
|
| Rate for Payer: WEA Trust Commercial |
$1,828.68
|
| Rate for Payer: WPS Commercial |
$2,462.65
|
|
|
DEVICE VOYANT 5MM FUSION (BLUNT) 37CM EB210
|
Facility
|
IP
|
$3,197.00
|
|
| Hospital Charge Code |
6153654
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,629.19 |
| Max. Negotiated Rate |
$3,058.89 |
| Rate for Payer: Aetna Commercial |
$2,992.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,859.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,762.19
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$3,058.89
|
| Rate for Payer: Health EOS Commercial |
$2,959.14
|
| Rate for Payer: HFN Commercial |
$3,058.89
|
| Rate for Payer: Multiplan Commercial |
$2,659.90
|
| Rate for Payer: Preferred Network Access Commercial |
$3,058.89
|
| Rate for Payer: Quartz Beloit One Network |
$1,629.19
|
| Rate for Payer: Quartz Commercial |
$1,994.93
|
| Rate for Payer: WEA Trust Commercial |
$1,828.68
|
| Rate for Payer: WPS Commercial |
$2,462.65
|
|
