|
Dispensing Fee, Monaural
|
Facility
|
OP
|
$997.00
|
|
|
Service Code
|
HCPCS V5241
|
| Hospital Charge Code |
3243597
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$290.33 |
| Max. Negotiated Rate |
$953.93 |
| Rate for Payer: Aetna Commercial |
$933.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$891.72
|
| Rate for Payer: Aetna Managed Medicare |
$290.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$673.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$518.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$497.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$549.55
|
| Rate for Payer: Cash Price |
$299.10
|
| Rate for Payer: Cigna Commercial |
$953.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$580.25
|
| Rate for Payer: Health EOS Commercial |
$922.82
|
| Rate for Payer: HFN Commercial |
$953.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$777.66
|
| Rate for Payer: Multiplan Commercial |
$829.50
|
| Rate for Payer: NAPHCARE Commercial |
$622.13
|
| Rate for Payer: Preferred Network Access Commercial |
$953.93
|
| Rate for Payer: Quartz Beloit One Network |
$508.07
|
| Rate for Payer: Quartz Commercial |
$673.97
|
| Rate for Payer: Quartz Medicare Advantage |
$622.13
|
| Rate for Payer: The Alliance Commercial |
$518.44
|
| Rate for Payer: United Healthcare PPO |
$777.66
|
| Rate for Payer: WEA Trust Commercial |
$570.28
|
| Rate for Payer: WPS Commercial |
$767.99
|
|
|
Dispensing Fee, Monaural
|
Facility
|
IP
|
$997.00
|
|
|
Service Code
|
HCPCS V5241
|
| Hospital Charge Code |
3243597
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$508.07 |
| Max. Negotiated Rate |
$953.93 |
| Rate for Payer: Aetna Commercial |
$933.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$891.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$549.55
|
| Rate for Payer: Cash Price |
$299.10
|
| Rate for Payer: Cigna Commercial |
$953.93
|
| Rate for Payer: Health EOS Commercial |
$922.82
|
| Rate for Payer: HFN Commercial |
$953.93
|
| Rate for Payer: Multiplan Commercial |
$829.50
|
| Rate for Payer: Preferred Network Access Commercial |
$953.93
|
| Rate for Payer: Quartz Beloit One Network |
$508.07
|
| Rate for Payer: Quartz Commercial |
$622.13
|
| Rate for Payer: WEA Trust Commercial |
$570.28
|
| Rate for Payer: WPS Commercial |
$767.99
|
|
|
Dispensing Fee, Monaural
|
Professional
|
Both
|
$997.00
|
|
|
Service Code
|
HCPCS V5241
|
| Hospital Charge Code |
3243597
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$456.23 |
| Max. Negotiated Rate |
$985.04 |
| Rate for Payer: Aetna Commercial |
$985.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$891.72
|
| Rate for Payer: Cash Price |
$299.10
|
| Rate for Payer: Cigna Commercial |
$985.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$518.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$622.13
|
| Rate for Payer: Health EOS Commercial |
$943.56
|
| Rate for Payer: HFN Commercial |
$985.04
|
| Rate for Payer: Multiplan Commercial |
$829.50
|
| Rate for Payer: Preferred Network Access Commercial |
$985.04
|
| Rate for Payer: Quartz Beloit One Network |
$456.23
|
| Rate for Payer: Quartz Commercial |
$591.02
|
| Rate for Payer: The Alliance Commercial |
$518.44
|
| Rate for Payer: WEA Trust Commercial |
$570.28
|
| Rate for Payer: WPS Commercial |
$767.99
|
|
|
Disposable adhesive
|
Facility
|
IP
|
$272.00
|
|
| Hospital Charge Code |
3025935
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$138.61 |
| Max. Negotiated Rate |
$260.25 |
| Rate for Payer: Aetna Commercial |
$254.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$243.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$149.93
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$260.25
|
| Rate for Payer: Health EOS Commercial |
$251.76
|
| Rate for Payer: HFN Commercial |
$260.25
|
| Rate for Payer: Multiplan Commercial |
$226.30
|
| Rate for Payer: Preferred Network Access Commercial |
$260.25
|
| Rate for Payer: Quartz Beloit One Network |
$138.61
|
| Rate for Payer: Quartz Commercial |
$169.73
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: WPS Commercial |
$209.52
|
|
|
Disposable adhesive
|
Facility
|
OP
|
$272.00
|
|
| Hospital Charge Code |
3025935
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$79.21 |
| Max. Negotiated Rate |
$260.25 |
| Rate for Payer: Aetna Commercial |
$254.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$243.28
|
| Rate for Payer: Aetna Managed Medicare |
$79.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$183.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$141.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$135.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$149.93
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$260.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$158.30
|
| Rate for Payer: Health EOS Commercial |
$251.76
|
| Rate for Payer: HFN Commercial |
$260.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$212.16
|
| Rate for Payer: Multiplan Commercial |
$226.30
|
| Rate for Payer: NAPHCARE Commercial |
$169.73
|
| Rate for Payer: Preferred Network Access Commercial |
$260.25
|
| Rate for Payer: Quartz Beloit One Network |
$138.61
|
| Rate for Payer: Quartz Commercial |
$183.87
|
| Rate for Payer: Quartz Medicare Advantage |
$169.73
|
| Rate for Payer: The Alliance Commercial |
$141.44
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: WPS Commercial |
$209.52
|
|
|
DISPOSABLE BONE MILL STRYKER MEDIUM 5400-701-000
|
Facility
|
OP
|
$4,690.00
|
|
| Hospital Charge Code |
4447693
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,365.73 |
| Max. Negotiated Rate |
$4,487.39 |
| Rate for Payer: Aetna Commercial |
$4,389.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,194.74
|
| Rate for Payer: Aetna Managed Medicare |
$1,365.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,170.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,438.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,341.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.13
|
| Rate for Payer: Cash Price |
$1,407.00
|
| Rate for Payer: Cigna Commercial |
$4,487.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,729.58
|
| Rate for Payer: Health EOS Commercial |
$4,341.06
|
| Rate for Payer: HFN Commercial |
$4,487.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,658.20
|
| Rate for Payer: Multiplan Commercial |
$3,902.08
|
| Rate for Payer: NAPHCARE Commercial |
$2,926.56
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.39
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.02
|
| Rate for Payer: Quartz Commercial |
$3,170.44
|
| Rate for Payer: Quartz Medicare Advantage |
$2,926.56
|
| Rate for Payer: The Alliance Commercial |
$2,438.80
|
| Rate for Payer: WEA Trust Commercial |
$2,682.68
|
| Rate for Payer: WPS Commercial |
$3,612.71
|
|
|
DISPOSABLE BONE MILL STRYKER MEDIUM 5400-701-000
|
Facility
|
IP
|
$4,690.00
|
|
| Hospital Charge Code |
4447693
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,390.02 |
| Max. Negotiated Rate |
$4,487.39 |
| Rate for Payer: Aetna Commercial |
$4,389.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,194.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,585.13
|
| Rate for Payer: Cash Price |
$1,407.00
|
| Rate for Payer: Cigna Commercial |
$4,487.39
|
| Rate for Payer: Health EOS Commercial |
$4,341.06
|
| Rate for Payer: HFN Commercial |
$4,487.39
|
| Rate for Payer: Multiplan Commercial |
$3,902.08
|
| Rate for Payer: Preferred Network Access Commercial |
$4,487.39
|
| Rate for Payer: Quartz Beloit One Network |
$2,390.02
|
| Rate for Payer: Quartz Commercial |
$2,926.56
|
| Rate for Payer: WEA Trust Commercial |
$2,682.68
|
| Rate for Payer: WPS Commercial |
$3,612.71
|
|
|
Disposable Bvm - Adult
|
Facility
|
IP
|
$19.00
|
|
| Hospital Charge Code |
3040344
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$18.18 |
| Rate for Payer: Aetna Commercial |
$17.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.47
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$18.18
|
| Rate for Payer: Health EOS Commercial |
$17.59
|
| Rate for Payer: HFN Commercial |
$18.18
|
| Rate for Payer: Multiplan Commercial |
$15.81
|
| Rate for Payer: Preferred Network Access Commercial |
$18.18
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$11.86
|
| Rate for Payer: WEA Trust Commercial |
$10.87
|
| Rate for Payer: WPS Commercial |
$14.64
|
|
|
Disposable Bvm - Adult
|
Facility
|
OP
|
$19.00
|
|
| Hospital Charge Code |
3040344
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5.53 |
| Max. Negotiated Rate |
$18.18 |
| Rate for Payer: Aetna Commercial |
$17.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.99
|
| Rate for Payer: Aetna Managed Medicare |
$5.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.47
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$18.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.06
|
| Rate for Payer: Health EOS Commercial |
$17.59
|
| Rate for Payer: HFN Commercial |
$18.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.82
|
| Rate for Payer: Multiplan Commercial |
$15.81
|
| Rate for Payer: NAPHCARE Commercial |
$11.86
|
| Rate for Payer: Preferred Network Access Commercial |
$18.18
|
| Rate for Payer: Quartz Beloit One Network |
$9.68
|
| Rate for Payer: Quartz Commercial |
$12.84
|
| Rate for Payer: Quartz Medicare Advantage |
$11.86
|
| Rate for Payer: The Alliance Commercial |
$9.88
|
| Rate for Payer: WEA Trust Commercial |
$10.87
|
| Rate for Payer: WPS Commercial |
$14.64
|
|
|
Disposable Bvm Mask Infant
|
Facility
|
IP
|
$48.00
|
|
| Hospital Charge Code |
3040343
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$45.93 |
| Rate for Payer: Aetna Commercial |
$44.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.46
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.93
|
| Rate for Payer: Health EOS Commercial |
$44.43
|
| Rate for Payer: HFN Commercial |
$45.93
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: Preferred Network Access Commercial |
$45.93
|
| Rate for Payer: Quartz Beloit One Network |
$24.46
|
| Rate for Payer: Quartz Commercial |
$29.95
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$36.97
|
|
|
Disposable Bvm Mask Infant
|
Facility
|
OP
|
$48.00
|
|
| Hospital Charge Code |
3040343
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$13.98 |
| Max. Negotiated Rate |
$45.93 |
| Rate for Payer: Aetna Commercial |
$44.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Aetna Managed Medicare |
$13.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.46
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.94
|
| Rate for Payer: Health EOS Commercial |
$44.43
|
| Rate for Payer: HFN Commercial |
$45.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.44
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: NAPHCARE Commercial |
$29.95
|
| Rate for Payer: Preferred Network Access Commercial |
$45.93
|
| Rate for Payer: Quartz Beloit One Network |
$24.46
|
| Rate for Payer: Quartz Commercial |
$32.45
|
| Rate for Payer: Quartz Medicare Advantage |
$29.95
|
| Rate for Payer: The Alliance Commercial |
$24.96
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$36.97
|
|
|
Disposable Bvm - Pediatric
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
3040342
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.27 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Aetna Managed Medicare |
$14.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.52
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.22
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: NAPHCARE Commercial |
$30.58
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$33.12
|
| Rate for Payer: Quartz Medicare Advantage |
$30.58
|
| Rate for Payer: The Alliance Commercial |
$25.48
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
Disposable Bvm - Pediatric
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
3040342
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.97 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$30.58
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
DISPOSABLE ENDOSCOPIC GASTROCNEMIUS RECESSION EGR EXPRESS 3200-D
|
Facility
|
OP
|
$3,246.00
|
|
| Hospital Charge Code |
6151664
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$945.24 |
| Max. Negotiated Rate |
$3,105.77 |
| Rate for Payer: Aetna Commercial |
$3,038.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,903.22
|
| Rate for Payer: Aetna Managed Medicare |
$945.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,194.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,687.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,620.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,789.20
|
| Rate for Payer: Cash Price |
$973.80
|
| Rate for Payer: Cigna Commercial |
$3,105.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,889.17
|
| Rate for Payer: Health EOS Commercial |
$3,004.50
|
| Rate for Payer: HFN Commercial |
$3,105.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,531.88
|
| Rate for Payer: Multiplan Commercial |
$2,700.67
|
| Rate for Payer: NAPHCARE Commercial |
$2,025.50
|
| Rate for Payer: Preferred Network Access Commercial |
$3,105.77
|
| Rate for Payer: Quartz Beloit One Network |
$1,654.16
|
| Rate for Payer: Quartz Commercial |
$2,194.30
|
| Rate for Payer: Quartz Medicare Advantage |
$2,025.50
|
| Rate for Payer: The Alliance Commercial |
$1,687.92
|
| Rate for Payer: WEA Trust Commercial |
$1,856.71
|
| Rate for Payer: WPS Commercial |
$2,500.39
|
|
|
DISPOSABLE ENDOSCOPIC GASTROCNEMIUS RECESSION EGR EXPRESS 3200-D
|
Facility
|
IP
|
$3,246.00
|
|
| Hospital Charge Code |
6151664
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,654.16 |
| Max. Negotiated Rate |
$3,105.77 |
| Rate for Payer: Aetna Commercial |
$3,038.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,903.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,789.20
|
| Rate for Payer: Cash Price |
$973.80
|
| Rate for Payer: Cigna Commercial |
$3,105.77
|
| Rate for Payer: Health EOS Commercial |
$3,004.50
|
| Rate for Payer: HFN Commercial |
$3,105.77
|
| Rate for Payer: Multiplan Commercial |
$2,700.67
|
| Rate for Payer: Preferred Network Access Commercial |
$3,105.77
|
| Rate for Payer: Quartz Beloit One Network |
$1,654.16
|
| Rate for Payer: Quartz Commercial |
$2,025.50
|
| Rate for Payer: WEA Trust Commercial |
$1,856.71
|
| Rate for Payer: WPS Commercial |
$2,500.39
|
|
|
DISPOSABLE INSTRUMENT KIT MINI S-TAK AR-1322DSC
|
Facility
|
OP
|
$2,659.00
|
|
| Hospital Charge Code |
5384919
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$774.30 |
| Max. Negotiated Rate |
$2,544.13 |
| Rate for Payer: Aetna Commercial |
$2,488.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,378.21
|
| Rate for Payer: Aetna Managed Medicare |
$774.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,797.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,382.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,327.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,465.64
|
| Rate for Payer: Cash Price |
$797.70
|
| Rate for Payer: Cigna Commercial |
$2,544.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,547.54
|
| Rate for Payer: Health EOS Commercial |
$2,461.17
|
| Rate for Payer: HFN Commercial |
$2,544.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,074.02
|
| Rate for Payer: Multiplan Commercial |
$2,212.29
|
| Rate for Payer: NAPHCARE Commercial |
$1,659.22
|
| Rate for Payer: Preferred Network Access Commercial |
$2,544.13
|
| Rate for Payer: Quartz Beloit One Network |
$1,355.03
|
| Rate for Payer: Quartz Commercial |
$1,797.48
|
| Rate for Payer: Quartz Medicare Advantage |
$1,659.22
|
| Rate for Payer: The Alliance Commercial |
$1,382.68
|
| Rate for Payer: WEA Trust Commercial |
$1,520.95
|
| Rate for Payer: WPS Commercial |
$2,048.23
|
|
|
DISPOSABLE INSTRUMENT KIT MINI S-TAK AR-1322DSC
|
Facility
|
IP
|
$2,659.00
|
|
| Hospital Charge Code |
5384919
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,355.03 |
| Max. Negotiated Rate |
$2,544.13 |
| Rate for Payer: Aetna Commercial |
$2,488.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,378.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,465.64
|
| Rate for Payer: Cash Price |
$797.70
|
| Rate for Payer: Cigna Commercial |
$2,544.13
|
| Rate for Payer: Health EOS Commercial |
$2,461.17
|
| Rate for Payer: HFN Commercial |
$2,544.13
|
| Rate for Payer: Multiplan Commercial |
$2,212.29
|
| Rate for Payer: Preferred Network Access Commercial |
$2,544.13
|
| Rate for Payer: Quartz Beloit One Network |
$1,355.03
|
| Rate for Payer: Quartz Commercial |
$1,659.22
|
| Rate for Payer: WEA Trust Commercial |
$1,520.95
|
| Rate for Payer: WPS Commercial |
$2,048.23
|
|
|
DISPOSABLE KIT 2.4MM PUSHLOCK AR-2924DHS
|
Facility
|
OP
|
$2,705.00
|
|
| Hospital Charge Code |
5414767
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$787.70 |
| Max. Negotiated Rate |
$2,588.14 |
| Rate for Payer: Aetna Commercial |
$2,531.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,419.35
|
| Rate for Payer: Aetna Managed Medicare |
$787.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,828.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,406.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,350.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,491.00
|
| Rate for Payer: Cash Price |
$811.50
|
| Rate for Payer: Cigna Commercial |
$2,588.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,574.31
|
| Rate for Payer: Health EOS Commercial |
$2,503.75
|
| Rate for Payer: HFN Commercial |
$2,588.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,109.90
|
| Rate for Payer: Multiplan Commercial |
$2,250.56
|
| Rate for Payer: NAPHCARE Commercial |
$1,687.92
|
| Rate for Payer: Preferred Network Access Commercial |
$2,588.14
|
| Rate for Payer: Quartz Beloit One Network |
$1,378.47
|
| Rate for Payer: Quartz Commercial |
$1,828.58
|
| Rate for Payer: Quartz Medicare Advantage |
$1,687.92
|
| Rate for Payer: The Alliance Commercial |
$1,406.60
|
| Rate for Payer: WEA Trust Commercial |
$1,547.26
|
| Rate for Payer: WPS Commercial |
$2,083.66
|
|
|
DISPOSABLE KIT 2.4MM PUSHLOCK AR-2924DHS
|
Facility
|
IP
|
$2,705.00
|
|
| Hospital Charge Code |
5414767
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,378.47 |
| Max. Negotiated Rate |
$2,588.14 |
| Rate for Payer: Aetna Commercial |
$2,531.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,419.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,491.00
|
| Rate for Payer: Cash Price |
$811.50
|
| Rate for Payer: Cigna Commercial |
$2,588.14
|
| Rate for Payer: Health EOS Commercial |
$2,503.75
|
| Rate for Payer: HFN Commercial |
$2,588.14
|
| Rate for Payer: Multiplan Commercial |
$2,250.56
|
| Rate for Payer: Preferred Network Access Commercial |
$2,588.14
|
| Rate for Payer: Quartz Beloit One Network |
$1,378.47
|
| Rate for Payer: Quartz Commercial |
$1,687.92
|
| Rate for Payer: WEA Trust Commercial |
$1,547.26
|
| Rate for Payer: WPS Commercial |
$2,083.66
|
|
|
DISPOSABLE KIT 2.9MM PUSHLOCK AR-2923DS
|
Facility
|
OP
|
$2,459.00
|
|
| Hospital Charge Code |
5349154
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$716.06 |
| Max. Negotiated Rate |
$2,352.77 |
| Rate for Payer: Aetna Commercial |
$2,301.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,199.33
|
| Rate for Payer: Aetna Managed Medicare |
$716.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,662.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,278.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,227.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,355.40
|
| Rate for Payer: Cash Price |
$737.70
|
| Rate for Payer: Cigna Commercial |
$2,352.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,431.14
|
| Rate for Payer: Health EOS Commercial |
$2,276.05
|
| Rate for Payer: HFN Commercial |
$2,352.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,918.02
|
| Rate for Payer: Multiplan Commercial |
$2,045.89
|
| Rate for Payer: NAPHCARE Commercial |
$1,534.42
|
| Rate for Payer: Preferred Network Access Commercial |
$2,352.77
|
| Rate for Payer: Quartz Beloit One Network |
$1,253.11
|
| Rate for Payer: Quartz Commercial |
$1,662.28
|
| Rate for Payer: Quartz Medicare Advantage |
$1,534.42
|
| Rate for Payer: The Alliance Commercial |
$1,278.68
|
| Rate for Payer: WEA Trust Commercial |
$1,406.55
|
| Rate for Payer: WPS Commercial |
$1,894.17
|
|
|
DISPOSABLE KIT 2.9MM PUSHLOCK AR-2923DS
|
Facility
|
IP
|
$2,459.00
|
|
| Hospital Charge Code |
5349154
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,253.11 |
| Max. Negotiated Rate |
$2,352.77 |
| Rate for Payer: Aetna Commercial |
$2,301.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,199.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,355.40
|
| Rate for Payer: Cash Price |
$737.70
|
| Rate for Payer: Cigna Commercial |
$2,352.77
|
| Rate for Payer: Health EOS Commercial |
$2,276.05
|
| Rate for Payer: HFN Commercial |
$2,352.77
|
| Rate for Payer: Multiplan Commercial |
$2,045.89
|
| Rate for Payer: Preferred Network Access Commercial |
$2,352.77
|
| Rate for Payer: Quartz Beloit One Network |
$1,253.11
|
| Rate for Payer: Quartz Commercial |
$1,534.42
|
| Rate for Payer: WEA Trust Commercial |
$1,406.55
|
| Rate for Payer: WPS Commercial |
$1,894.17
|
|
|
DISPOSABLE KIT PUSHLOCK 2.9MM AR-1923DS
|
Facility
|
OP
|
$3,049.00
|
|
| Hospital Charge Code |
3072506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$887.87 |
| Max. Negotiated Rate |
$2,917.28 |
| Rate for Payer: Aetna Commercial |
$2,853.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,727.03
|
| Rate for Payer: Aetna Managed Medicare |
$887.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,061.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,585.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,522.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,680.61
|
| Rate for Payer: Cash Price |
$914.70
|
| Rate for Payer: Cigna Commercial |
$2,917.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,774.52
|
| Rate for Payer: Health EOS Commercial |
$2,822.15
|
| Rate for Payer: HFN Commercial |
$2,917.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,378.22
|
| Rate for Payer: Multiplan Commercial |
$2,536.77
|
| Rate for Payer: NAPHCARE Commercial |
$1,902.58
|
| Rate for Payer: Preferred Network Access Commercial |
$2,917.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,553.77
|
| Rate for Payer: Quartz Commercial |
$2,061.12
|
| Rate for Payer: Quartz Medicare Advantage |
$1,902.58
|
| Rate for Payer: The Alliance Commercial |
$1,585.48
|
| Rate for Payer: WEA Trust Commercial |
$1,744.03
|
| Rate for Payer: WPS Commercial |
$2,348.64
|
|
|
DISPOSABLE KIT PUSHLOCK 2.9MM AR-1923DS
|
Facility
|
IP
|
$3,049.00
|
|
| Hospital Charge Code |
3072506
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,553.77 |
| Max. Negotiated Rate |
$2,917.28 |
| Rate for Payer: Aetna Commercial |
$2,853.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,727.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,680.61
|
| Rate for Payer: Cash Price |
$914.70
|
| Rate for Payer: Cigna Commercial |
$2,917.28
|
| Rate for Payer: Health EOS Commercial |
$2,822.15
|
| Rate for Payer: HFN Commercial |
$2,917.28
|
| Rate for Payer: Multiplan Commercial |
$2,536.77
|
| Rate for Payer: Preferred Network Access Commercial |
$2,917.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,553.77
|
| Rate for Payer: Quartz Commercial |
$1,902.58
|
| Rate for Payer: WEA Trust Commercial |
$1,744.03
|
| Rate for Payer: WPS Commercial |
$2,348.64
|
|
|
DISPOSABLE KIT T3 AMZ AR-13217
|
Facility
|
IP
|
$5,916.00
|
|
| Hospital Charge Code |
5521096
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,014.79 |
| Max. Negotiated Rate |
$5,660.43 |
| Rate for Payer: Aetna Commercial |
$5,537.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,291.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,260.90
|
| Rate for Payer: Cash Price |
$1,774.80
|
| Rate for Payer: Cigna Commercial |
$5,660.43
|
| Rate for Payer: Health EOS Commercial |
$5,475.85
|
| Rate for Payer: HFN Commercial |
$5,660.43
|
| Rate for Payer: Multiplan Commercial |
$4,922.11
|
| Rate for Payer: Preferred Network Access Commercial |
$5,660.43
|
| Rate for Payer: Quartz Beloit One Network |
$3,014.79
|
| Rate for Payer: Quartz Commercial |
$3,691.58
|
| Rate for Payer: WEA Trust Commercial |
$3,383.95
|
| Rate for Payer: WPS Commercial |
$4,557.09
|
|
|
DISPOSABLE KIT T3 AMZ AR-13217
|
Facility
|
OP
|
$5,916.00
|
|
| Hospital Charge Code |
5521096
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,722.74 |
| Max. Negotiated Rate |
$5,660.43 |
| Rate for Payer: Aetna Commercial |
$5,537.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,291.27
|
| Rate for Payer: Aetna Managed Medicare |
$1,722.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,999.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,076.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,953.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,260.90
|
| Rate for Payer: Cash Price |
$1,774.80
|
| Rate for Payer: Cigna Commercial |
$5,660.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,443.11
|
| Rate for Payer: Health EOS Commercial |
$5,475.85
|
| Rate for Payer: HFN Commercial |
$5,660.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,614.48
|
| Rate for Payer: Multiplan Commercial |
$4,922.11
|
| Rate for Payer: NAPHCARE Commercial |
$3,691.58
|
| Rate for Payer: Preferred Network Access Commercial |
$5,660.43
|
| Rate for Payer: Quartz Beloit One Network |
$3,014.79
|
| Rate for Payer: Quartz Commercial |
$3,999.22
|
| Rate for Payer: Quartz Medicare Advantage |
$3,691.58
|
| Rate for Payer: The Alliance Commercial |
$3,076.32
|
| Rate for Payer: WEA Trust Commercial |
$3,383.95
|
| Rate for Payer: WPS Commercial |
$4,557.09
|
|
