|
END CAP FOR APEX PIN 04 5027-1-040
|
Facility
|
IP
|
$483.00
|
|
| Hospital Charge Code |
6167873
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$236.67 |
| Max. Negotiated Rate |
$444.36 |
| Rate for Payer: Aetna Commercial |
$434.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$415.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.99
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Cigna Commercial |
$444.36
|
| Rate for Payer: Health EOS Commercial |
$429.87
|
| Rate for Payer: HFN Commercial |
$444.36
|
| Rate for Payer: Multiplan Commercial |
$386.40
|
| Rate for Payer: NAPHCARE Commercial |
$289.80
|
| Rate for Payer: Preferred Network Access Commercial |
$444.36
|
| Rate for Payer: Quartz Beloit One Network |
$236.67
|
| Rate for Payer: Quartz Commercial |
$289.80
|
| Rate for Payer: WEA Trust Commercial |
$265.65
|
| Rate for Payer: WPS Commercial |
$357.76
|
|
|
END CAP FOR APEX PIN 04 5027-1-040
|
Facility
|
OP
|
$483.00
|
|
| Hospital Charge Code |
6167873
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$135.24 |
| Max. Negotiated Rate |
$1,932.00 |
| Rate for Payer: Aetna Commercial |
$434.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$415.38
|
| Rate for Payer: Aetna Managed Medicare |
$135.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$313.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$241.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$231.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.99
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Cigna Commercial |
$444.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$270.29
|
| Rate for Payer: Health EOS Commercial |
$429.87
|
| Rate for Payer: HFN Commercial |
$444.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$362.25
|
| Rate for Payer: Multiplan Commercial |
$386.40
|
| Rate for Payer: NAPHCARE Commercial |
$289.80
|
| Rate for Payer: Preferred Network Access Commercial |
$444.36
|
| Rate for Payer: Quartz Beloit One Network |
$236.67
|
| Rate for Payer: Quartz Commercial |
$313.95
|
| Rate for Payer: Quartz Medicare Advantage |
$289.80
|
| Rate for Payer: The Alliance Commercial |
$1,932.00
|
| Rate for Payer: WEA Trust Commercial |
$265.65
|
| Rate for Payer: WPS Commercial |
$357.76
|
|
|
END CAP FOR APEX PIN 05 5027-1-050
|
Facility
|
IP
|
$476.00
|
|
| Hospital Charge Code |
5603591
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$233.24 |
| Max. Negotiated Rate |
$437.92 |
| Rate for Payer: Aetna Commercial |
$428.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$409.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$252.28
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cigna Commercial |
$437.92
|
| Rate for Payer: Health EOS Commercial |
$423.64
|
| Rate for Payer: HFN Commercial |
$437.92
|
| Rate for Payer: Multiplan Commercial |
$380.80
|
| Rate for Payer: NAPHCARE Commercial |
$285.60
|
| Rate for Payer: Preferred Network Access Commercial |
$437.92
|
| Rate for Payer: Quartz Beloit One Network |
$233.24
|
| Rate for Payer: Quartz Commercial |
$285.60
|
| Rate for Payer: WEA Trust Commercial |
$261.80
|
| Rate for Payer: WPS Commercial |
$352.57
|
|
|
END CAP FOR APEX PIN 05 5027-1-050
|
Facility
|
OP
|
$476.00
|
|
| Hospital Charge Code |
5603591
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$133.28 |
| Max. Negotiated Rate |
$1,904.00 |
| Rate for Payer: Aetna Commercial |
$428.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$409.36
|
| Rate for Payer: Aetna Managed Medicare |
$133.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$309.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$238.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$228.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$252.28
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cigna Commercial |
$437.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$266.37
|
| Rate for Payer: Health EOS Commercial |
$423.64
|
| Rate for Payer: HFN Commercial |
$437.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$357.00
|
| Rate for Payer: Multiplan Commercial |
$380.80
|
| Rate for Payer: NAPHCARE Commercial |
$285.60
|
| Rate for Payer: Preferred Network Access Commercial |
$437.92
|
| Rate for Payer: Quartz Beloit One Network |
$233.24
|
| Rate for Payer: Quartz Commercial |
$309.40
|
| Rate for Payer: Quartz Medicare Advantage |
$285.60
|
| Rate for Payer: The Alliance Commercial |
$1,904.00
|
| Rate for Payer: WEA Trust Commercial |
$261.80
|
| Rate for Payer: WPS Commercial |
$352.57
|
|
|
END CAP OMM EXTENSION TI 04.004.000S
|
Facility
|
IP
|
$2,556.00
|
|
| Hospital Charge Code |
2966231
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,252.44 |
| Max. Negotiated Rate |
$2,351.52 |
| Rate for Payer: Aetna Commercial |
$2,300.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,198.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,354.68
|
| Rate for Payer: Cash Price |
$766.80
|
| Rate for Payer: Cigna Commercial |
$2,351.52
|
| Rate for Payer: Health EOS Commercial |
$2,274.84
|
| Rate for Payer: HFN Commercial |
$2,351.52
|
| Rate for Payer: Multiplan Commercial |
$2,044.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,533.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,351.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,252.44
|
| Rate for Payer: Quartz Commercial |
$1,533.60
|
| Rate for Payer: WEA Trust Commercial |
$1,405.80
|
| Rate for Payer: WPS Commercial |
$1,893.23
|
|
|
END CAP OMM EXTENSION TI 04.004.000S
|
Facility
|
OP
|
$2,556.00
|
|
| Hospital Charge Code |
2966231
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$715.68 |
| Max. Negotiated Rate |
$10,224.00 |
| Rate for Payer: Aetna Commercial |
$2,300.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,198.16
|
| Rate for Payer: Aetna Managed Medicare |
$715.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,661.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,278.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,226.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,354.68
|
| Rate for Payer: Cash Price |
$766.80
|
| Rate for Payer: Cigna Commercial |
$2,351.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,430.34
|
| Rate for Payer: Health EOS Commercial |
$2,274.84
|
| Rate for Payer: HFN Commercial |
$2,351.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,917.00
|
| Rate for Payer: Multiplan Commercial |
$2,044.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,533.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,351.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,252.44
|
| Rate for Payer: Quartz Commercial |
$1,661.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,533.60
|
| Rate for Payer: The Alliance Commercial |
$10,224.00
|
| Rate for Payer: WEA Trust Commercial |
$1,405.80
|
| Rate for Payer: WPS Commercial |
$1,893.23
|
|
|
END CAP SCN 1826-0003S
|
Facility
|
IP
|
$2,052.00
|
|
| Hospital Charge Code |
3072610
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,005.48 |
| Max. Negotiated Rate |
$1,887.84 |
| Rate for Payer: Aetna Commercial |
$1,846.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,764.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,087.56
|
| Rate for Payer: Cash Price |
$615.60
|
| Rate for Payer: Cigna Commercial |
$1,887.84
|
| Rate for Payer: Health EOS Commercial |
$1,826.28
|
| Rate for Payer: HFN Commercial |
$1,887.84
|
| Rate for Payer: Multiplan Commercial |
$1,641.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,231.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,887.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,005.48
|
| Rate for Payer: Quartz Commercial |
$1,231.20
|
| Rate for Payer: WEA Trust Commercial |
$1,128.60
|
| Rate for Payer: WPS Commercial |
$1,519.92
|
|
|
END CAP SCN 1826-0003S
|
Facility
|
OP
|
$2,052.00
|
|
| Hospital Charge Code |
3072610
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$574.56 |
| Max. Negotiated Rate |
$8,208.00 |
| Rate for Payer: Aetna Commercial |
$1,846.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,764.72
|
| Rate for Payer: Aetna Managed Medicare |
$574.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,333.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,026.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$984.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,087.56
|
| Rate for Payer: Cash Price |
$615.60
|
| Rate for Payer: Cigna Commercial |
$1,887.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,148.30
|
| Rate for Payer: Health EOS Commercial |
$1,826.28
|
| Rate for Payer: HFN Commercial |
$1,887.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,539.00
|
| Rate for Payer: Multiplan Commercial |
$1,641.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,231.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,887.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,005.48
|
| Rate for Payer: Quartz Commercial |
$1,333.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,231.20
|
| Rate for Payer: The Alliance Commercial |
$8,208.00
|
| Rate for Payer: WEA Trust Commercial |
$1,128.60
|
| Rate for Payer: WPS Commercial |
$1,519.92
|
|
|
END CAP TIBIAL NAIL 5MM TI 04.045.855S
|
Facility
|
OP
|
$2,536.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
6175604
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$710.08 |
| Max. Negotiated Rate |
$10,144.00 |
| Rate for Payer: Aetna Commercial |
$2,282.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,180.96
|
| Rate for Payer: Aetna Managed Medicare |
$710.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,648.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,268.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,217.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,344.08
|
| Rate for Payer: Cash Price |
$760.80
|
| Rate for Payer: Cigna Commercial |
$2,333.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,419.15
|
| Rate for Payer: Health EOS Commercial |
$2,257.04
|
| Rate for Payer: HFN Commercial |
$2,333.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,902.00
|
| Rate for Payer: Multiplan Commercial |
$2,028.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,521.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,333.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,242.64
|
| Rate for Payer: Quartz Commercial |
$1,648.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,521.60
|
| Rate for Payer: The Alliance Commercial |
$10,144.00
|
| Rate for Payer: WEA Trust Commercial |
$1,394.80
|
| Rate for Payer: WPS Commercial |
$1,878.42
|
|
|
END CAP TIBIAL NAIL 5MM TI 04.045.855S
|
Facility
|
IP
|
$2,536.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
6175604
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,242.64 |
| Max. Negotiated Rate |
$2,333.12 |
| Rate for Payer: Aetna Commercial |
$2,282.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,180.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,344.08
|
| Rate for Payer: Cash Price |
$760.80
|
| Rate for Payer: Cigna Commercial |
$2,333.12
|
| Rate for Payer: Health EOS Commercial |
$2,257.04
|
| Rate for Payer: HFN Commercial |
$2,333.12
|
| Rate for Payer: Multiplan Commercial |
$2,028.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,521.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,333.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,242.64
|
| Rate for Payer: Quartz Commercial |
$1,521.60
|
| Rate for Payer: WEA Trust Commercial |
$1,394.80
|
| Rate for Payer: WPS Commercial |
$1,878.42
|
|
|
END CAP TIBIAL NAIL 5MM TI 04.045.865S
|
Facility
|
OP
|
$2,438.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
6180622
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$682.64 |
| Max. Negotiated Rate |
$9,752.00 |
| Rate for Payer: Aetna Commercial |
$2,194.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,096.68
|
| Rate for Payer: Aetna Managed Medicare |
$682.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,584.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,219.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,170.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,292.14
|
| Rate for Payer: Cash Price |
$731.40
|
| Rate for Payer: Cigna Commercial |
$2,242.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,364.30
|
| Rate for Payer: Health EOS Commercial |
$2,169.82
|
| Rate for Payer: HFN Commercial |
$2,242.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,828.50
|
| Rate for Payer: Multiplan Commercial |
$1,950.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,462.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,242.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,194.62
|
| Rate for Payer: Quartz Commercial |
$1,584.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,462.80
|
| Rate for Payer: The Alliance Commercial |
$9,752.00
|
| Rate for Payer: WEA Trust Commercial |
$1,340.90
|
| Rate for Payer: WPS Commercial |
$1,805.83
|
|
|
END CAP TIBIAL NAIL 5MM TI 04.045.865S
|
Facility
|
IP
|
$2,438.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
6180622
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.62 |
| Max. Negotiated Rate |
$2,242.96 |
| Rate for Payer: Aetna Commercial |
$2,194.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,096.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,292.14
|
| Rate for Payer: Cash Price |
$731.40
|
| Rate for Payer: Cigna Commercial |
$2,242.96
|
| Rate for Payer: Health EOS Commercial |
$2,169.82
|
| Rate for Payer: HFN Commercial |
$2,242.96
|
| Rate for Payer: Multiplan Commercial |
$1,950.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,462.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,242.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,194.62
|
| Rate for Payer: Quartz Commercial |
$1,462.80
|
| Rate for Payer: WEA Trust Commercial |
$1,340.90
|
| Rate for Payer: WPS Commercial |
$1,805.83
|
|
|
END CAP TITANIUM 0MM EXTENSION
|
Facility
|
IP
|
$2,521.00
|
|
| Hospital Charge Code |
2966230
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,235.29 |
| Max. Negotiated Rate |
$2,319.32 |
| Rate for Payer: Aetna Commercial |
$2,268.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,168.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,336.13
|
| Rate for Payer: Cash Price |
$756.30
|
| Rate for Payer: Cigna Commercial |
$2,319.32
|
| Rate for Payer: Health EOS Commercial |
$2,243.69
|
| Rate for Payer: HFN Commercial |
$2,319.32
|
| Rate for Payer: Multiplan Commercial |
$2,016.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,512.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,319.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,235.29
|
| Rate for Payer: Quartz Commercial |
$1,512.60
|
| Rate for Payer: WEA Trust Commercial |
$1,386.55
|
| Rate for Payer: WPS Commercial |
$1,867.30
|
|
|
END CAP TITANIUM 0MM EXTENSION
|
Facility
|
OP
|
$2,521.00
|
|
| Hospital Charge Code |
2966230
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$705.88 |
| Max. Negotiated Rate |
$10,084.00 |
| Rate for Payer: Aetna Commercial |
$2,268.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,168.06
|
| Rate for Payer: Aetna Managed Medicare |
$705.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,638.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,260.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,210.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,336.13
|
| Rate for Payer: Cash Price |
$756.30
|
| Rate for Payer: Cigna Commercial |
$2,319.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,410.75
|
| Rate for Payer: Health EOS Commercial |
$2,243.69
|
| Rate for Payer: HFN Commercial |
$2,319.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,890.75
|
| Rate for Payer: Multiplan Commercial |
$2,016.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,512.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,319.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,235.29
|
| Rate for Payer: Quartz Commercial |
$1,638.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,512.60
|
| Rate for Payer: The Alliance Commercial |
$10,084.00
|
| Rate for Payer: WEA Trust Commercial |
$1,386.55
|
| Rate for Payer: WPS Commercial |
$1,867.30
|
|
|
ENDOCAVITY BALLOON ACCUCARE 610-898
|
Facility
|
OP
|
$843.00
|
|
| Hospital Charge Code |
5459008
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$236.04 |
| Max. Negotiated Rate |
$3,372.00 |
| Rate for Payer: Aetna Commercial |
$758.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$724.98
|
| Rate for Payer: Aetna Managed Medicare |
$236.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$547.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$421.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$404.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$446.79
|
| Rate for Payer: Cash Price |
$252.90
|
| Rate for Payer: Cigna Commercial |
$775.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$471.74
|
| Rate for Payer: Health EOS Commercial |
$750.27
|
| Rate for Payer: HFN Commercial |
$775.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$632.25
|
| Rate for Payer: Multiplan Commercial |
$674.40
|
| Rate for Payer: NAPHCARE Commercial |
$505.80
|
| Rate for Payer: Preferred Network Access Commercial |
$775.56
|
| Rate for Payer: Quartz Beloit One Network |
$413.07
|
| Rate for Payer: Quartz Commercial |
$547.95
|
| Rate for Payer: Quartz Medicare Advantage |
$505.80
|
| Rate for Payer: The Alliance Commercial |
$3,372.00
|
| Rate for Payer: WEA Trust Commercial |
$463.65
|
| Rate for Payer: WPS Commercial |
$624.41
|
|
|
ENDOCAVITY BALLOON ACCUCARE 610-898
|
Facility
|
IP
|
$843.00
|
|
| Hospital Charge Code |
5459008
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$413.07 |
| Max. Negotiated Rate |
$775.56 |
| Rate for Payer: Aetna Commercial |
$758.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$724.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$446.79
|
| Rate for Payer: Cash Price |
$252.90
|
| Rate for Payer: Cigna Commercial |
$775.56
|
| Rate for Payer: Health EOS Commercial |
$750.27
|
| Rate for Payer: HFN Commercial |
$775.56
|
| Rate for Payer: Multiplan Commercial |
$674.40
|
| Rate for Payer: NAPHCARE Commercial |
$505.80
|
| Rate for Payer: Preferred Network Access Commercial |
$775.56
|
| Rate for Payer: Quartz Beloit One Network |
$413.07
|
| Rate for Payer: Quartz Commercial |
$505.80
|
| Rate for Payer: WEA Trust Commercial |
$463.65
|
| Rate for Payer: WPS Commercial |
$624.41
|
|
|
Endocervical Curettage 57505
|
Professional
|
Both
|
$345.00
|
|
|
Service Code
|
CPT 57505
|
| Hospital Charge Code |
1188888
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$60.40 |
| Max. Negotiated Rate |
$356.57 |
| Rate for Payer: Aetna Commercial |
$327.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.70
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$327.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.00
|
| Rate for Payer: Health EOS Commercial |
$313.95
|
| Rate for Payer: HFN Commercial |
$327.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$356.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$356.57
|
| Rate for Payer: Multiplan Commercial |
$276.00
|
| Rate for Payer: Preferred Network Access Commercial |
$327.75
|
| Rate for Payer: Quartz Beloit One Network |
$151.80
|
| Rate for Payer: Quartz Commercial |
$196.65
|
| Rate for Payer: The Alliance Commercial |
$172.50
|
| Rate for Payer: United Healthcare Medicaid |
$60.40
|
| Rate for Payer: WEA Trust Commercial |
$189.75
|
| Rate for Payer: WPS Commercial |
$255.54
|
|
|
ENDOCLIP 5MM CLIP APPLIER 176620
|
Facility
|
IP
|
$4,538.00
|
|
| Hospital Charge Code |
2963073
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,223.62 |
| Max. Negotiated Rate |
$4,174.96 |
| Rate for Payer: Aetna Commercial |
$4,084.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,902.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,405.14
|
| Rate for Payer: Cash Price |
$1,361.40
|
| Rate for Payer: Cigna Commercial |
$4,174.96
|
| Rate for Payer: Health EOS Commercial |
$4,038.82
|
| Rate for Payer: HFN Commercial |
$4,174.96
|
| Rate for Payer: Multiplan Commercial |
$3,630.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,722.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,174.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,223.62
|
| Rate for Payer: Quartz Commercial |
$2,722.80
|
| Rate for Payer: WEA Trust Commercial |
$2,495.90
|
| Rate for Payer: WPS Commercial |
$3,361.30
|
|
|
ENDOCLIP 5MM CLIP APPLIER 176620
|
Facility
|
OP
|
$4,538.00
|
|
| Hospital Charge Code |
2963073
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,270.64 |
| Max. Negotiated Rate |
$18,152.00 |
| Rate for Payer: Aetna Commercial |
$4,084.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,902.68
|
| Rate for Payer: Aetna Managed Medicare |
$1,270.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,949.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,269.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,178.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,405.14
|
| Rate for Payer: Cash Price |
$1,361.40
|
| Rate for Payer: Cigna Commercial |
$4,174.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,539.46
|
| Rate for Payer: Health EOS Commercial |
$4,038.82
|
| Rate for Payer: HFN Commercial |
$4,174.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,403.50
|
| Rate for Payer: Multiplan Commercial |
$3,630.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,722.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,174.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,223.62
|
| Rate for Payer: Quartz Commercial |
$2,949.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,722.80
|
| Rate for Payer: The Alliance Commercial |
$18,152.00
|
| Rate for Payer: WEA Trust Commercial |
$2,495.90
|
| Rate for Payer: WPS Commercial |
$3,361.30
|
|
|
ENDOCLIP 5MM ENDOSCOPIC MULTIPLE CLIP APPLIER EL5ML
|
Facility
|
OP
|
$5,776.00
|
|
| Hospital Charge Code |
4283272
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,617.28 |
| Max. Negotiated Rate |
$23,104.00 |
| Rate for Payer: Aetna Commercial |
$5,198.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,967.36
|
| Rate for Payer: Aetna Managed Medicare |
$1,617.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,754.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,888.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,772.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,061.28
|
| Rate for Payer: Cash Price |
$1,732.80
|
| Rate for Payer: Cigna Commercial |
$5,313.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,232.25
|
| Rate for Payer: Health EOS Commercial |
$5,140.64
|
| Rate for Payer: HFN Commercial |
$5,313.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,332.00
|
| Rate for Payer: Multiplan Commercial |
$4,620.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,465.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,313.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,830.24
|
| Rate for Payer: Quartz Commercial |
$3,754.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,465.60
|
| Rate for Payer: The Alliance Commercial |
$23,104.00
|
| Rate for Payer: WEA Trust Commercial |
$3,176.80
|
| Rate for Payer: WPS Commercial |
$4,278.28
|
|
|
ENDOCLIP 5MM ENDOSCOPIC MULTIPLE CLIP APPLIER EL5ML
|
Facility
|
IP
|
$5,776.00
|
|
| Hospital Charge Code |
4283272
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,830.24 |
| Max. Negotiated Rate |
$5,313.92 |
| Rate for Payer: Aetna Commercial |
$5,198.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,967.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,061.28
|
| Rate for Payer: Cash Price |
$1,732.80
|
| Rate for Payer: Cigna Commercial |
$5,313.92
|
| Rate for Payer: Health EOS Commercial |
$5,140.64
|
| Rate for Payer: HFN Commercial |
$5,313.92
|
| Rate for Payer: Multiplan Commercial |
$4,620.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,465.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,313.92
|
| Rate for Payer: Quartz Beloit One Network |
$2,830.24
|
| Rate for Payer: Quartz Commercial |
$3,465.60
|
| Rate for Payer: WEA Trust Commercial |
$3,176.80
|
| Rate for Payer: WPS Commercial |
$4,278.28
|
|
|
ENDOCRINE DISORDERS WITH CC
|
Facility
|
IP
|
$28,547.00
|
|
|
Service Code
|
MSDRG 644
|
| Min. Negotiated Rate |
$10,268.62 |
| Max. Negotiated Rate |
$28,547.00 |
| Rate for Payer: Aetna Managed Medicare |
$10,268.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22,238.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,045.86
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,194.68
|
| Rate for Payer: Anthem Medicare Advantage |
$10,268.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,268.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,268.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,268.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17,977.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,268.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,703.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,268.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,268.62
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,268.62
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,268.62
|
| Rate for Payer: NAPHCARE Commercial |
$15,402.93
|
| Rate for Payer: Quartz Medicare Advantage |
$10,268.62
|
| Rate for Payer: The Alliance Commercial |
$28,547.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,268.62
|
| Rate for Payer: United Healthcare PPO |
$16,117.67
|
| Rate for Payer: Wellcare Medicare |
$10,268.62
|
|
|
ENDOCRINE DISORDERS WITH MCC
|
Facility
|
IP
|
$44,057.00
|
|
|
Service Code
|
MSDRG 643
|
| Min. Negotiated Rate |
$15,847.84 |
| Max. Negotiated Rate |
$44,057.00 |
| Rate for Payer: Aetna Managed Medicare |
$15,847.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34,617.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,533.65
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,208.70
|
| Rate for Payer: Anthem Medicare Advantage |
$15,847.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,847.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,847.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,847.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27,983.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,847.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32,079.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,847.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,847.84
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,847.84
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,847.84
|
| Rate for Payer: NAPHCARE Commercial |
$23,771.76
|
| Rate for Payer: Quartz Medicare Advantage |
$15,847.84
|
| Rate for Payer: The Alliance Commercial |
$44,057.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,847.84
|
| Rate for Payer: United Healthcare PPO |
$24,974.26
|
| Rate for Payer: Wellcare Medicare |
$15,847.84
|
|
|
ENDOCRINE DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$20,550.00
|
|
|
Service Code
|
MSDRG 645
|
| Min. Negotiated Rate |
$7,391.97 |
| Max. Negotiated Rate |
$20,550.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,391.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,944.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,221.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,611.28
|
| Rate for Payer: Anthem Medicare Advantage |
$7,391.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,391.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,391.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,391.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,889.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,391.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,837.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,391.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,391.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,391.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,391.97
|
| Rate for Payer: NAPHCARE Commercial |
$11,087.96
|
| Rate for Payer: Quartz Medicare Advantage |
$7,391.97
|
| Rate for Payer: The Alliance Commercial |
$20,550.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,391.97
|
| Rate for Payer: United Healthcare PPO |
$11,551.22
|
| Rate for Payer: Wellcare Medicare |
$7,391.97
|
|
|
ENDODONTICS
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960005
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
