|
FISTULA PRESSURE CLAMP
|
Facility
|
IP
|
$261.00
|
|
| Hospital Charge Code |
2972360
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$133.01 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$162.86
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
|
FISTULA PRESSURE CLAMP
|
Facility
|
OP
|
$261.00
|
|
| Hospital Charge Code |
2972360
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$76.00 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$244.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.44
|
| Rate for Payer: Aetna Managed Medicare |
$76.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$176.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$135.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.86
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$249.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.90
|
| Rate for Payer: Health EOS Commercial |
$241.58
|
| Rate for Payer: HFN Commercial |
$249.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$203.58
|
| Rate for Payer: Multiplan Commercial |
$217.15
|
| Rate for Payer: NAPHCARE Commercial |
$162.86
|
| Rate for Payer: Preferred Network Access Commercial |
$249.72
|
| Rate for Payer: Quartz Beloit One Network |
$133.01
|
| Rate for Payer: Quartz Commercial |
$176.44
|
| Rate for Payer: Quartz Medicare Advantage |
$162.86
|
| Rate for Payer: The Alliance Commercial |
$135.72
|
| Rate for Payer: WEA Trust Commercial |
$149.29
|
| Rate for Payer: WPS Commercial |
$201.05
|
|
|
Fistula Tract Procedure
|
Facility
|
OP
|
$853.00
|
|
|
Service Code
|
CPT 76080
|
| Hospital Charge Code |
3072725
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$313.04 |
| Max. Negotiated Rate |
$2,300.15 |
| Rate for Payer: Aetna Commercial |
$798.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$762.92
|
| Rate for Payer: Aetna Managed Medicare |
$575.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,126.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,701.27
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,616.21
|
| Rate for Payer: Anthem Medicare Advantage |
$575.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$575.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$575.04
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cigna Commercial |
$816.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$575.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$496.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$575.04
|
| Rate for Payer: Health EOS Commercial |
$789.54
|
| Rate for Payer: HFN Commercial |
$816.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,139.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$575.04
|
| Rate for Payer: Independent Care Health Plan Medicare |
$575.04
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$575.04
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$575.04
|
| Rate for Payer: Multiplan Commercial |
$709.70
|
| Rate for Payer: NAPHCARE Commercial |
$862.56
|
| Rate for Payer: Preferred Network Access Commercial |
$816.15
|
| Rate for Payer: Quartz Beloit One Network |
$434.69
|
| Rate for Payer: Quartz Commercial |
$576.63
|
| Rate for Payer: Quartz Medicare Advantage |
$575.04
|
| Rate for Payer: The Alliance Commercial |
$2,300.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$575.04
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$487.92
|
| Rate for Payer: Wellcare Medicare |
$575.04
|
| Rate for Payer: WPS Commercial |
$657.07
|
|
|
Fistula Tract Procedure
|
Facility
|
IP
|
$853.00
|
|
|
Service Code
|
CPT 76080
|
| Hospital Charge Code |
3072725
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$434.69 |
| Max. Negotiated Rate |
$816.15 |
| Rate for Payer: Aetna Commercial |
$798.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$762.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.17
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cigna Commercial |
$816.15
|
| Rate for Payer: Health EOS Commercial |
$789.54
|
| Rate for Payer: HFN Commercial |
$816.15
|
| Rate for Payer: Multiplan Commercial |
$709.70
|
| Rate for Payer: Preferred Network Access Commercial |
$816.15
|
| Rate for Payer: Quartz Beloit One Network |
$434.69
|
| Rate for Payer: Quartz Commercial |
$532.27
|
| Rate for Payer: WEA Trust Commercial |
$487.92
|
| Rate for Payer: WPS Commercial |
$657.07
|
|
|
Fistula Tract Procedure
|
Professional
|
Both
|
$853.00
|
|
|
Service Code
|
CPT 76080
|
| Hospital Charge Code |
3072725
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$58.21 |
| Max. Negotiated Rate |
$842.76 |
| Rate for Payer: Aetna Commercial |
$842.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$762.92
|
| Rate for Payer: Aetna Managed Medicare |
$58.21
|
| Rate for Payer: Anthem Medicare Advantage |
$58.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$58.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$58.21
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cash Price |
$255.90
|
| Rate for Payer: Cigna Commercial |
$842.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$443.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.21
|
| Rate for Payer: Health EOS Commercial |
$807.28
|
| Rate for Payer: HFN Commercial |
$842.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$213.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$58.21
|
| Rate for Payer: Multiplan Commercial |
$709.70
|
| Rate for Payer: NAPHCARE Commercial |
$87.31
|
| Rate for Payer: Preferred Network Access Commercial |
$842.76
|
| Rate for Payer: Quartz Beloit One Network |
$390.33
|
| Rate for Payer: Quartz Commercial |
$505.66
|
| Rate for Payer: Quartz Medicare Advantage |
$58.21
|
| Rate for Payer: The Alliance Commercial |
$221.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$58.21
|
| Rate for Payer: WEA Trust Commercial |
$487.92
|
| Rate for Payer: WPS Commercial |
$291.04
|
|
|
FISTULECTOMY
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960382
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
FISTULECTOMY
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960382
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
Fitting And Insertion Of Pessary
|
Professional
|
Both
|
$85.00
|
|
|
Service Code
|
CPT 57160
|
| Hospital Charge Code |
1188877
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$15.66 |
| Max. Negotiated Rate |
$171.66 |
| Rate for Payer: Aetna Commercial |
$83.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.02
|
| Rate for Payer: Aetna Managed Medicare |
$38.15
|
| Rate for Payer: Anthem Medicare Advantage |
$38.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$38.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$38.15
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$83.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.15
|
| Rate for Payer: Health EOS Commercial |
$80.44
|
| Rate for Payer: HFN Commercial |
$83.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$160.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$160.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$38.15
|
| Rate for Payer: Multiplan Commercial |
$70.72
|
| Rate for Payer: NAPHCARE Commercial |
$57.22
|
| Rate for Payer: Preferred Network Access Commercial |
$83.98
|
| Rate for Payer: Quartz Beloit One Network |
$38.90
|
| Rate for Payer: Quartz Commercial |
$50.39
|
| Rate for Payer: Quartz Medicare Advantage |
$38.15
|
| Rate for Payer: The Alliance Commercial |
$162.13
|
| Rate for Payer: United Healthcare Medicaid |
$15.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.15
|
| Rate for Payer: WEA Trust Commercial |
$48.62
|
| Rate for Payer: WPS Commercial |
$171.66
|
|
|
FITTING OF DIAPHRAGM/CAP 57170
|
Professional
|
Both
|
$346.00
|
|
|
Service Code
|
CPT 57170
|
| Hospital Charge Code |
3015072
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$32.30 |
| Max. Negotiated Rate |
$341.85 |
| Rate for Payer: Aetna Commercial |
$341.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.46
|
| Rate for Payer: Aetna Managed Medicare |
$38.95
|
| Rate for Payer: Anthem Medicare Advantage |
$38.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$38.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$38.95
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Cigna Commercial |
$341.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$32.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.95
|
| Rate for Payer: Health EOS Commercial |
$327.45
|
| Rate for Payer: HFN Commercial |
$341.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$164.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$164.51
|
| Rate for Payer: Independent Care Health Plan Medicare |
$38.95
|
| Rate for Payer: Multiplan Commercial |
$287.87
|
| Rate for Payer: NAPHCARE Commercial |
$58.42
|
| Rate for Payer: Preferred Network Access Commercial |
$341.85
|
| Rate for Payer: Quartz Beloit One Network |
$158.33
|
| Rate for Payer: Quartz Commercial |
$205.11
|
| Rate for Payer: Quartz Medicare Advantage |
$38.95
|
| Rate for Payer: The Alliance Commercial |
$165.53
|
| Rate for Payer: United Healthcare Medicaid |
$32.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.95
|
| Rate for Payer: WEA Trust Commercial |
$197.91
|
| Rate for Payer: WPS Commercial |
$175.27
|
|
|
FIXATION DEVICE INSERTION OR REPLACEMENT PROCEDURES
|
Facility
|
OP
|
$1,225.13
|
|
|
Service Code
|
EAPG 00054
|
| Min. Negotiated Rate |
$1,178.01 |
| Max. Negotiated Rate |
$1,225.13 |
| Rate for Payer: Anthem Medicaid |
$1,178.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$1,178.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,178.01
|
| Rate for Payer: Dean Health Medicaid |
$1,178.01
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$1,178.01
|
| Rate for Payer: Managed Health Services Medicaid |
$1,225.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,178.01
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$1,178.01
|
| Rate for Payer: United Healthcare Medicaid |
$1,178.01
|
|
|
FIXATION PACK LAPIPLASTY LESSER TMT SK28
|
Facility
|
IP
|
$14,610.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6175035
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,445.26 |
| Max. Negotiated Rate |
$13,978.85 |
| Rate for Payer: Aetna Commercial |
$13,674.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,067.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,053.03
|
| Rate for Payer: Cash Price |
$4,383.00
|
| Rate for Payer: Cigna Commercial |
$13,978.85
|
| Rate for Payer: Health EOS Commercial |
$13,523.02
|
| Rate for Payer: HFN Commercial |
$13,978.85
|
| Rate for Payer: Multiplan Commercial |
$12,155.52
|
| Rate for Payer: Preferred Network Access Commercial |
$13,978.85
|
| Rate for Payer: Quartz Beloit One Network |
$7,445.26
|
| Rate for Payer: Quartz Commercial |
$9,116.64
|
| Rate for Payer: WEA Trust Commercial |
$8,356.92
|
| Rate for Payer: WPS Commercial |
$11,254.08
|
|
|
FIXATION PACK LAPIPLASTY LESSER TMT SK28
|
Facility
|
OP
|
$14,610.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6175035
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,254.43 |
| Max. Negotiated Rate |
$13,978.85 |
| Rate for Payer: Aetna Commercial |
$13,674.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,067.18
|
| Rate for Payer: Aetna Managed Medicare |
$4,254.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,876.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,597.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,293.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,053.03
|
| Rate for Payer: Cash Price |
$4,383.00
|
| Rate for Payer: Cigna Commercial |
$13,978.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,503.02
|
| Rate for Payer: Health EOS Commercial |
$13,523.02
|
| Rate for Payer: HFN Commercial |
$13,978.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,395.80
|
| Rate for Payer: Multiplan Commercial |
$12,155.52
|
| Rate for Payer: NAPHCARE Commercial |
$9,116.64
|
| Rate for Payer: Preferred Network Access Commercial |
$13,978.85
|
| Rate for Payer: Quartz Beloit One Network |
$7,445.26
|
| Rate for Payer: Quartz Commercial |
$9,876.36
|
| Rate for Payer: Quartz Medicare Advantage |
$9,116.64
|
| Rate for Payer: The Alliance Commercial |
$7,597.20
|
| Rate for Payer: WEA Trust Commercial |
$8,356.92
|
| Rate for Payer: WPS Commercial |
$11,254.08
|
|
|
FIXATION PIN TEMPORARY 1.4MM LG 58820024
|
Facility
|
OP
|
$1,412.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5729839
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$411.17 |
| Max. Negotiated Rate |
$1,351.00 |
| Rate for Payer: Aetna Commercial |
$1,321.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,262.89
|
| Rate for Payer: Aetna Managed Medicare |
$411.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$954.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$734.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$704.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$778.29
|
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Cigna Commercial |
$1,351.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$821.78
|
| Rate for Payer: Health EOS Commercial |
$1,306.95
|
| Rate for Payer: HFN Commercial |
$1,351.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,101.36
|
| Rate for Payer: Multiplan Commercial |
$1,174.78
|
| Rate for Payer: NAPHCARE Commercial |
$881.09
|
| Rate for Payer: Preferred Network Access Commercial |
$1,351.00
|
| Rate for Payer: Quartz Beloit One Network |
$719.56
|
| Rate for Payer: Quartz Commercial |
$954.51
|
| Rate for Payer: Quartz Medicare Advantage |
$881.09
|
| Rate for Payer: The Alliance Commercial |
$734.24
|
| Rate for Payer: WEA Trust Commercial |
$807.66
|
| Rate for Payer: WPS Commercial |
$1,087.66
|
|
|
FIXATION PIN TEMPORARY 1.4MM LG 58820024
|
Facility
|
IP
|
$1,412.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
5729839
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$719.56 |
| Max. Negotiated Rate |
$1,351.00 |
| Rate for Payer: Aetna Commercial |
$1,321.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,262.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$778.29
|
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Cigna Commercial |
$1,351.00
|
| Rate for Payer: Health EOS Commercial |
$1,306.95
|
| Rate for Payer: HFN Commercial |
$1,351.00
|
| Rate for Payer: Multiplan Commercial |
$1,174.78
|
| Rate for Payer: Preferred Network Access Commercial |
$1,351.00
|
| Rate for Payer: Quartz Beloit One Network |
$719.56
|
| Rate for Payer: Quartz Commercial |
$881.09
|
| Rate for Payer: WEA Trust Commercial |
$807.66
|
| Rate for Payer: WPS Commercial |
$1,087.66
|
|
|
FIXATION STAPLE SPIKED LARGE 128696
|
Facility
|
IP
|
$2,086.00
|
|
| Hospital Charge Code |
2966012
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,063.03 |
| Max. Negotiated Rate |
$1,995.88 |
| Rate for Payer: Aetna Commercial |
$1,952.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,865.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,149.80
|
| Rate for Payer: Cash Price |
$625.80
|
| Rate for Payer: Cigna Commercial |
$1,995.88
|
| Rate for Payer: Health EOS Commercial |
$1,930.80
|
| Rate for Payer: HFN Commercial |
$1,995.88
|
| Rate for Payer: Multiplan Commercial |
$1,735.55
|
| Rate for Payer: Preferred Network Access Commercial |
$1,995.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,063.03
|
| Rate for Payer: Quartz Commercial |
$1,301.66
|
| Rate for Payer: WEA Trust Commercial |
$1,193.19
|
| Rate for Payer: WPS Commercial |
$1,606.85
|
|
|
FIXATION STAPLE SPIKED LARGE 128696
|
Facility
|
OP
|
$2,086.00
|
|
| Hospital Charge Code |
2966012
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$607.44 |
| Max. Negotiated Rate |
$1,995.88 |
| Rate for Payer: Aetna Commercial |
$1,952.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,865.72
|
| Rate for Payer: Aetna Managed Medicare |
$607.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,410.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,084.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,041.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,149.80
|
| Rate for Payer: Cash Price |
$625.80
|
| Rate for Payer: Cigna Commercial |
$1,995.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,214.05
|
| Rate for Payer: Health EOS Commercial |
$1,930.80
|
| Rate for Payer: HFN Commercial |
$1,995.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,627.08
|
| Rate for Payer: Multiplan Commercial |
$1,735.55
|
| Rate for Payer: NAPHCARE Commercial |
$1,301.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,995.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,063.03
|
| Rate for Payer: Quartz Commercial |
$1,410.14
|
| Rate for Payer: Quartz Medicare Advantage |
$1,301.66
|
| Rate for Payer: The Alliance Commercial |
$1,084.72
|
| Rate for Payer: WEA Trust Commercial |
$1,193.19
|
| Rate for Payer: WPS Commercial |
$1,606.85
|
|
|
FIXATION STAPLE SPIKED MEDIUM 128694
|
Facility
|
IP
|
$2,086.00
|
|
| Hospital Charge Code |
2966013
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,063.03 |
| Max. Negotiated Rate |
$1,995.88 |
| Rate for Payer: Aetna Commercial |
$1,952.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,865.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,149.80
|
| Rate for Payer: Cash Price |
$625.80
|
| Rate for Payer: Cigna Commercial |
$1,995.88
|
| Rate for Payer: Health EOS Commercial |
$1,930.80
|
| Rate for Payer: HFN Commercial |
$1,995.88
|
| Rate for Payer: Multiplan Commercial |
$1,735.55
|
| Rate for Payer: Preferred Network Access Commercial |
$1,995.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,063.03
|
| Rate for Payer: Quartz Commercial |
$1,301.66
|
| Rate for Payer: WEA Trust Commercial |
$1,193.19
|
| Rate for Payer: WPS Commercial |
$1,606.85
|
|
|
FIXATION STAPLE SPIKED MEDIUM 128694
|
Facility
|
OP
|
$2,086.00
|
|
| Hospital Charge Code |
2966013
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$607.44 |
| Max. Negotiated Rate |
$1,995.88 |
| Rate for Payer: Aetna Commercial |
$1,952.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,865.72
|
| Rate for Payer: Aetna Managed Medicare |
$607.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,410.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,084.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,041.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,149.80
|
| Rate for Payer: Cash Price |
$625.80
|
| Rate for Payer: Cigna Commercial |
$1,995.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,214.05
|
| Rate for Payer: Health EOS Commercial |
$1,930.80
|
| Rate for Payer: HFN Commercial |
$1,995.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,627.08
|
| Rate for Payer: Multiplan Commercial |
$1,735.55
|
| Rate for Payer: NAPHCARE Commercial |
$1,301.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1,995.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,063.03
|
| Rate for Payer: Quartz Commercial |
$1,410.14
|
| Rate for Payer: Quartz Medicare Advantage |
$1,301.66
|
| Rate for Payer: The Alliance Commercial |
$1,084.72
|
| Rate for Payer: WEA Trust Commercial |
$1,193.19
|
| Rate for Payer: WPS Commercial |
$1,606.85
|
|
|
FIXATION STUD 8.5mm
|
Facility
|
IP
|
$5,235.00
|
|
| Hospital Charge Code |
2964730
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,667.76 |
| Max. Negotiated Rate |
$5,008.85 |
| Rate for Payer: Aetna Commercial |
$4,899.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,682.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,885.53
|
| Rate for Payer: Cash Price |
$1,570.50
|
| Rate for Payer: Cigna Commercial |
$5,008.85
|
| Rate for Payer: Health EOS Commercial |
$4,845.52
|
| Rate for Payer: HFN Commercial |
$5,008.85
|
| Rate for Payer: Multiplan Commercial |
$4,355.52
|
| Rate for Payer: Preferred Network Access Commercial |
$5,008.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,667.76
|
| Rate for Payer: Quartz Commercial |
$3,266.64
|
| Rate for Payer: WEA Trust Commercial |
$2,994.42
|
| Rate for Payer: WPS Commercial |
$4,032.52
|
|
|
FIXATION STUD 8.5mm
|
Facility
|
OP
|
$5,235.00
|
|
| Hospital Charge Code |
2964730
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,524.43 |
| Max. Negotiated Rate |
$5,008.85 |
| Rate for Payer: Aetna Commercial |
$4,899.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,682.18
|
| Rate for Payer: Aetna Managed Medicare |
$1,524.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,538.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,722.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,613.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,885.53
|
| Rate for Payer: Cash Price |
$1,570.50
|
| Rate for Payer: Cigna Commercial |
$5,008.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,046.77
|
| Rate for Payer: Health EOS Commercial |
$4,845.52
|
| Rate for Payer: HFN Commercial |
$5,008.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,083.30
|
| Rate for Payer: Multiplan Commercial |
$4,355.52
|
| Rate for Payer: NAPHCARE Commercial |
$3,266.64
|
| Rate for Payer: Preferred Network Access Commercial |
$5,008.85
|
| Rate for Payer: Quartz Beloit One Network |
$2,667.76
|
| Rate for Payer: Quartz Commercial |
$3,538.86
|
| Rate for Payer: Quartz Medicare Advantage |
$3,266.64
|
| Rate for Payer: The Alliance Commercial |
$2,722.20
|
| Rate for Payer: WEA Trust Commercial |
$2,994.42
|
| Rate for Payer: WPS Commercial |
$4,032.52
|
|
|
FIX G/COLON TUBE W/DEVICE 49460
|
Professional
|
Both
|
$6,214.00
|
|
|
Service Code
|
CPT 49460
|
| Hospital Charge Code |
3014889
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$41.26 |
| Max. Negotiated Rate |
$6,139.43 |
| Rate for Payer: Aetna Commercial |
$6,139.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,557.80
|
| Rate for Payer: Aetna Managed Medicare |
$41.26
|
| Rate for Payer: Anthem Medicare Advantage |
$41.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$41.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$41.26
|
| Rate for Payer: Cash Price |
$1,864.20
|
| Rate for Payer: Cash Price |
$1,864.20
|
| Rate for Payer: Cash Price |
$1,864.20
|
| Rate for Payer: Cigna Commercial |
$6,139.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$638.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.26
|
| Rate for Payer: Health EOS Commercial |
$5,880.93
|
| Rate for Payer: HFN Commercial |
$6,139.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$169.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$169.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$41.26
|
| Rate for Payer: Multiplan Commercial |
$5,170.05
|
| Rate for Payer: NAPHCARE Commercial |
$61.89
|
| Rate for Payer: Preferred Network Access Commercial |
$6,139.43
|
| Rate for Payer: Quartz Beloit One Network |
$2,843.53
|
| Rate for Payer: Quartz Commercial |
$3,683.66
|
| Rate for Payer: Quartz Medicare Advantage |
$41.26
|
| Rate for Payer: The Alliance Commercial |
$175.34
|
| Rate for Payer: United Healthcare Medicaid |
$638.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.26
|
| Rate for Payer: WEA Trust Commercial |
$3,554.41
|
| Rate for Payer: WPS Commercial |
$185.66
|
|
|
FLANGE CONVEX 1.75 IN 14802
|
Facility
|
OP
|
$86.00
|
|
| Hospital Charge Code |
5107220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.04 |
| Max. Negotiated Rate |
$82.28 |
| Rate for Payer: Aetna Commercial |
$80.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.92
|
| Rate for Payer: Aetna Managed Medicare |
$25.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.40
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$82.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.05
|
| Rate for Payer: Health EOS Commercial |
$79.60
|
| Rate for Payer: HFN Commercial |
$82.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.08
|
| Rate for Payer: Multiplan Commercial |
$71.55
|
| Rate for Payer: NAPHCARE Commercial |
$53.66
|
| Rate for Payer: Preferred Network Access Commercial |
$82.28
|
| Rate for Payer: Quartz Beloit One Network |
$43.83
|
| Rate for Payer: Quartz Commercial |
$58.14
|
| Rate for Payer: Quartz Medicare Advantage |
$53.66
|
| Rate for Payer: The Alliance Commercial |
$44.72
|
| Rate for Payer: WEA Trust Commercial |
$49.19
|
| Rate for Payer: WPS Commercial |
$66.25
|
|
|
FLANGE CONVEX 1.75 IN 14802
|
Facility
|
IP
|
$86.00
|
|
| Hospital Charge Code |
5107220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.83 |
| Max. Negotiated Rate |
$82.28 |
| Rate for Payer: Aetna Commercial |
$80.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.40
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$82.28
|
| Rate for Payer: Health EOS Commercial |
$79.60
|
| Rate for Payer: HFN Commercial |
$82.28
|
| Rate for Payer: Multiplan Commercial |
$71.55
|
| Rate for Payer: Preferred Network Access Commercial |
$82.28
|
| Rate for Payer: Quartz Beloit One Network |
$43.83
|
| Rate for Payer: Quartz Commercial |
$53.66
|
| Rate for Payer: WEA Trust Commercial |
$49.19
|
| Rate for Payer: WPS Commercial |
$66.25
|
|
|
FLANGE FLOATING 2.25 14203
|
Facility
|
OP
|
$56.00
|
|
| Hospital Charge Code |
2964062
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$16.31 |
| Max. Negotiated Rate |
$53.58 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Aetna Managed Medicare |
$16.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.59
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.68
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: NAPHCARE Commercial |
$34.94
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$37.86
|
| Rate for Payer: Quartz Medicare Advantage |
$34.94
|
| Rate for Payer: The Alliance Commercial |
$29.12
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
FLANGE FLOATING 2.25 14203
|
Facility
|
IP
|
$56.00
|
|
| Hospital Charge Code |
2964062
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$28.54 |
| Max. Negotiated Rate |
$53.58 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$34.94
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
