|
filgrastim charge
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J1442
|
| Hospital Charge Code |
2958972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$0.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$0.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$0.99
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.99
|
| Rate for Payer: Anthem Medicare Advantage |
$0.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.99
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$0.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$0.99
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.99
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$0.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.48
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$0.99
|
| Rate for Payer: The Alliance Commercial |
$3.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.99
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: Wellcare Medicare |
$0.99
|
| Rate for Payer: WPS Commercial |
$2.48
|
|
|
filgrastim charge
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J1442
|
| Hospital Charge Code |
2958972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
filgrastim charge
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J1442
|
| Hospital Charge Code |
2958972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.99
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: HFN Commercial |
$6.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.39
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: The Alliance Commercial |
$3.50
|
| Rate for Payer: United Healthcare Medicaid |
$0.99
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$2.48
|
|
|
Filgrastim Injection J1442
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J1442
|
| Hospital Charge Code |
4062091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Filgrastim Injection J1442
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J1442
|
| Hospital Charge Code |
4062091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$0.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$0.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$0.99
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.99
|
| Rate for Payer: Anthem Medicare Advantage |
$0.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.99
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$0.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$0.99
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.99
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$0.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.48
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$0.99
|
| Rate for Payer: The Alliance Commercial |
$3.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.99
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: Wellcare Medicare |
$0.99
|
| Rate for Payer: WPS Commercial |
$2.48
|
|
|
Filgrastim Injection J1442
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J1442
|
| Hospital Charge Code |
4062091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.99
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: HFN Commercial |
$6.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.39
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: The Alliance Commercial |
$3.50
|
| Rate for Payer: United Healthcare Medicaid |
$0.99
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$2.48
|
|
|
FILLETED FINGER OR TOE FLAP, INCLUDING PREPARATION OF RECIPIENT SITE
|
Facility
|
OP
|
$7,209.92
|
|
|
Service Code
|
CPT 14350
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.48 |
| Max. Negotiated Rate |
$7,209.92 |
| Rate for Payer: Aetna Managed Medicare |
$1,802.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,802.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,802.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,802.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,705.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,802.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,802.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,802.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,802.48
|
| Rate for Payer: NAPHCARE Commercial |
$2,703.72
|
| Rate for Payer: Quartz Medicare Advantage |
$1,802.48
|
| Rate for Payer: The Alliance Commercial |
$7,209.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,802.48
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$1,802.48
|
|
|
FILL KIT IMPLANT 350-8400
|
Facility
|
IP
|
$397.00
|
|
| Hospital Charge Code |
2969473
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$194.53 |
| Max. Negotiated Rate |
$365.24 |
| Rate for Payer: Aetna Commercial |
$357.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$341.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.41
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$365.24
|
| Rate for Payer: Health EOS Commercial |
$353.33
|
| Rate for Payer: HFN Commercial |
$365.24
|
| Rate for Payer: Multiplan Commercial |
$317.60
|
| Rate for Payer: NAPHCARE Commercial |
$238.20
|
| Rate for Payer: Preferred Network Access Commercial |
$365.24
|
| Rate for Payer: Quartz Beloit One Network |
$194.53
|
| Rate for Payer: Quartz Commercial |
$238.20
|
| Rate for Payer: WEA Trust Commercial |
$218.35
|
| Rate for Payer: WPS Commercial |
$294.06
|
|
|
FILL KIT IMPLANT 350-8400
|
Facility
|
OP
|
$397.00
|
|
| Hospital Charge Code |
2969473
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$111.16 |
| Max. Negotiated Rate |
$1,588.00 |
| Rate for Payer: Aetna Commercial |
$357.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$341.42
|
| Rate for Payer: Aetna Managed Medicare |
$111.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$258.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$198.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$190.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.41
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$365.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.16
|
| Rate for Payer: Health EOS Commercial |
$353.33
|
| Rate for Payer: HFN Commercial |
$365.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$297.75
|
| Rate for Payer: Multiplan Commercial |
$317.60
|
| Rate for Payer: NAPHCARE Commercial |
$238.20
|
| Rate for Payer: Preferred Network Access Commercial |
$365.24
|
| Rate for Payer: Quartz Beloit One Network |
$194.53
|
| Rate for Payer: Quartz Commercial |
$258.05
|
| Rate for Payer: Quartz Medicare Advantage |
$238.20
|
| Rate for Payer: The Alliance Commercial |
$1,588.00
|
| Rate for Payer: WEA Trust Commercial |
$218.35
|
| Rate for Payer: WPS Commercial |
$294.06
|
|
|
FILL KIT IMPLANT/EXPANDER
|
Facility
|
IP
|
$397.00
|
|
| Hospital Charge Code |
2974025
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$194.53 |
| Max. Negotiated Rate |
$365.24 |
| Rate for Payer: Aetna Commercial |
$357.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$341.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.41
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$365.24
|
| Rate for Payer: Health EOS Commercial |
$353.33
|
| Rate for Payer: HFN Commercial |
$365.24
|
| Rate for Payer: Multiplan Commercial |
$317.60
|
| Rate for Payer: NAPHCARE Commercial |
$238.20
|
| Rate for Payer: Preferred Network Access Commercial |
$365.24
|
| Rate for Payer: Quartz Beloit One Network |
$194.53
|
| Rate for Payer: Quartz Commercial |
$238.20
|
| Rate for Payer: WEA Trust Commercial |
$218.35
|
| Rate for Payer: WPS Commercial |
$294.06
|
|
|
FILL KIT IMPLANT/EXPANDER
|
Facility
|
OP
|
$397.00
|
|
| Hospital Charge Code |
2974025
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$111.16 |
| Max. Negotiated Rate |
$1,588.00 |
| Rate for Payer: Aetna Commercial |
$357.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$341.42
|
| Rate for Payer: Aetna Managed Medicare |
$111.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$258.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$198.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$190.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.41
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$365.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.16
|
| Rate for Payer: Health EOS Commercial |
$353.33
|
| Rate for Payer: HFN Commercial |
$365.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$297.75
|
| Rate for Payer: Multiplan Commercial |
$317.60
|
| Rate for Payer: NAPHCARE Commercial |
$238.20
|
| Rate for Payer: Preferred Network Access Commercial |
$365.24
|
| Rate for Payer: Quartz Beloit One Network |
$194.53
|
| Rate for Payer: Quartz Commercial |
$258.05
|
| Rate for Payer: Quartz Medicare Advantage |
$238.20
|
| Rate for Payer: The Alliance Commercial |
$1,588.00
|
| Rate for Payer: WEA Trust Commercial |
$218.35
|
| Rate for Payer: WPS Commercial |
$294.06
|
|
|
FILTER AIR INLET #88-M1161007
|
Facility
|
OP
|
$69.00
|
|
| Hospital Charge Code |
2971097
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$19.32 |
| Max. Negotiated Rate |
$276.00 |
| Rate for Payer: Aetna Commercial |
$62.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.34
|
| Rate for Payer: Aetna Managed Medicare |
$19.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.57
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$63.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.61
|
| Rate for Payer: Health EOS Commercial |
$61.41
|
| Rate for Payer: HFN Commercial |
$63.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.75
|
| Rate for Payer: Multiplan Commercial |
$55.20
|
| Rate for Payer: NAPHCARE Commercial |
$41.40
|
| Rate for Payer: Preferred Network Access Commercial |
$63.48
|
| Rate for Payer: Quartz Beloit One Network |
$33.81
|
| Rate for Payer: Quartz Commercial |
$44.85
|
| Rate for Payer: Quartz Medicare Advantage |
$41.40
|
| Rate for Payer: The Alliance Commercial |
$276.00
|
| Rate for Payer: WEA Trust Commercial |
$37.95
|
| Rate for Payer: WPS Commercial |
$51.11
|
|
|
FILTER AIR INLET #88-M1161007
|
Facility
|
IP
|
$69.00
|
|
| Hospital Charge Code |
2971097
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$33.81 |
| Max. Negotiated Rate |
$63.48 |
| Rate for Payer: Aetna Commercial |
$62.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.57
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$63.48
|
| Rate for Payer: Health EOS Commercial |
$61.41
|
| Rate for Payer: HFN Commercial |
$63.48
|
| Rate for Payer: Multiplan Commercial |
$55.20
|
| Rate for Payer: NAPHCARE Commercial |
$41.40
|
| Rate for Payer: Preferred Network Access Commercial |
$63.48
|
| Rate for Payer: Quartz Beloit One Network |
$33.81
|
| Rate for Payer: Quartz Commercial |
$41.40
|
| Rate for Payer: WEA Trust Commercial |
$37.95
|
| Rate for Payer: WPS Commercial |
$51.11
|
|
|
FILTER AIR INLET V60 1054279
|
Facility
|
OP
|
$248.00
|
|
| Hospital Charge Code |
2971774
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$69.44 |
| Max. Negotiated Rate |
$992.00 |
| Rate for Payer: Aetna Commercial |
$223.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$213.28
|
| Rate for Payer: Aetna Managed Medicare |
$69.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$161.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$124.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$119.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.44
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$228.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$138.78
|
| Rate for Payer: Health EOS Commercial |
$220.72
|
| Rate for Payer: HFN Commercial |
$228.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$186.00
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: NAPHCARE Commercial |
$148.80
|
| Rate for Payer: Preferred Network Access Commercial |
$228.16
|
| Rate for Payer: Quartz Beloit One Network |
$121.52
|
| Rate for Payer: Quartz Commercial |
$161.20
|
| Rate for Payer: Quartz Medicare Advantage |
$148.80
|
| Rate for Payer: The Alliance Commercial |
$992.00
|
| Rate for Payer: WEA Trust Commercial |
$136.40
|
| Rate for Payer: WPS Commercial |
$183.69
|
|
|
FILTER AIR INLET V60 1054279
|
Facility
|
IP
|
$248.00
|
|
| Hospital Charge Code |
2971774
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$121.52 |
| Max. Negotiated Rate |
$228.16 |
| Rate for Payer: Aetna Commercial |
$223.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$213.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.44
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$228.16
|
| Rate for Payer: Health EOS Commercial |
$220.72
|
| Rate for Payer: HFN Commercial |
$228.16
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: NAPHCARE Commercial |
$148.80
|
| Rate for Payer: Preferred Network Access Commercial |
$228.16
|
| Rate for Payer: Quartz Beloit One Network |
$121.52
|
| Rate for Payer: Quartz Commercial |
$148.80
|
| Rate for Payer: WEA Trust Commercial |
$136.40
|
| Rate for Payer: WPS Commercial |
$183.69
|
|
|
FILTER BACTERIA VIRAL RHF605U
|
Facility
|
IP
|
$33.00
|
|
| Hospital Charge Code |
2974553
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.17 |
| Max. Negotiated Rate |
$30.36 |
| Rate for Payer: Aetna Commercial |
$29.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.49
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$30.36
|
| Rate for Payer: Health EOS Commercial |
$29.37
|
| Rate for Payer: HFN Commercial |
$30.36
|
| Rate for Payer: Multiplan Commercial |
$26.40
|
| Rate for Payer: NAPHCARE Commercial |
$19.80
|
| Rate for Payer: Preferred Network Access Commercial |
$30.36
|
| Rate for Payer: Quartz Beloit One Network |
$16.17
|
| Rate for Payer: Quartz Commercial |
$19.80
|
| Rate for Payer: WEA Trust Commercial |
$18.15
|
| Rate for Payer: WPS Commercial |
$24.44
|
|
|
FILTER BACTERIA VIRAL RHF605U
|
Facility
|
OP
|
$33.00
|
|
| Hospital Charge Code |
2974553
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$132.00 |
| Rate for Payer: Aetna Commercial |
$29.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28.38
|
| Rate for Payer: Aetna Managed Medicare |
$9.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.49
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$30.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.47
|
| Rate for Payer: Health EOS Commercial |
$29.37
|
| Rate for Payer: HFN Commercial |
$30.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.75
|
| Rate for Payer: Multiplan Commercial |
$26.40
|
| Rate for Payer: NAPHCARE Commercial |
$19.80
|
| Rate for Payer: Preferred Network Access Commercial |
$30.36
|
| Rate for Payer: Quartz Beloit One Network |
$16.17
|
| Rate for Payer: Quartz Commercial |
$21.45
|
| Rate for Payer: Quartz Medicare Advantage |
$19.80
|
| Rate for Payer: The Alliance Commercial |
$132.00
|
| Rate for Payer: WEA Trust Commercial |
$18.15
|
| Rate for Payer: WPS Commercial |
$24.44
|
|
|
FILTER BLOOD TRANSFUSION PALL SQ40S
|
Facility
|
OP
|
$261.00
|
|
| Hospital Charge Code |
2973503
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.08 |
| Max. Negotiated Rate |
$1,044.00 |
| Rate for Payer: Aetna Commercial |
$234.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.46
|
| Rate for Payer: Aetna Managed Medicare |
$73.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$169.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$130.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$125.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.33
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$240.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.06
|
| Rate for Payer: Health EOS Commercial |
$232.29
|
| Rate for Payer: HFN Commercial |
$240.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$195.75
|
| Rate for Payer: Multiplan Commercial |
$208.80
|
| Rate for Payer: NAPHCARE Commercial |
$156.60
|
| Rate for Payer: Preferred Network Access Commercial |
$240.12
|
| Rate for Payer: Quartz Beloit One Network |
$127.89
|
| Rate for Payer: Quartz Commercial |
$169.65
|
| Rate for Payer: Quartz Medicare Advantage |
$156.60
|
| Rate for Payer: The Alliance Commercial |
$1,044.00
|
| Rate for Payer: WEA Trust Commercial |
$143.55
|
| Rate for Payer: WPS Commercial |
$193.32
|
|
|
FILTER BLOOD TRANSFUSION PALL SQ40S
|
Facility
|
IP
|
$261.00
|
|
| Hospital Charge Code |
2973503
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$127.89 |
| Max. Negotiated Rate |
$240.12 |
| Rate for Payer: Aetna Commercial |
$234.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.33
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$240.12
|
| Rate for Payer: Health EOS Commercial |
$232.29
|
| Rate for Payer: HFN Commercial |
$240.12
|
| Rate for Payer: Multiplan Commercial |
$208.80
|
| Rate for Payer: NAPHCARE Commercial |
$156.60
|
| Rate for Payer: Preferred Network Access Commercial |
$240.12
|
| Rate for Payer: Quartz Beloit One Network |
$127.89
|
| Rate for Payer: Quartz Commercial |
$156.60
|
| Rate for Payer: WEA Trust Commercial |
$143.55
|
| Rate for Payer: WPS Commercial |
$193.32
|
|
|
FILTER COOLING FAN V60 1054280
|
Facility
|
OP
|
$67.00
|
|
| Hospital Charge Code |
2970863
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$18.76 |
| Max. Negotiated Rate |
$268.00 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Aetna Managed Medicare |
$18.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.51
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$61.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.49
|
| Rate for Payer: Health EOS Commercial |
$59.63
|
| Rate for Payer: HFN Commercial |
$61.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.25
|
| Rate for Payer: Multiplan Commercial |
$53.60
|
| Rate for Payer: NAPHCARE Commercial |
$40.20
|
| Rate for Payer: Preferred Network Access Commercial |
$61.64
|
| Rate for Payer: Quartz Beloit One Network |
$32.83
|
| Rate for Payer: Quartz Commercial |
$43.55
|
| Rate for Payer: Quartz Medicare Advantage |
$40.20
|
| Rate for Payer: The Alliance Commercial |
$268.00
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
|
FILTER COOLING FAN V60 1054280
|
Facility
|
IP
|
$67.00
|
|
| Hospital Charge Code |
2970863
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$32.83 |
| Max. Negotiated Rate |
$61.64 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.51
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$61.64
|
| Rate for Payer: Health EOS Commercial |
$59.63
|
| Rate for Payer: HFN Commercial |
$61.64
|
| Rate for Payer: Multiplan Commercial |
$53.60
|
| Rate for Payer: NAPHCARE Commercial |
$40.20
|
| Rate for Payer: Preferred Network Access Commercial |
$61.64
|
| Rate for Payer: Quartz Beloit One Network |
$32.83
|
| Rate for Payer: Quartz Commercial |
$40.20
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
|
FILTER, HME, SMALL VOLUME #BB25A
|
Facility
|
IP
|
$181.00
|
|
| Hospital Charge Code |
2973475
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$88.69 |
| Max. Negotiated Rate |
$166.52 |
| Rate for Payer: Aetna Commercial |
$162.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$155.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.93
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cigna Commercial |
$166.52
|
| Rate for Payer: Health EOS Commercial |
$161.09
|
| Rate for Payer: HFN Commercial |
$166.52
|
| Rate for Payer: Multiplan Commercial |
$144.80
|
| Rate for Payer: NAPHCARE Commercial |
$108.60
|
| Rate for Payer: Preferred Network Access Commercial |
$166.52
|
| Rate for Payer: Quartz Beloit One Network |
$88.69
|
| Rate for Payer: Quartz Commercial |
$108.60
|
| Rate for Payer: WEA Trust Commercial |
$99.55
|
| Rate for Payer: WPS Commercial |
$134.07
|
|
|
FILTER, HME, SMALL VOLUME #BB25A
|
Facility
|
OP
|
$181.00
|
|
| Hospital Charge Code |
2973475
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$50.68 |
| Max. Negotiated Rate |
$724.00 |
| Rate for Payer: Aetna Commercial |
$162.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$155.66
|
| Rate for Payer: Aetna Managed Medicare |
$50.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$117.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$90.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$86.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.93
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cigna Commercial |
$166.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$101.29
|
| Rate for Payer: Health EOS Commercial |
$161.09
|
| Rate for Payer: HFN Commercial |
$166.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$135.75
|
| Rate for Payer: Multiplan Commercial |
$144.80
|
| Rate for Payer: NAPHCARE Commercial |
$108.60
|
| Rate for Payer: Preferred Network Access Commercial |
$166.52
|
| Rate for Payer: Quartz Beloit One Network |
$88.69
|
| Rate for Payer: Quartz Commercial |
$117.65
|
| Rate for Payer: Quartz Medicare Advantage |
$108.60
|
| Rate for Payer: The Alliance Commercial |
$724.00
|
| Rate for Payer: WEA Trust Commercial |
$99.55
|
| Rate for Payer: WPS Commercial |
$134.07
|
|
|
FILTER NEPTUNE SMOKE EVAC PREFILTER 700-22
|
Facility
|
IP
|
$375.00
|
|
| Hospital Charge Code |
4294571
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$183.75 |
| Max. Negotiated Rate |
$345.00 |
| Rate for Payer: Aetna Commercial |
$337.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$322.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$198.75
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$345.00
|
| Rate for Payer: Health EOS Commercial |
$333.75
|
| Rate for Payer: HFN Commercial |
$345.00
|
| Rate for Payer: Multiplan Commercial |
$300.00
|
| Rate for Payer: NAPHCARE Commercial |
$225.00
|
| Rate for Payer: Preferred Network Access Commercial |
$345.00
|
| Rate for Payer: Quartz Beloit One Network |
$183.75
|
| Rate for Payer: Quartz Commercial |
$225.00
|
| Rate for Payer: WEA Trust Commercial |
$206.25
|
| Rate for Payer: WPS Commercial |
$277.76
|
|
|
FILTER NEPTUNE SMOKE EVAC PREFILTER 700-22
|
Facility
|
OP
|
$375.00
|
|
| Hospital Charge Code |
4294571
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$337.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$322.50
|
| Rate for Payer: Aetna Managed Medicare |
$105.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$243.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$187.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$180.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$198.75
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$345.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$209.85
|
| Rate for Payer: Health EOS Commercial |
$333.75
|
| Rate for Payer: HFN Commercial |
$345.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.25
|
| Rate for Payer: Multiplan Commercial |
$300.00
|
| Rate for Payer: NAPHCARE Commercial |
$225.00
|
| Rate for Payer: Preferred Network Access Commercial |
$345.00
|
| Rate for Payer: Quartz Beloit One Network |
$183.75
|
| Rate for Payer: Quartz Commercial |
$243.75
|
| Rate for Payer: Quartz Medicare Advantage |
$225.00
|
| Rate for Payer: The Alliance Commercial |
$1,500.00
|
| Rate for Payer: WEA Trust Commercial |
$206.25
|
| Rate for Payer: WPS Commercial |
$277.76
|
|
