|
FOAM BANDAGE #9274-17
|
Facility
|
IP
|
$101.00
|
|
| Hospital Charge Code |
2974060
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$51.47 |
| Max. Negotiated Rate |
$96.64 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.67
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$96.64
|
| Rate for Payer: Health EOS Commercial |
$93.49
|
| Rate for Payer: HFN Commercial |
$96.64
|
| Rate for Payer: Multiplan Commercial |
$84.03
|
| Rate for Payer: Preferred Network Access Commercial |
$96.64
|
| Rate for Payer: Quartz Beloit One Network |
$51.47
|
| Rate for Payer: Quartz Commercial |
$63.02
|
| Rate for Payer: WEA Trust Commercial |
$57.77
|
| Rate for Payer: WPS Commercial |
$77.80
|
|
|
FOAM BANDAGE #9274-17
|
Facility
|
OP
|
$101.00
|
|
| Hospital Charge Code |
2974060
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$29.41 |
| Max. Negotiated Rate |
$96.64 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.33
|
| Rate for Payer: Aetna Managed Medicare |
$29.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.67
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$96.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.78
|
| Rate for Payer: Health EOS Commercial |
$93.49
|
| Rate for Payer: HFN Commercial |
$96.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.78
|
| Rate for Payer: Multiplan Commercial |
$84.03
|
| Rate for Payer: NAPHCARE Commercial |
$63.02
|
| Rate for Payer: Preferred Network Access Commercial |
$96.64
|
| Rate for Payer: Quartz Beloit One Network |
$51.47
|
| Rate for Payer: Quartz Commercial |
$68.28
|
| Rate for Payer: Quartz Medicare Advantage |
$63.02
|
| Rate for Payer: The Alliance Commercial |
$52.52
|
| Rate for Payer: WEA Trust Commercial |
$57.77
|
| Rate for Payer: WPS Commercial |
$77.80
|
|
|
FOAM BLOCKS R-LITE GREEN #5601-85
|
Facility
|
IP
|
$735.00
|
|
| Hospital Charge Code |
2970197
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$374.56 |
| Max. Negotiated Rate |
$703.25 |
| Rate for Payer: Aetna Commercial |
$687.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$657.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$405.13
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$703.25
|
| Rate for Payer: Health EOS Commercial |
$680.32
|
| Rate for Payer: HFN Commercial |
$703.25
|
| Rate for Payer: Multiplan Commercial |
$611.52
|
| Rate for Payer: Preferred Network Access Commercial |
$703.25
|
| Rate for Payer: Quartz Beloit One Network |
$374.56
|
| Rate for Payer: Quartz Commercial |
$458.64
|
| Rate for Payer: WEA Trust Commercial |
$420.42
|
| Rate for Payer: WPS Commercial |
$566.17
|
|
|
FOAM BLOCKS R-LITE GREEN #5601-85
|
Facility
|
OP
|
$735.00
|
|
| Hospital Charge Code |
2970197
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$214.03 |
| Max. Negotiated Rate |
$703.25 |
| Rate for Payer: Aetna Commercial |
$687.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$657.38
|
| Rate for Payer: Aetna Managed Medicare |
$214.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$496.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$382.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$366.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$405.13
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$703.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$427.77
|
| Rate for Payer: Health EOS Commercial |
$680.32
|
| Rate for Payer: HFN Commercial |
$703.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$573.30
|
| Rate for Payer: Multiplan Commercial |
$611.52
|
| Rate for Payer: NAPHCARE Commercial |
$458.64
|
| Rate for Payer: Preferred Network Access Commercial |
$703.25
|
| Rate for Payer: Quartz Beloit One Network |
$374.56
|
| Rate for Payer: Quartz Commercial |
$496.86
|
| Rate for Payer: Quartz Medicare Advantage |
$458.64
|
| Rate for Payer: The Alliance Commercial |
$382.20
|
| Rate for Payer: WEA Trust Commercial |
$420.42
|
| Rate for Payer: WPS Commercial |
$566.17
|
|
|
FOAM BLOCKS R-LITE YELLOW #A908-5
|
Facility
|
OP
|
$42.00
|
|
| Hospital Charge Code |
2969690
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.23 |
| Max. Negotiated Rate |
$40.19 |
| Rate for Payer: Aetna Commercial |
$39.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.56
|
| Rate for Payer: Aetna Managed Medicare |
$12.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.15
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$40.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.44
|
| Rate for Payer: Health EOS Commercial |
$38.88
|
| Rate for Payer: HFN Commercial |
$40.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.76
|
| Rate for Payer: Multiplan Commercial |
$34.94
|
| Rate for Payer: NAPHCARE Commercial |
$26.21
|
| Rate for Payer: Preferred Network Access Commercial |
$40.19
|
| Rate for Payer: Quartz Beloit One Network |
$21.40
|
| Rate for Payer: Quartz Commercial |
$28.39
|
| Rate for Payer: Quartz Medicare Advantage |
$26.21
|
| Rate for Payer: The Alliance Commercial |
$21.84
|
| Rate for Payer: WEA Trust Commercial |
$24.02
|
| Rate for Payer: WPS Commercial |
$32.35
|
|
|
FOAM BLOCKS R-LITE YELLOW #A908-5
|
Facility
|
IP
|
$42.00
|
|
| Hospital Charge Code |
2969690
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.40 |
| Max. Negotiated Rate |
$40.19 |
| Rate for Payer: Aetna Commercial |
$39.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.15
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$40.19
|
| Rate for Payer: Health EOS Commercial |
$38.88
|
| Rate for Payer: HFN Commercial |
$40.19
|
| Rate for Payer: Multiplan Commercial |
$34.94
|
| Rate for Payer: Preferred Network Access Commercial |
$40.19
|
| Rate for Payer: Quartz Beloit One Network |
$21.40
|
| Rate for Payer: Quartz Commercial |
$26.21
|
| Rate for Payer: WEA Trust Commercial |
$24.02
|
| Rate for Payer: WPS Commercial |
$32.35
|
|
|
FOAM BLOCKS ROLYAN R-LITE BLUE/MED #A908-7
|
Facility
|
IP
|
$42.00
|
|
| Hospital Charge Code |
2969691
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.40 |
| Max. Negotiated Rate |
$40.19 |
| Rate for Payer: Aetna Commercial |
$39.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.15
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$40.19
|
| Rate for Payer: Health EOS Commercial |
$38.88
|
| Rate for Payer: HFN Commercial |
$40.19
|
| Rate for Payer: Multiplan Commercial |
$34.94
|
| Rate for Payer: Preferred Network Access Commercial |
$40.19
|
| Rate for Payer: Quartz Beloit One Network |
$21.40
|
| Rate for Payer: Quartz Commercial |
$26.21
|
| Rate for Payer: WEA Trust Commercial |
$24.02
|
| Rate for Payer: WPS Commercial |
$32.35
|
|
|
FOAM BLOCKS ROLYAN R-LITE BLUE/MED #A908-7
|
Facility
|
OP
|
$42.00
|
|
| Hospital Charge Code |
2969691
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.23 |
| Max. Negotiated Rate |
$40.19 |
| Rate for Payer: Aetna Commercial |
$39.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.56
|
| Rate for Payer: Aetna Managed Medicare |
$12.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.15
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$40.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.44
|
| Rate for Payer: Health EOS Commercial |
$38.88
|
| Rate for Payer: HFN Commercial |
$40.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.76
|
| Rate for Payer: Multiplan Commercial |
$34.94
|
| Rate for Payer: NAPHCARE Commercial |
$26.21
|
| Rate for Payer: Preferred Network Access Commercial |
$40.19
|
| Rate for Payer: Quartz Beloit One Network |
$21.40
|
| Rate for Payer: Quartz Commercial |
$28.39
|
| Rate for Payer: Quartz Medicare Advantage |
$26.21
|
| Rate for Payer: The Alliance Commercial |
$21.84
|
| Rate for Payer: WEA Trust Commercial |
$24.02
|
| Rate for Payer: WPS Commercial |
$32.35
|
|
|
Foam charge
|
Facility
|
IP
|
$151.00
|
|
| Hospital Charge Code |
2844913
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$76.95 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$94.22
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
Foam charge
|
Facility
|
OP
|
$151.00
|
|
| Hospital Charge Code |
2844913
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$43.97 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Aetna Managed Medicare |
$43.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.88
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.78
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: NAPHCARE Commercial |
$94.22
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$102.08
|
| Rate for Payer: Quartz Medicare Advantage |
$94.22
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
FOAM PACK VITOSS BA2X SYNTHETIC BONE GRAFT SUBSTITUTE 1.2CC 2102-2101
|
Facility
|
OP
|
$4,608.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5617700
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,341.85 |
| Max. Negotiated Rate |
$4,408.93 |
| Rate for Payer: Aetna Commercial |
$4,313.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,121.40
|
| Rate for Payer: Aetna Managed Medicare |
$1,341.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,115.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,396.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,300.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,539.93
|
| Rate for Payer: Cash Price |
$1,382.40
|
| Rate for Payer: Cigna Commercial |
$4,408.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,681.86
|
| Rate for Payer: Health EOS Commercial |
$4,265.16
|
| Rate for Payer: HFN Commercial |
$4,408.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,594.24
|
| Rate for Payer: Multiplan Commercial |
$3,833.86
|
| Rate for Payer: NAPHCARE Commercial |
$2,875.39
|
| Rate for Payer: Preferred Network Access Commercial |
$4,408.93
|
| Rate for Payer: Quartz Beloit One Network |
$2,348.24
|
| Rate for Payer: Quartz Commercial |
$3,115.01
|
| Rate for Payer: Quartz Medicare Advantage |
$2,875.39
|
| Rate for Payer: The Alliance Commercial |
$2,396.16
|
| Rate for Payer: WEA Trust Commercial |
$2,635.78
|
| Rate for Payer: WPS Commercial |
$3,549.54
|
|
|
FOAM PACK VITOSS BA2X SYNTHETIC BONE GRAFT SUBSTITUTE 1.2CC 2102-2101
|
Facility
|
IP
|
$4,608.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
5617700
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,348.24 |
| Max. Negotiated Rate |
$4,408.93 |
| Rate for Payer: Aetna Commercial |
$4,313.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,121.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,539.93
|
| Rate for Payer: Cash Price |
$1,382.40
|
| Rate for Payer: Cigna Commercial |
$4,408.93
|
| Rate for Payer: Health EOS Commercial |
$4,265.16
|
| Rate for Payer: HFN Commercial |
$4,408.93
|
| Rate for Payer: Multiplan Commercial |
$3,833.86
|
| Rate for Payer: Preferred Network Access Commercial |
$4,408.93
|
| Rate for Payer: Quartz Beloit One Network |
$2,348.24
|
| Rate for Payer: Quartz Commercial |
$2,875.39
|
| Rate for Payer: WEA Trust Commercial |
$2,635.78
|
| Rate for Payer: WPS Commercial |
$3,549.54
|
|
|
FOAM PADDING SOFT #55978101
|
Facility
|
IP
|
$153.00
|
|
| Hospital Charge Code |
2974050
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$77.97 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$95.47
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
FOAM PADDING SOFT #55978101
|
Facility
|
OP
|
$153.00
|
|
| Hospital Charge Code |
2974050
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.55 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Aetna Managed Medicare |
$44.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$103.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.05
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.34
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: NAPHCARE Commercial |
$95.47
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$103.43
|
| Rate for Payer: Quartz Medicare Advantage |
$95.47
|
| Rate for Payer: The Alliance Commercial |
$79.56
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
Folate Level
|
Professional
|
Both
|
$197.00
|
|
|
Service Code
|
CPT 82746
|
| Hospital Charge Code |
633729
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$194.64 |
| Rate for Payer: Aetna Commercial |
$194.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.20
|
| Rate for Payer: Aetna Managed Medicare |
$15.29
|
| Rate for Payer: Anthem Medicare Advantage |
$15.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.29
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$194.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$102.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.29
|
| Rate for Payer: Health EOS Commercial |
$186.44
|
| Rate for Payer: HFN Commercial |
$194.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.29
|
| Rate for Payer: Multiplan Commercial |
$163.90
|
| Rate for Payer: NAPHCARE Commercial |
$22.93
|
| Rate for Payer: Preferred Network Access Commercial |
$194.64
|
| Rate for Payer: Quartz Beloit One Network |
$90.15
|
| Rate for Payer: Quartz Commercial |
$116.78
|
| Rate for Payer: Quartz Medicare Advantage |
$15.29
|
| Rate for Payer: The Alliance Commercial |
$60.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.29
|
| Rate for Payer: WEA Trust Commercial |
$112.68
|
| Rate for Payer: WPS Commercial |
$67.27
|
|
|
Folate Level
|
Facility
|
IP
|
$197.00
|
|
|
Service Code
|
CPT 82746
|
| Hospital Charge Code |
633729
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$100.39 |
| Max. Negotiated Rate |
$188.49 |
| Rate for Payer: Aetna Commercial |
$184.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.59
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$188.49
|
| Rate for Payer: Health EOS Commercial |
$182.34
|
| Rate for Payer: HFN Commercial |
$188.49
|
| Rate for Payer: Multiplan Commercial |
$163.90
|
| Rate for Payer: Preferred Network Access Commercial |
$188.49
|
| Rate for Payer: Quartz Beloit One Network |
$100.39
|
| Rate for Payer: Quartz Commercial |
$122.93
|
| Rate for Payer: WEA Trust Commercial |
$112.68
|
| Rate for Payer: WPS Commercial |
$151.75
|
|
|
Folate Level
|
Facility
|
OP
|
$197.00
|
|
|
Service Code
|
CPT 82746
|
| Hospital Charge Code |
633729
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$188.49 |
| Rate for Payer: Aetna Commercial |
$184.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$176.20
|
| Rate for Payer: Aetna Managed Medicare |
$15.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.75
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.38
|
| Rate for Payer: Anthem Medicare Advantage |
$15.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.29
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$188.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.65
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.29
|
| Rate for Payer: Health EOS Commercial |
$182.34
|
| Rate for Payer: HFN Commercial |
$188.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.29
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.29
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.29
|
| Rate for Payer: Multiplan Commercial |
$163.90
|
| Rate for Payer: NAPHCARE Commercial |
$22.93
|
| Rate for Payer: Preferred Network Access Commercial |
$188.49
|
| Rate for Payer: Quartz Beloit One Network |
$100.39
|
| Rate for Payer: Quartz Commercial |
$133.17
|
| Rate for Payer: Quartz Medicare Advantage |
$15.29
|
| Rate for Payer: The Alliance Commercial |
$61.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.29
|
| Rate for Payer: United Healthcare PPO |
$153.66
|
| Rate for Payer: WEA Trust Commercial |
$112.68
|
| Rate for Payer: Wellcare Medicare |
$15.29
|
| Rate for Payer: WPS Commercial |
$151.75
|
|
|
FOLEY CATHETER 24FR 30CC 3-WAY HOTTER RED LATEX 6003L24
|
Facility
|
IP
|
$96.00
|
|
| Hospital Charge Code |
2963590
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.92 |
| Max. Negotiated Rate |
$91.85 |
| Rate for Payer: Aetna Commercial |
$89.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$52.92
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$91.85
|
| Rate for Payer: Health EOS Commercial |
$88.86
|
| Rate for Payer: HFN Commercial |
$91.85
|
| Rate for Payer: Multiplan Commercial |
$79.87
|
| Rate for Payer: Preferred Network Access Commercial |
$91.85
|
| Rate for Payer: Quartz Beloit One Network |
$48.92
|
| Rate for Payer: Quartz Commercial |
$59.90
|
| Rate for Payer: WEA Trust Commercial |
$54.91
|
| Rate for Payer: WPS Commercial |
$73.95
|
|
|
FOLEY CATHETER 24FR 30CC 3-WAY HOTTER RED LATEX 6003L24
|
Facility
|
OP
|
$96.00
|
|
| Hospital Charge Code |
2963590
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.96 |
| Max. Negotiated Rate |
$91.85 |
| Rate for Payer: Aetna Commercial |
$89.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.86
|
| Rate for Payer: Aetna Managed Medicare |
$27.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$52.92
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$91.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$55.87
|
| Rate for Payer: Health EOS Commercial |
$88.86
|
| Rate for Payer: HFN Commercial |
$91.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$74.88
|
| Rate for Payer: Multiplan Commercial |
$79.87
|
| Rate for Payer: NAPHCARE Commercial |
$59.90
|
| Rate for Payer: Preferred Network Access Commercial |
$91.85
|
| Rate for Payer: Quartz Beloit One Network |
$48.92
|
| Rate for Payer: Quartz Commercial |
$64.90
|
| Rate for Payer: Quartz Medicare Advantage |
$59.90
|
| Rate for Payer: The Alliance Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$54.91
|
| Rate for Payer: WPS Commercial |
$73.95
|
|
|
Follicle Stimulating Hormone Level
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
CPT 83001
|
| Hospital Charge Code |
633730
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.32 |
| Max. Negotiated Rate |
$312.87 |
| Rate for Payer: Aetna Commercial |
$306.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$292.47
|
| Rate for Payer: Aetna Managed Medicare |
$19.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.82
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.08
|
| Rate for Payer: Anthem Medicare Advantage |
$19.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$180.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.32
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$312.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$190.31
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.32
|
| Rate for Payer: Health EOS Commercial |
$302.67
|
| Rate for Payer: HFN Commercial |
$312.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.32
|
| Rate for Payer: Multiplan Commercial |
$272.06
|
| Rate for Payer: NAPHCARE Commercial |
$28.98
|
| Rate for Payer: Preferred Network Access Commercial |
$312.87
|
| Rate for Payer: Quartz Beloit One Network |
$166.64
|
| Rate for Payer: Quartz Commercial |
$221.05
|
| Rate for Payer: Quartz Medicare Advantage |
$19.32
|
| Rate for Payer: The Alliance Commercial |
$77.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.32
|
| Rate for Payer: United Healthcare PPO |
$255.06
|
| Rate for Payer: WEA Trust Commercial |
$187.04
|
| Rate for Payer: Wellcare Medicare |
$19.32
|
| Rate for Payer: WPS Commercial |
$251.89
|
|
|
Follicle Stimulating Hormone Level
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
CPT 83001
|
| Hospital Charge Code |
633730
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$166.64 |
| Max. Negotiated Rate |
$312.87 |
| Rate for Payer: Aetna Commercial |
$306.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$292.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$180.24
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$312.87
|
| Rate for Payer: Health EOS Commercial |
$302.67
|
| Rate for Payer: HFN Commercial |
$312.87
|
| Rate for Payer: Multiplan Commercial |
$272.06
|
| Rate for Payer: Preferred Network Access Commercial |
$312.87
|
| Rate for Payer: Quartz Beloit One Network |
$166.64
|
| Rate for Payer: Quartz Commercial |
$204.05
|
| Rate for Payer: WEA Trust Commercial |
$187.04
|
| Rate for Payer: WPS Commercial |
$251.89
|
|
|
Follicle Stimulating Hormone Level
|
Professional
|
Both
|
$327.00
|
|
|
Service Code
|
CPT 83001
|
| Hospital Charge Code |
633730
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.32 |
| Max. Negotiated Rate |
$323.08 |
| Rate for Payer: Aetna Commercial |
$323.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$292.47
|
| Rate for Payer: Aetna Managed Medicare |
$19.32
|
| Rate for Payer: Anthem Medicare Advantage |
$19.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.32
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$323.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$170.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.32
|
| Rate for Payer: Health EOS Commercial |
$309.47
|
| Rate for Payer: HFN Commercial |
$323.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$68.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.32
|
| Rate for Payer: Multiplan Commercial |
$272.06
|
| Rate for Payer: NAPHCARE Commercial |
$28.98
|
| Rate for Payer: Preferred Network Access Commercial |
$323.08
|
| Rate for Payer: Quartz Beloit One Network |
$149.64
|
| Rate for Payer: Quartz Commercial |
$193.85
|
| Rate for Payer: Quartz Medicare Advantage |
$19.32
|
| Rate for Payer: The Alliance Commercial |
$76.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.32
|
| Rate for Payer: WEA Trust Commercial |
$187.04
|
| Rate for Payer: WPS Commercial |
$85.02
|
|
|
FOLLOWER 10FR HEYMAN 021310
|
Facility
|
OP
|
$547.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.73 |
| Max. Negotiated Rate |
$523.37 |
| Rate for Payer: Aetna Commercial |
$511.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$489.24
|
| Rate for Payer: Aetna Managed Medicare |
$159.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$369.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$284.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$273.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.51
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$523.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$318.35
|
| Rate for Payer: Health EOS Commercial |
$506.30
|
| Rate for Payer: HFN Commercial |
$523.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$426.66
|
| Rate for Payer: Multiplan Commercial |
$455.10
|
| Rate for Payer: NAPHCARE Commercial |
$341.33
|
| Rate for Payer: Preferred Network Access Commercial |
$523.37
|
| Rate for Payer: Quartz Beloit One Network |
$278.75
|
| Rate for Payer: Quartz Commercial |
$369.77
|
| Rate for Payer: Quartz Medicare Advantage |
$341.33
|
| Rate for Payer: The Alliance Commercial |
$10.73
|
| Rate for Payer: WEA Trust Commercial |
$312.88
|
| Rate for Payer: WPS Commercial |
$421.35
|
|
|
FOLLOWER 10FR HEYMAN 021310
|
Facility
|
IP
|
$547.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$278.75 |
| Max. Negotiated Rate |
$523.37 |
| Rate for Payer: Aetna Commercial |
$511.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$489.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.51
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$523.37
|
| Rate for Payer: Health EOS Commercial |
$506.30
|
| Rate for Payer: HFN Commercial |
$523.37
|
| Rate for Payer: Multiplan Commercial |
$455.10
|
| Rate for Payer: Preferred Network Access Commercial |
$523.37
|
| Rate for Payer: Quartz Beloit One Network |
$278.75
|
| Rate for Payer: Quartz Commercial |
$341.33
|
| Rate for Payer: WEA Trust Commercial |
$312.88
|
| Rate for Payer: WPS Commercial |
$421.35
|
|
|
FOLLOWER 12FR HEYMAN 021312
|
Facility
|
IP
|
$547.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974004
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$278.75 |
| Max. Negotiated Rate |
$523.37 |
| Rate for Payer: Aetna Commercial |
$511.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$489.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.51
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$523.37
|
| Rate for Payer: Health EOS Commercial |
$506.30
|
| Rate for Payer: HFN Commercial |
$523.37
|
| Rate for Payer: Multiplan Commercial |
$455.10
|
| Rate for Payer: Preferred Network Access Commercial |
$523.37
|
| Rate for Payer: Quartz Beloit One Network |
$278.75
|
| Rate for Payer: Quartz Commercial |
$341.33
|
| Rate for Payer: WEA Trust Commercial |
$312.88
|
| Rate for Payer: WPS Commercial |
$421.35
|
|
