|
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 |
$26.88 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$86.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.56
|
| Rate for Payer: Aetna Managed Medicare |
$26.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.88
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$88.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.72
|
| Rate for Payer: Health EOS Commercial |
$85.44
|
| Rate for Payer: HFN Commercial |
$88.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.00
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: NAPHCARE Commercial |
$57.60
|
| Rate for Payer: Preferred Network Access Commercial |
$88.32
|
| Rate for Payer: Quartz Beloit One Network |
$47.04
|
| Rate for Payer: Quartz Commercial |
$62.40
|
| Rate for Payer: Quartz Medicare Advantage |
$57.60
|
| Rate for Payer: The Alliance Commercial |
$384.00
|
| Rate for Payer: WEA Trust Commercial |
$52.80
|
| Rate for Payer: WPS Commercial |
$71.11
|
|
|
Follicle Stimulating Hormone Level
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
CPT 83001
|
| Hospital Charge Code |
633730
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$160.23 |
| Max. Negotiated Rate |
$300.84 |
| Rate for Payer: Aetna Commercial |
$294.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$281.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$173.31
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$300.84
|
| Rate for Payer: Health EOS Commercial |
$291.03
|
| Rate for Payer: HFN Commercial |
$300.84
|
| Rate for Payer: Multiplan Commercial |
$261.60
|
| Rate for Payer: NAPHCARE Commercial |
$196.20
|
| Rate for Payer: Preferred Network Access Commercial |
$300.84
|
| Rate for Payer: Quartz Beloit One Network |
$160.23
|
| Rate for Payer: Quartz Commercial |
$196.20
|
| Rate for Payer: WEA Trust Commercial |
$179.85
|
| Rate for Payer: WPS Commercial |
$242.21
|
|
|
Follicle Stimulating Hormone Level
|
Professional
|
Both
|
$327.00
|
|
|
Service Code
|
CPT 83001
|
| Hospital Charge Code |
633730
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.59 |
| Max. Negotiated Rate |
$310.65 |
| Rate for Payer: Aetna Commercial |
$310.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$281.22
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$310.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$163.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$196.20
|
| Rate for Payer: Health EOS Commercial |
$297.57
|
| Rate for Payer: HFN Commercial |
$310.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.59
|
| Rate for Payer: Multiplan Commercial |
$261.60
|
| Rate for Payer: Preferred Network Access Commercial |
$310.65
|
| Rate for Payer: Quartz Beloit One Network |
$143.88
|
| Rate for Payer: Quartz Commercial |
$186.39
|
| Rate for Payer: The Alliance Commercial |
$163.50
|
| Rate for Payer: WEA Trust Commercial |
$179.85
|
| Rate for Payer: WPS Commercial |
$242.21
|
|
|
Follicle Stimulating Hormone Level
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
CPT 83001
|
| Hospital Charge Code |
633730
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.58 |
| Max. Negotiated Rate |
$300.84 |
| Rate for Payer: Aetna Commercial |
$294.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$281.22
|
| Rate for Payer: Aetna Managed Medicare |
$18.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.84
|
| Rate for Payer: Anthem Medicaid |
$19.20
|
| Rate for Payer: Anthem Medicare Advantage |
$18.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$173.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.58
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$300.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182.99
|
| Rate for Payer: Dean Health Medicaid |
$19.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.58
|
| Rate for Payer: Health EOS Commercial |
$291.03
|
| Rate for Payer: HFN Commercial |
$300.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.58
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.58
|
| Rate for Payer: Managed Health Services Medicaid |
$19.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.58
|
| Rate for Payer: Multiplan Commercial |
$261.60
|
| Rate for Payer: NAPHCARE Commercial |
$27.87
|
| Rate for Payer: Preferred Network Access Commercial |
$300.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.20
|
| Rate for Payer: Quartz Beloit One Network |
$160.23
|
| Rate for Payer: Quartz Commercial |
$212.55
|
| Rate for Payer: Quartz Medicare Advantage |
$18.58
|
| Rate for Payer: The Alliance Commercial |
$74.32
|
| Rate for Payer: United Healthcare Medicaid |
$19.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.58
|
| Rate for Payer: United Healthcare PPO |
$245.25
|
| Rate for Payer: WEA Trust Commercial |
$179.85
|
| Rate for Payer: Wellcare Medicare |
$18.58
|
| Rate for Payer: WMAP Medicaid |
$19.20
|
| Rate for Payer: WPS Commercial |
$242.21
|
|
|
FOLLOWER 10FR HEYMAN 021310
|
Facility
|
IP
|
$547.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$268.03 |
| Max. Negotiated Rate |
$503.24 |
| Rate for Payer: Aetna Commercial |
$492.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$470.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.91
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$503.24
|
| Rate for Payer: Health EOS Commercial |
$486.83
|
| Rate for Payer: HFN Commercial |
$503.24
|
| Rate for Payer: Multiplan Commercial |
$437.60
|
| Rate for Payer: NAPHCARE Commercial |
$328.20
|
| Rate for Payer: Preferred Network Access Commercial |
$503.24
|
| Rate for Payer: Quartz Beloit One Network |
$268.03
|
| Rate for Payer: Quartz Commercial |
$328.20
|
| Rate for Payer: WEA Trust Commercial |
$300.85
|
| Rate for Payer: WPS Commercial |
$405.16
|
|
|
FOLLOWER 10FR HEYMAN 021310
|
Facility
|
OP
|
$547.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$153.16 |
| Max. Negotiated Rate |
$2,188.00 |
| Rate for Payer: Aetna Commercial |
$492.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$470.42
|
| Rate for Payer: Aetna Managed Medicare |
$153.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$355.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$273.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$262.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.91
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$503.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$306.10
|
| Rate for Payer: Health EOS Commercial |
$486.83
|
| Rate for Payer: HFN Commercial |
$503.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$410.25
|
| Rate for Payer: Multiplan Commercial |
$437.60
|
| Rate for Payer: NAPHCARE Commercial |
$328.20
|
| Rate for Payer: Preferred Network Access Commercial |
$503.24
|
| Rate for Payer: Quartz Beloit One Network |
$268.03
|
| Rate for Payer: Quartz Commercial |
$355.55
|
| Rate for Payer: Quartz Medicare Advantage |
$328.20
|
| Rate for Payer: The Alliance Commercial |
$2,188.00
|
| Rate for Payer: WEA Trust Commercial |
$300.85
|
| Rate for Payer: WPS Commercial |
$405.16
|
|
|
FOLLOWER 12FR HEYMAN 021312
|
Facility
|
OP
|
$547.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974004
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$153.16 |
| Max. Negotiated Rate |
$2,188.00 |
| Rate for Payer: Aetna Commercial |
$492.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$470.42
|
| Rate for Payer: Aetna Managed Medicare |
$153.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$355.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$273.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$262.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.91
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$503.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$306.10
|
| Rate for Payer: Health EOS Commercial |
$486.83
|
| Rate for Payer: HFN Commercial |
$503.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$410.25
|
| Rate for Payer: Multiplan Commercial |
$437.60
|
| Rate for Payer: NAPHCARE Commercial |
$328.20
|
| Rate for Payer: Preferred Network Access Commercial |
$503.24
|
| Rate for Payer: Quartz Beloit One Network |
$268.03
|
| Rate for Payer: Quartz Commercial |
$355.55
|
| Rate for Payer: Quartz Medicare Advantage |
$328.20
|
| Rate for Payer: The Alliance Commercial |
$2,188.00
|
| Rate for Payer: WEA Trust Commercial |
$300.85
|
| Rate for Payer: WPS Commercial |
$405.16
|
|
|
FOLLOWER 12FR HEYMAN 021312
|
Facility
|
IP
|
$547.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974004
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$268.03 |
| Max. Negotiated Rate |
$503.24 |
| Rate for Payer: Aetna Commercial |
$492.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$470.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.91
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$503.24
|
| Rate for Payer: Health EOS Commercial |
$486.83
|
| Rate for Payer: HFN Commercial |
$503.24
|
| Rate for Payer: Multiplan Commercial |
$437.60
|
| Rate for Payer: NAPHCARE Commercial |
$328.20
|
| Rate for Payer: Preferred Network Access Commercial |
$503.24
|
| Rate for Payer: Quartz Beloit One Network |
$268.03
|
| Rate for Payer: Quartz Commercial |
$328.20
|
| Rate for Payer: WEA Trust Commercial |
$300.85
|
| Rate for Payer: WPS Commercial |
$405.16
|
|
|
FOLLOWER 14FR HEYMAN 021314
|
Facility
|
IP
|
$568.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974005
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$278.32 |
| Max. Negotiated Rate |
$522.56 |
| Rate for Payer: Aetna Commercial |
$511.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$488.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.04
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$522.56
|
| Rate for Payer: Health EOS Commercial |
$505.52
|
| Rate for Payer: HFN Commercial |
$522.56
|
| Rate for Payer: Multiplan Commercial |
$454.40
|
| Rate for Payer: NAPHCARE Commercial |
$340.80
|
| Rate for Payer: Preferred Network Access Commercial |
$522.56
|
| Rate for Payer: Quartz Beloit One Network |
$278.32
|
| Rate for Payer: Quartz Commercial |
$340.80
|
| Rate for Payer: WEA Trust Commercial |
$312.40
|
| Rate for Payer: WPS Commercial |
$420.72
|
|
|
FOLLOWER 14FR HEYMAN 021314
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974005
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$159.04 |
| Max. Negotiated Rate |
$2,272.00 |
| Rate for Payer: Aetna Commercial |
$511.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$488.48
|
| Rate for Payer: Aetna Managed Medicare |
$159.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$369.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$284.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.04
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Cigna Commercial |
$522.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$317.85
|
| Rate for Payer: Health EOS Commercial |
$505.52
|
| Rate for Payer: HFN Commercial |
$522.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$426.00
|
| Rate for Payer: Multiplan Commercial |
$454.40
|
| Rate for Payer: NAPHCARE Commercial |
$340.80
|
| Rate for Payer: Preferred Network Access Commercial |
$522.56
|
| Rate for Payer: Quartz Beloit One Network |
$278.32
|
| Rate for Payer: Quartz Commercial |
$369.20
|
| Rate for Payer: Quartz Medicare Advantage |
$340.80
|
| Rate for Payer: The Alliance Commercial |
$2,272.00
|
| Rate for Payer: WEA Trust Commercial |
$312.40
|
| Rate for Payer: WPS Commercial |
$420.72
|
|
|
FOLLOWER 16FR HEYMAN 021316
|
Facility
|
OP
|
$547.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$153.16 |
| Max. Negotiated Rate |
$2,188.00 |
| Rate for Payer: Aetna Commercial |
$492.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$470.42
|
| Rate for Payer: Aetna Managed Medicare |
$153.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$355.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$273.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$262.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.91
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$503.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$306.10
|
| Rate for Payer: Health EOS Commercial |
$486.83
|
| Rate for Payer: HFN Commercial |
$503.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$410.25
|
| Rate for Payer: Multiplan Commercial |
$437.60
|
| Rate for Payer: NAPHCARE Commercial |
$328.20
|
| Rate for Payer: Preferred Network Access Commercial |
$503.24
|
| Rate for Payer: Quartz Beloit One Network |
$268.03
|
| Rate for Payer: Quartz Commercial |
$355.55
|
| Rate for Payer: Quartz Medicare Advantage |
$328.20
|
| Rate for Payer: The Alliance Commercial |
$2,188.00
|
| Rate for Payer: WEA Trust Commercial |
$300.85
|
| Rate for Payer: WPS Commercial |
$405.16
|
|
|
FOLLOWER 16FR HEYMAN 021316
|
Facility
|
IP
|
$547.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$268.03 |
| Max. Negotiated Rate |
$503.24 |
| Rate for Payer: Aetna Commercial |
$492.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$470.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$289.91
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$503.24
|
| Rate for Payer: Health EOS Commercial |
$486.83
|
| Rate for Payer: HFN Commercial |
$503.24
|
| Rate for Payer: Multiplan Commercial |
$437.60
|
| Rate for Payer: NAPHCARE Commercial |
$328.20
|
| Rate for Payer: Preferred Network Access Commercial |
$503.24
|
| Rate for Payer: Quartz Beloit One Network |
$268.03
|
| Rate for Payer: Quartz Commercial |
$328.20
|
| Rate for Payer: WEA Trust Commercial |
$300.85
|
| Rate for Payer: WPS Commercial |
$405.16
|
|
|
FOLLOWER 18FR HEYMAN 021318
|
Facility
|
OP
|
$517.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$144.76 |
| Max. Negotiated Rate |
$2,068.00 |
| Rate for Payer: Aetna Commercial |
$465.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$444.62
|
| Rate for Payer: Aetna Managed Medicare |
$144.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$336.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$258.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$248.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$274.01
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cigna Commercial |
$475.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$289.31
|
| Rate for Payer: Health EOS Commercial |
$460.13
|
| Rate for Payer: HFN Commercial |
$475.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$387.75
|
| Rate for Payer: Multiplan Commercial |
$413.60
|
| Rate for Payer: NAPHCARE Commercial |
$310.20
|
| Rate for Payer: Preferred Network Access Commercial |
$475.64
|
| Rate for Payer: Quartz Beloit One Network |
$253.33
|
| Rate for Payer: Quartz Commercial |
$336.05
|
| Rate for Payer: Quartz Medicare Advantage |
$310.20
|
| Rate for Payer: The Alliance Commercial |
$2,068.00
|
| Rate for Payer: WEA Trust Commercial |
$284.35
|
| Rate for Payer: WPS Commercial |
$382.94
|
|
|
FOLLOWER 18FR HEYMAN 021318
|
Facility
|
IP
|
$517.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$253.33 |
| Max. Negotiated Rate |
$475.64 |
| Rate for Payer: Aetna Commercial |
$465.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$444.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$274.01
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cigna Commercial |
$475.64
|
| Rate for Payer: Health EOS Commercial |
$460.13
|
| Rate for Payer: HFN Commercial |
$475.64
|
| Rate for Payer: Multiplan Commercial |
$413.60
|
| Rate for Payer: NAPHCARE Commercial |
$310.20
|
| Rate for Payer: Preferred Network Access Commercial |
$475.64
|
| Rate for Payer: Quartz Beloit One Network |
$253.33
|
| Rate for Payer: Quartz Commercial |
$310.20
|
| Rate for Payer: WEA Trust Commercial |
$284.35
|
| Rate for Payer: WPS Commercial |
$382.94
|
|
|
FOLLOWER 20FR HEYMAN 021320
|
Facility
|
IP
|
$261.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974011
|
|
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
|
|
|
FOLLOWER 20FR HEYMAN 021320
|
Facility
|
OP
|
$261.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974011
|
|
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
|
|
|
FOLLOWER 22FR HEYMAN 021322
|
Facility
|
IP
|
$252.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$123.48 |
| Max. Negotiated Rate |
$231.84 |
| Rate for Payer: Aetna Commercial |
$226.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$216.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.56
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$231.84
|
| Rate for Payer: Health EOS Commercial |
$224.28
|
| Rate for Payer: HFN Commercial |
$231.84
|
| Rate for Payer: Multiplan Commercial |
$201.60
|
| Rate for Payer: NAPHCARE Commercial |
$151.20
|
| Rate for Payer: Preferred Network Access Commercial |
$231.84
|
| Rate for Payer: Quartz Beloit One Network |
$123.48
|
| Rate for Payer: Quartz Commercial |
$151.20
|
| Rate for Payer: WEA Trust Commercial |
$138.60
|
| Rate for Payer: WPS Commercial |
$186.66
|
|
|
FOLLOWER 22FR HEYMAN 021322
|
Facility
|
OP
|
$252.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$1,008.00 |
| Rate for Payer: Aetna Commercial |
$226.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$216.72
|
| Rate for Payer: Aetna Managed Medicare |
$70.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$163.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$126.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$120.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.56
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cigna Commercial |
$231.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.02
|
| Rate for Payer: Health EOS Commercial |
$224.28
|
| Rate for Payer: HFN Commercial |
$231.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.00
|
| Rate for Payer: Multiplan Commercial |
$201.60
|
| Rate for Payer: NAPHCARE Commercial |
$151.20
|
| Rate for Payer: Preferred Network Access Commercial |
$231.84
|
| Rate for Payer: Quartz Beloit One Network |
$123.48
|
| Rate for Payer: Quartz Commercial |
$163.80
|
| Rate for Payer: Quartz Medicare Advantage |
$151.20
|
| Rate for Payer: The Alliance Commercial |
$1,008.00
|
| Rate for Payer: WEA Trust Commercial |
$138.60
|
| Rate for Payer: WPS Commercial |
$186.66
|
|
|
FOLLOWER 24FR HEYMAN 021324
|
Facility
|
OP
|
$261.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974013
|
|
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
|
|
|
FOLLOWER 24FR HEYMAN 021324
|
Facility
|
IP
|
$261.00
|
|
|
Service Code
|
HCPCS A4351
|
| Hospital Charge Code |
2974013
|
|
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
|
|
|
FOLLOWUP EVAL OF FOOT PT LOP G0246
|
Professional
|
Both
|
$146.00
|
|
|
Service Code
|
HCPCS G0246
|
| Hospital Charge Code |
5381863
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$64.24 |
| Max. Negotiated Rate |
$138.70 |
| Rate for Payer: Aetna Commercial |
$138.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$138.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$73.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.60
|
| Rate for Payer: Health EOS Commercial |
$132.86
|
| Rate for Payer: HFN Commercial |
$138.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$70.07
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: Preferred Network Access Commercial |
$138.70
|
| Rate for Payer: Quartz Beloit One Network |
$64.24
|
| Rate for Payer: Quartz Commercial |
$83.22
|
| Rate for Payer: The Alliance Commercial |
$73.00
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
FOLOTYN 1 mg Charge
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
HCPCS J9307
|
| Hospital Charge Code |
2958951
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.23 |
| Max. Negotiated Rate |
$24.84 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$16.20
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
FOLOTYN 1 mg Charge
|
Professional
|
Both
|
$27.00
|
|
|
Service Code
|
HCPCS J9307
|
| Hospital Charge Code |
2958951
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$748.20 |
| Rate for Payer: Aetna Commercial |
$25.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$25.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$289.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$299.28
|
| Rate for Payer: Health EOS Commercial |
$24.57
|
| Rate for Payer: HFN Commercial |
$25.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$453.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$453.93
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: Preferred Network Access Commercial |
$25.65
|
| Rate for Payer: Quartz Beloit One Network |
$11.88
|
| Rate for Payer: Quartz Commercial |
$15.39
|
| Rate for Payer: The Alliance Commercial |
$13.50
|
| Rate for Payer: United Healthcare Medicaid |
$289.14
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$748.20
|
|
|
FOLOTYN 1 mg Charge
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
HCPCS J9307
|
| Hospital Charge Code |
2958951
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.96 |
| Max. Negotiated Rate |
$1,156.56 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Aetna Managed Medicare |
$289.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.96
|
| Rate for Payer: Anthem Medicare Advantage |
$289.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$289.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$289.14
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$289.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$395.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$289.14
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,075.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$289.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$289.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$289.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$289.14
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$433.71
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$17.55
|
| Rate for Payer: Quartz Medicare Advantage |
$289.14
|
| Rate for Payer: The Alliance Commercial |
$1,156.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$289.14
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: Wellcare Medicare |
$289.14
|
| Rate for Payer: WPS Commercial |
$748.20
|
|
|
FO nontorsion joint CF L3935
|
Professional
|
Both
|
$710.00
|
|
|
Service Code
|
HCPCS L3935
|
| Hospital Charge Code |
3206212
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$312.40 |
| Max. Negotiated Rate |
$712.42 |
| Rate for Payer: Aetna Commercial |
$674.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$610.60
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cigna Commercial |
$674.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$355.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$426.00
|
| Rate for Payer: Health EOS Commercial |
$646.10
|
| Rate for Payer: HFN Commercial |
$674.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$712.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$712.42
|
| Rate for Payer: Multiplan Commercial |
$568.00
|
| Rate for Payer: Preferred Network Access Commercial |
$674.50
|
| Rate for Payer: Quartz Beloit One Network |
$312.40
|
| Rate for Payer: Quartz Commercial |
$404.70
|
| Rate for Payer: The Alliance Commercial |
$355.00
|
| Rate for Payer: WEA Trust Commercial |
$390.50
|
| Rate for Payer: WPS Commercial |
$525.90
|
|
