|
FOOT SPLINT ANKLE LEFT
|
Facility
|
IP
|
$801.00
|
|
| Hospital Charge Code |
2971656
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$392.49 |
| Max. Negotiated Rate |
$736.92 |
| Rate for Payer: Aetna Commercial |
$720.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$688.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$424.53
|
| Rate for Payer: Cash Price |
$240.30
|
| Rate for Payer: Cigna Commercial |
$736.92
|
| Rate for Payer: Health EOS Commercial |
$712.89
|
| Rate for Payer: HFN Commercial |
$736.92
|
| Rate for Payer: Multiplan Commercial |
$640.80
|
| Rate for Payer: NAPHCARE Commercial |
$480.60
|
| Rate for Payer: Preferred Network Access Commercial |
$736.92
|
| Rate for Payer: Quartz Beloit One Network |
$392.49
|
| Rate for Payer: Quartz Commercial |
$480.60
|
| Rate for Payer: WEA Trust Commercial |
$440.55
|
| Rate for Payer: WPS Commercial |
$593.30
|
|
|
FOOT SPLINT ANKLE RIGHT
|
Facility
|
OP
|
$801.00
|
|
| Hospital Charge Code |
2971655
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$224.28 |
| Max. Negotiated Rate |
$3,204.00 |
| Rate for Payer: Aetna Commercial |
$720.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$688.86
|
| Rate for Payer: Aetna Managed Medicare |
$224.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$520.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$400.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$384.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$424.53
|
| Rate for Payer: Cash Price |
$240.30
|
| Rate for Payer: Cigna Commercial |
$736.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$448.24
|
| Rate for Payer: Health EOS Commercial |
$712.89
|
| Rate for Payer: HFN Commercial |
$736.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$600.75
|
| Rate for Payer: Multiplan Commercial |
$640.80
|
| Rate for Payer: NAPHCARE Commercial |
$480.60
|
| Rate for Payer: Preferred Network Access Commercial |
$736.92
|
| Rate for Payer: Quartz Beloit One Network |
$392.49
|
| Rate for Payer: Quartz Commercial |
$520.65
|
| Rate for Payer: Quartz Medicare Advantage |
$480.60
|
| Rate for Payer: The Alliance Commercial |
$3,204.00
|
| Rate for Payer: WEA Trust Commercial |
$440.55
|
| Rate for Payer: WPS Commercial |
$593.30
|
|
|
FOOT SPLINT ANKLE RIGHT
|
Facility
|
IP
|
$801.00
|
|
| Hospital Charge Code |
2971655
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$392.49 |
| Max. Negotiated Rate |
$736.92 |
| Rate for Payer: Aetna Commercial |
$720.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$688.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$424.53
|
| Rate for Payer: Cash Price |
$240.30
|
| Rate for Payer: Cigna Commercial |
$736.92
|
| Rate for Payer: Health EOS Commercial |
$712.89
|
| Rate for Payer: HFN Commercial |
$736.92
|
| Rate for Payer: Multiplan Commercial |
$640.80
|
| Rate for Payer: NAPHCARE Commercial |
$480.60
|
| Rate for Payer: Preferred Network Access Commercial |
$736.92
|
| Rate for Payer: Quartz Beloit One Network |
$392.49
|
| Rate for Payer: Quartz Commercial |
$480.60
|
| Rate for Payer: WEA Trust Commercial |
$440.55
|
| Rate for Payer: WPS Commercial |
$593.30
|
|
|
FOOT, TENDON & NERVE REPAIR
|
Facility
|
IP
|
$4,170.00
|
|
| Hospital Charge Code |
2960421
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,043.30 |
| Max. Negotiated Rate |
$3,836.40 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,502.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
FOOT, TENDON & NERVE REPAIR
|
Facility
|
OP
|
$4,170.00
|
|
| Hospital Charge Code |
2960421
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,167.60 |
| Max. Negotiated Rate |
$16,680.00 |
| Rate for Payer: Aetna Commercial |
$3,753.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,586.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,167.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,710.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,085.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,001.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,210.10
|
| Rate for Payer: Cash Price |
$1,251.00
|
| Rate for Payer: Cigna Commercial |
$3,836.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,333.53
|
| Rate for Payer: Health EOS Commercial |
$3,711.30
|
| Rate for Payer: HFN Commercial |
$3,836.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,127.50
|
| Rate for Payer: Multiplan Commercial |
$3,336.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,502.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,836.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,043.30
|
| Rate for Payer: Quartz Commercial |
$2,710.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,502.00
|
| Rate for Payer: The Alliance Commercial |
$16,680.00
|
| Rate for Payer: WEA Trust Commercial |
$2,293.50
|
| Rate for Payer: WPS Commercial |
$3,088.72
|
|
|
FORAMEN OVALE, REPAIR OF PATENT
|
Facility
|
IP
|
$15,894.00
|
|
| Hospital Charge Code |
2950337
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,788.06 |
| Max. Negotiated Rate |
$14,622.48 |
| Rate for Payer: Aetna Commercial |
$14,304.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,668.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,423.82
|
| Rate for Payer: Cash Price |
$4,768.20
|
| Rate for Payer: Cigna Commercial |
$14,622.48
|
| Rate for Payer: Health EOS Commercial |
$14,145.66
|
| Rate for Payer: HFN Commercial |
$14,622.48
|
| Rate for Payer: Multiplan Commercial |
$12,715.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,536.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,622.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,788.06
|
| Rate for Payer: Quartz Commercial |
$9,536.40
|
| Rate for Payer: WEA Trust Commercial |
$8,741.70
|
| Rate for Payer: WPS Commercial |
$11,772.69
|
|
|
FORAMEN OVALE, REPAIR OF PATENT
|
Facility
|
OP
|
$15,894.00
|
|
| Hospital Charge Code |
2950337
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,450.32 |
| Max. Negotiated Rate |
$63,576.00 |
| Rate for Payer: Aetna Commercial |
$14,304.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,668.84
|
| Rate for Payer: Aetna Managed Medicare |
$4,450.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,331.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,947.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,629.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,423.82
|
| Rate for Payer: Cash Price |
$4,768.20
|
| Rate for Payer: Cigna Commercial |
$14,622.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,894.28
|
| Rate for Payer: Health EOS Commercial |
$14,145.66
|
| Rate for Payer: HFN Commercial |
$14,622.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,920.50
|
| Rate for Payer: Multiplan Commercial |
$12,715.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,536.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,622.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,788.06
|
| Rate for Payer: Quartz Commercial |
$10,331.10
|
| Rate for Payer: Quartz Medicare Advantage |
$9,536.40
|
| Rate for Payer: The Alliance Commercial |
$63,576.00
|
| Rate for Payer: WEA Trust Commercial |
$8,741.70
|
| Rate for Payer: WPS Commercial |
$11,772.69
|
|
|
FORCEP 5 MOSQUTO CURV 106-102
|
Facility
|
IP
|
$1,020.00
|
|
| Hospital Charge Code |
2963651
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$499.80 |
| Max. Negotiated Rate |
$938.40 |
| Rate for Payer: Aetna Commercial |
$918.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$877.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$540.60
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cigna Commercial |
$938.40
|
| Rate for Payer: Health EOS Commercial |
$907.80
|
| Rate for Payer: HFN Commercial |
$938.40
|
| Rate for Payer: Multiplan Commercial |
$816.00
|
| Rate for Payer: NAPHCARE Commercial |
$612.00
|
| Rate for Payer: Preferred Network Access Commercial |
$938.40
|
| Rate for Payer: Quartz Beloit One Network |
$499.80
|
| Rate for Payer: Quartz Commercial |
$612.00
|
| Rate for Payer: WEA Trust Commercial |
$561.00
|
| Rate for Payer: WPS Commercial |
$755.51
|
|
|
FORCEP 5 MOSQUTO CURV 106-102
|
Facility
|
OP
|
$1,020.00
|
|
| Hospital Charge Code |
2963651
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$285.60 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$918.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$877.20
|
| Rate for Payer: Aetna Managed Medicare |
$285.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$663.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$510.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$489.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$540.60
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cigna Commercial |
$938.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$570.79
|
| Rate for Payer: Health EOS Commercial |
$907.80
|
| Rate for Payer: HFN Commercial |
$938.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$765.00
|
| Rate for Payer: Multiplan Commercial |
$816.00
|
| Rate for Payer: NAPHCARE Commercial |
$612.00
|
| Rate for Payer: Preferred Network Access Commercial |
$938.40
|
| Rate for Payer: Quartz Beloit One Network |
$499.80
|
| Rate for Payer: Quartz Commercial |
$663.00
|
| Rate for Payer: Quartz Medicare Advantage |
$612.00
|
| Rate for Payer: The Alliance Commercial |
$4,080.00
|
| Rate for Payer: WEA Trust Commercial |
$561.00
|
| Rate for Payer: WPS Commercial |
$755.51
|
|
|
FORCEP BIOPSY DISP ALLIGATOR
|
Facility
|
OP
|
$1,245.00
|
|
| Hospital Charge Code |
2973776
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$348.60 |
| Max. Negotiated Rate |
$4,980.00 |
| Rate for Payer: Aetna Commercial |
$1,120.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,070.70
|
| Rate for Payer: Aetna Managed Medicare |
$348.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$809.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$622.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$597.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$659.85
|
| Rate for Payer: Cash Price |
$373.50
|
| Rate for Payer: Cigna Commercial |
$1,145.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$696.70
|
| Rate for Payer: Health EOS Commercial |
$1,108.05
|
| Rate for Payer: HFN Commercial |
$1,145.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$933.75
|
| Rate for Payer: Multiplan Commercial |
$996.00
|
| Rate for Payer: NAPHCARE Commercial |
$747.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,145.40
|
| Rate for Payer: Quartz Beloit One Network |
$610.05
|
| Rate for Payer: Quartz Commercial |
$809.25
|
| Rate for Payer: Quartz Medicare Advantage |
$747.00
|
| Rate for Payer: The Alliance Commercial |
$4,980.00
|
| Rate for Payer: WEA Trust Commercial |
$684.75
|
| Rate for Payer: WPS Commercial |
$922.17
|
|
|
FORCEP BIOPSY DISP ALLIGATOR
|
Facility
|
IP
|
$1,245.00
|
|
| Hospital Charge Code |
2973776
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$610.05 |
| Max. Negotiated Rate |
$1,145.40 |
| Rate for Payer: Aetna Commercial |
$1,120.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,070.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$659.85
|
| Rate for Payer: Cash Price |
$373.50
|
| Rate for Payer: Cigna Commercial |
$1,145.40
|
| Rate for Payer: Health EOS Commercial |
$1,108.05
|
| Rate for Payer: HFN Commercial |
$1,145.40
|
| Rate for Payer: Multiplan Commercial |
$996.00
|
| Rate for Payer: NAPHCARE Commercial |
$747.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,145.40
|
| Rate for Payer: Quartz Beloit One Network |
$610.05
|
| Rate for Payer: Quartz Commercial |
$747.00
|
| Rate for Payer: WEA Trust Commercial |
$684.75
|
| Rate for Payer: WPS Commercial |
$922.17
|
|
|
FORCEP GRASPING 2.5FR 115CM G16702
|
Facility
|
OP
|
$1,635.00
|
|
| Hospital Charge Code |
2965864
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$457.80 |
| Max. Negotiated Rate |
$6,540.00 |
| Rate for Payer: Aetna Commercial |
$1,471.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,406.10
|
| Rate for Payer: Aetna Managed Medicare |
$457.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,062.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$817.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$784.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$866.55
|
| Rate for Payer: Cash Price |
$490.50
|
| Rate for Payer: Cigna Commercial |
$1,504.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$914.95
|
| Rate for Payer: Health EOS Commercial |
$1,455.15
|
| Rate for Payer: HFN Commercial |
$1,504.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,226.25
|
| Rate for Payer: Multiplan Commercial |
$1,308.00
|
| Rate for Payer: NAPHCARE Commercial |
$981.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,504.20
|
| Rate for Payer: Quartz Beloit One Network |
$801.15
|
| Rate for Payer: Quartz Commercial |
$1,062.75
|
| Rate for Payer: Quartz Medicare Advantage |
$981.00
|
| Rate for Payer: The Alliance Commercial |
$6,540.00
|
| Rate for Payer: WEA Trust Commercial |
$899.25
|
| Rate for Payer: WPS Commercial |
$1,211.04
|
|
|
FORCEP GRASPING 2.5FR 115CM G16702
|
Facility
|
IP
|
$1,635.00
|
|
| Hospital Charge Code |
2965864
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$801.15 |
| Max. Negotiated Rate |
$1,504.20 |
| Rate for Payer: Aetna Commercial |
$1,471.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,406.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$866.55
|
| Rate for Payer: Cash Price |
$490.50
|
| Rate for Payer: Cigna Commercial |
$1,504.20
|
| Rate for Payer: Health EOS Commercial |
$1,455.15
|
| Rate for Payer: HFN Commercial |
$1,504.20
|
| Rate for Payer: Multiplan Commercial |
$1,308.00
|
| Rate for Payer: NAPHCARE Commercial |
$981.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,504.20
|
| Rate for Payer: Quartz Beloit One Network |
$801.15
|
| Rate for Payer: Quartz Commercial |
$981.00
|
| Rate for Payer: WEA Trust Commercial |
$899.25
|
| Rate for Payer: WPS Commercial |
$1,211.04
|
|
|
FORCEP GRASPING DISP FG-52D
|
Facility
|
OP
|
$3,369.00
|
|
| Hospital Charge Code |
2973362
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$943.32 |
| Max. Negotiated Rate |
$13,476.00 |
| Rate for Payer: Aetna Commercial |
$3,032.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,897.34
|
| Rate for Payer: Aetna Managed Medicare |
$943.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,189.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,684.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,617.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,785.57
|
| Rate for Payer: Cash Price |
$1,010.70
|
| Rate for Payer: Cigna Commercial |
$3,099.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,885.29
|
| Rate for Payer: Health EOS Commercial |
$2,998.41
|
| Rate for Payer: HFN Commercial |
$3,099.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,526.75
|
| Rate for Payer: Multiplan Commercial |
$2,695.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,021.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,099.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,650.81
|
| Rate for Payer: Quartz Commercial |
$2,189.85
|
| Rate for Payer: Quartz Medicare Advantage |
$2,021.40
|
| Rate for Payer: The Alliance Commercial |
$13,476.00
|
| Rate for Payer: WEA Trust Commercial |
$1,852.95
|
| Rate for Payer: WPS Commercial |
$2,495.42
|
|
|
FORCEP GRASPING DISP FG-52D
|
Facility
|
IP
|
$3,369.00
|
|
| Hospital Charge Code |
2973362
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,650.81 |
| Max. Negotiated Rate |
$3,099.48 |
| Rate for Payer: Aetna Commercial |
$3,032.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,897.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,785.57
|
| Rate for Payer: Cash Price |
$1,010.70
|
| Rate for Payer: Cigna Commercial |
$3,099.48
|
| Rate for Payer: Health EOS Commercial |
$2,998.41
|
| Rate for Payer: HFN Commercial |
$3,099.48
|
| Rate for Payer: Multiplan Commercial |
$2,695.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,021.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,099.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,650.81
|
| Rate for Payer: Quartz Commercial |
$2,021.40
|
| Rate for Payer: WEA Trust Commercial |
$1,852.95
|
| Rate for Payer: WPS Commercial |
$2,495.42
|
|
|
FORCEP GRASPING DISP FG-54D
|
Facility
|
OP
|
$3,589.00
|
|
| Hospital Charge Code |
2973405
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,004.92 |
| Max. Negotiated Rate |
$14,356.00 |
| Rate for Payer: Aetna Commercial |
$3,230.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,086.54
|
| Rate for Payer: Aetna Managed Medicare |
$1,004.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,332.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,794.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,722.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,902.17
|
| Rate for Payer: Cash Price |
$1,076.70
|
| Rate for Payer: Cigna Commercial |
$3,301.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,008.40
|
| Rate for Payer: Health EOS Commercial |
$3,194.21
|
| Rate for Payer: HFN Commercial |
$3,301.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,691.75
|
| Rate for Payer: Multiplan Commercial |
$2,871.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,153.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,301.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,758.61
|
| Rate for Payer: Quartz Commercial |
$2,332.85
|
| Rate for Payer: Quartz Medicare Advantage |
$2,153.40
|
| Rate for Payer: The Alliance Commercial |
$14,356.00
|
| Rate for Payer: WEA Trust Commercial |
$1,973.95
|
| Rate for Payer: WPS Commercial |
$2,658.37
|
|
|
FORCEP GRASPING DISP FG-54D
|
Facility
|
IP
|
$3,589.00
|
|
| Hospital Charge Code |
2973405
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,758.61 |
| Max. Negotiated Rate |
$3,301.88 |
| Rate for Payer: Aetna Commercial |
$3,230.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,086.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,902.17
|
| Rate for Payer: Cash Price |
$1,076.70
|
| Rate for Payer: Cigna Commercial |
$3,301.88
|
| Rate for Payer: Health EOS Commercial |
$3,194.21
|
| Rate for Payer: HFN Commercial |
$3,301.88
|
| Rate for Payer: Multiplan Commercial |
$2,871.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,153.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,301.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,758.61
|
| Rate for Payer: Quartz Commercial |
$2,153.40
|
| Rate for Payer: WEA Trust Commercial |
$1,973.95
|
| Rate for Payer: WPS Commercial |
$2,658.37
|
|
|
FORCEPS BIOPSY DISPOSABLE
|
Facility
|
IP
|
$53.00
|
|
| Hospital Charge Code |
2973654
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.97 |
| Max. Negotiated Rate |
$48.76 |
| Rate for Payer: Aetna Commercial |
$47.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.09
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$48.76
|
| Rate for Payer: Health EOS Commercial |
$47.17
|
| Rate for Payer: HFN Commercial |
$48.76
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: NAPHCARE Commercial |
$31.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.76
|
| Rate for Payer: Quartz Beloit One Network |
$25.97
|
| Rate for Payer: Quartz Commercial |
$31.80
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$39.26
|
|
|
FORCEPS BIOPSY DISPOSABLE
|
Facility
|
OP
|
$53.00
|
|
| Hospital Charge Code |
2973654
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$212.00 |
| Rate for Payer: Aetna Commercial |
$47.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Aetna Managed Medicare |
$14.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.09
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$48.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.66
|
| Rate for Payer: Health EOS Commercial |
$47.17
|
| Rate for Payer: HFN Commercial |
$48.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.75
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: NAPHCARE Commercial |
$31.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.76
|
| Rate for Payer: Quartz Beloit One Network |
$25.97
|
| Rate for Payer: Quartz Commercial |
$34.45
|
| Rate for Payer: Quartz Medicare Advantage |
$31.80
|
| Rate for Payer: The Alliance Commercial |
$212.00
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$39.26
|
|
|
FORCEP SHARK TOOTH CYSTOSCOPY DISP SINGLE USE FG-253SX
|
Facility
|
IP
|
$951.00
|
|
| Hospital Charge Code |
6178114
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$465.99 |
| Max. Negotiated Rate |
$874.92 |
| Rate for Payer: Aetna Commercial |
$855.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$817.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.03
|
| Rate for Payer: Cash Price |
$285.30
|
| Rate for Payer: Cigna Commercial |
$874.92
|
| Rate for Payer: Health EOS Commercial |
$846.39
|
| Rate for Payer: HFN Commercial |
$874.92
|
| Rate for Payer: Multiplan Commercial |
$760.80
|
| Rate for Payer: NAPHCARE Commercial |
$570.60
|
| Rate for Payer: Preferred Network Access Commercial |
$874.92
|
| Rate for Payer: Quartz Beloit One Network |
$465.99
|
| Rate for Payer: Quartz Commercial |
$570.60
|
| Rate for Payer: WEA Trust Commercial |
$523.05
|
| Rate for Payer: WPS Commercial |
$704.41
|
|
|
FORCEP SHARK TOOTH CYSTOSCOPY DISP SINGLE USE FG-253SX
|
Facility
|
OP
|
$951.00
|
|
| Hospital Charge Code |
6178114
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.28 |
| Max. Negotiated Rate |
$3,804.00 |
| Rate for Payer: Aetna Commercial |
$855.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$817.86
|
| Rate for Payer: Aetna Managed Medicare |
$266.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$618.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$475.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$456.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.03
|
| Rate for Payer: Cash Price |
$285.30
|
| Rate for Payer: Cigna Commercial |
$874.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$532.18
|
| Rate for Payer: Health EOS Commercial |
$846.39
|
| Rate for Payer: HFN Commercial |
$874.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$713.25
|
| Rate for Payer: Multiplan Commercial |
$760.80
|
| Rate for Payer: NAPHCARE Commercial |
$570.60
|
| Rate for Payer: Preferred Network Access Commercial |
$874.92
|
| Rate for Payer: Quartz Beloit One Network |
$465.99
|
| Rate for Payer: Quartz Commercial |
$618.15
|
| Rate for Payer: Quartz Medicare Advantage |
$570.60
|
| Rate for Payer: The Alliance Commercial |
$3,804.00
|
| Rate for Payer: WEA Trust Commercial |
$523.05
|
| Rate for Payer: WPS Commercial |
$704.41
|
|
|
Forceps - Individual Charges
|
Facility
|
OP
|
$641.00
|
|
| Hospital Charge Code |
3003919
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$179.48 |
| Max. Negotiated Rate |
$2,564.00 |
| Rate for Payer: Aetna Commercial |
$576.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$551.26
|
| Rate for Payer: Aetna Managed Medicare |
$179.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$416.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$320.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$307.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$339.73
|
| Rate for Payer: Cash Price |
$192.30
|
| Rate for Payer: Cigna Commercial |
$589.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$358.70
|
| Rate for Payer: Health EOS Commercial |
$570.49
|
| Rate for Payer: HFN Commercial |
$589.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$480.75
|
| Rate for Payer: Multiplan Commercial |
$512.80
|
| Rate for Payer: NAPHCARE Commercial |
$384.60
|
| Rate for Payer: Preferred Network Access Commercial |
$589.72
|
| Rate for Payer: Quartz Beloit One Network |
$314.09
|
| Rate for Payer: Quartz Commercial |
$416.65
|
| Rate for Payer: Quartz Medicare Advantage |
$384.60
|
| Rate for Payer: The Alliance Commercial |
$2,564.00
|
| Rate for Payer: United Healthcare PPO |
$480.75
|
| Rate for Payer: WEA Trust Commercial |
$352.55
|
| Rate for Payer: WPS Commercial |
$474.79
|
|
|
Forceps - Individual Charges
|
Facility
|
IP
|
$641.00
|
|
| Hospital Charge Code |
3003919
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$314.09 |
| Max. Negotiated Rate |
$589.72 |
| Rate for Payer: Aetna Commercial |
$576.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$551.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$339.73
|
| Rate for Payer: Cash Price |
$192.30
|
| Rate for Payer: Cigna Commercial |
$589.72
|
| Rate for Payer: Health EOS Commercial |
$570.49
|
| Rate for Payer: HFN Commercial |
$589.72
|
| Rate for Payer: Multiplan Commercial |
$512.80
|
| Rate for Payer: NAPHCARE Commercial |
$384.60
|
| Rate for Payer: Preferred Network Access Commercial |
$589.72
|
| Rate for Payer: Quartz Beloit One Network |
$314.09
|
| Rate for Payer: Quartz Commercial |
$384.60
|
| Rate for Payer: WEA Trust Commercial |
$352.55
|
| Rate for Payer: WPS Commercial |
$474.79
|
|
|
FORCEP TRIPOD GRASPING 230cm
|
Facility
|
OP
|
$5,491.00
|
|
| Hospital Charge Code |
2973590
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,537.48 |
| Max. Negotiated Rate |
$21,964.00 |
| Rate for Payer: Aetna Commercial |
$4,941.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,722.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,537.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,569.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,745.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,635.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,910.23
|
| Rate for Payer: Cash Price |
$1,647.30
|
| Rate for Payer: Cigna Commercial |
$5,051.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,072.76
|
| Rate for Payer: Health EOS Commercial |
$4,886.99
|
| Rate for Payer: HFN Commercial |
$5,051.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,118.25
|
| Rate for Payer: Multiplan Commercial |
$4,392.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,294.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,051.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,690.59
|
| Rate for Payer: Quartz Commercial |
$3,569.15
|
| Rate for Payer: Quartz Medicare Advantage |
$3,294.60
|
| Rate for Payer: The Alliance Commercial |
$21,964.00
|
| Rate for Payer: WEA Trust Commercial |
$3,020.05
|
| Rate for Payer: WPS Commercial |
$4,067.18
|
|
|
FORCEP TRIPOD GRASPING 230cm
|
Facility
|
IP
|
$5,491.00
|
|
| Hospital Charge Code |
2973590
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,690.59 |
| Max. Negotiated Rate |
$5,051.72 |
| Rate for Payer: Aetna Commercial |
$4,941.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,722.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,910.23
|
| Rate for Payer: Cash Price |
$1,647.30
|
| Rate for Payer: Cigna Commercial |
$5,051.72
|
| Rate for Payer: Health EOS Commercial |
$4,886.99
|
| Rate for Payer: HFN Commercial |
$5,051.72
|
| Rate for Payer: Multiplan Commercial |
$4,392.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,294.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,051.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,690.59
|
| Rate for Payer: Quartz Commercial |
$3,294.60
|
| Rate for Payer: WEA Trust Commercial |
$3,020.05
|
| Rate for Payer: WPS Commercial |
$4,067.18
|
|
