|
Gelatein Plus
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
3031435
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Aetna Managed Medicare |
$1.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.36
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3.60
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
Gelatein Plus
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
3031435
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$5.52 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.60
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
Gelfilm Ophthalmic [Med]
|
Facility
|
IP
|
$935.00
|
|
| Hospital Charge Code |
2974939
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$458.15 |
| Max. Negotiated Rate |
$860.20 |
| Rate for Payer: Aetna Commercial |
$841.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$804.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$495.55
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$860.20
|
| Rate for Payer: Health EOS Commercial |
$832.15
|
| Rate for Payer: HFN Commercial |
$860.20
|
| Rate for Payer: Multiplan Commercial |
$748.00
|
| Rate for Payer: NAPHCARE Commercial |
$561.00
|
| Rate for Payer: Preferred Network Access Commercial |
$860.20
|
| Rate for Payer: Quartz Beloit One Network |
$458.15
|
| Rate for Payer: Quartz Commercial |
$561.00
|
| Rate for Payer: WEA Trust Commercial |
$514.25
|
| Rate for Payer: WPS Commercial |
$692.55
|
|
|
Gelfilm Ophthalmic [Med]
|
Facility
|
OP
|
$935.00
|
|
| Hospital Charge Code |
2974939
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$261.80 |
| Max. Negotiated Rate |
$3,740.00 |
| Rate for Payer: Aetna Commercial |
$841.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$804.10
|
| Rate for Payer: Aetna Managed Medicare |
$261.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$607.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$467.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$448.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$495.55
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$860.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$523.23
|
| Rate for Payer: Health EOS Commercial |
$832.15
|
| Rate for Payer: HFN Commercial |
$860.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$701.25
|
| Rate for Payer: Multiplan Commercial |
$748.00
|
| Rate for Payer: NAPHCARE Commercial |
$561.00
|
| Rate for Payer: Preferred Network Access Commercial |
$860.20
|
| Rate for Payer: Quartz Beloit One Network |
$458.15
|
| Rate for Payer: Quartz Commercial |
$607.75
|
| Rate for Payer: Quartz Medicare Advantage |
$561.00
|
| Rate for Payer: The Alliance Commercial |
$3,740.00
|
| Rate for Payer: WEA Trust Commercial |
$514.25
|
| Rate for Payer: WPS Commercial |
$692.55
|
|
|
Gelfoam size 100 [Med]
|
Facility
|
IP
|
$144.00
|
|
| Hospital Charge Code |
2974940
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$132.48 |
| Rate for Payer: Aetna Commercial |
$129.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.32
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$132.48
|
| Rate for Payer: Health EOS Commercial |
$128.16
|
| Rate for Payer: HFN Commercial |
$132.48
|
| Rate for Payer: Multiplan Commercial |
$115.20
|
| Rate for Payer: NAPHCARE Commercial |
$86.40
|
| Rate for Payer: Preferred Network Access Commercial |
$132.48
|
| Rate for Payer: Quartz Beloit One Network |
$70.56
|
| Rate for Payer: Quartz Commercial |
$86.40
|
| Rate for Payer: WEA Trust Commercial |
$79.20
|
| Rate for Payer: WPS Commercial |
$106.66
|
|
|
Gelfoam size 100 [Med]
|
Facility
|
OP
|
$144.00
|
|
| Hospital Charge Code |
2974940
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.32 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$129.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.84
|
| Rate for Payer: Aetna Managed Medicare |
$40.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$72.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$69.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.32
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$132.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.58
|
| Rate for Payer: Health EOS Commercial |
$128.16
|
| Rate for Payer: HFN Commercial |
$132.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.00
|
| Rate for Payer: Multiplan Commercial |
$115.20
|
| Rate for Payer: NAPHCARE Commercial |
$86.40
|
| Rate for Payer: Preferred Network Access Commercial |
$132.48
|
| Rate for Payer: Quartz Beloit One Network |
$70.56
|
| Rate for Payer: Quartz Commercial |
$93.60
|
| Rate for Payer: Quartz Medicare Advantage |
$86.40
|
| Rate for Payer: The Alliance Commercial |
$576.00
|
| Rate for Payer: WEA Trust Commercial |
$79.20
|
| Rate for Payer: WPS Commercial |
$106.66
|
|
|
Gel-One Hyaluronate J7326
|
Professional
|
Both
|
$2,050.00
|
|
|
Service Code
|
HCPCS J7326
|
| Hospital Charge Code |
3397518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$497.29 |
| Max. Negotiated Rate |
$1,947.50 |
| Rate for Payer: Aetna Commercial |
$1,947.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,763.00
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cigna Commercial |
$1,947.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$497.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$522.37
|
| Rate for Payer: Health EOS Commercial |
$1,865.50
|
| Rate for Payer: HFN Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$784.55
|
| Rate for Payer: Multiplan Commercial |
$1,640.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,947.50
|
| Rate for Payer: Quartz Beloit One Network |
$902.00
|
| Rate for Payer: Quartz Commercial |
$1,168.50
|
| Rate for Payer: The Alliance Commercial |
$1,025.00
|
| Rate for Payer: United Healthcare Medicaid |
$497.29
|
| Rate for Payer: WEA Trust Commercial |
$1,127.50
|
| Rate for Payer: WPS Commercial |
$1,305.93
|
|
|
Gel-One Hyaluronate J7326
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS J7326
|
| Hospital Charge Code |
3397518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$497.29 |
| Max. Negotiated Rate |
$1,989.16 |
| Rate for Payer: Aetna Commercial |
$1,845.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,763.00
|
| Rate for Payer: Aetna Managed Medicare |
$497.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,332.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,025.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$984.00
|
| Rate for Payer: Anthem Medicare Advantage |
$497.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,086.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$497.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$497.29
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cigna Commercial |
$1,886.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$497.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$691.10
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$497.29
|
| Rate for Payer: Health EOS Commercial |
$1,824.50
|
| Rate for Payer: HFN Commercial |
$1,886.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,849.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$497.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$497.29
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$497.29
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$497.29
|
| Rate for Payer: Multiplan Commercial |
$1,640.00
|
| Rate for Payer: NAPHCARE Commercial |
$745.93
|
| Rate for Payer: Preferred Network Access Commercial |
$1,886.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,004.50
|
| Rate for Payer: Quartz Commercial |
$1,332.50
|
| Rate for Payer: Quartz Medicare Advantage |
$497.29
|
| Rate for Payer: The Alliance Commercial |
$1,989.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$497.29
|
| Rate for Payer: WEA Trust Commercial |
$1,127.50
|
| Rate for Payer: Wellcare Medicare |
$497.29
|
| Rate for Payer: WPS Commercial |
$1,305.93
|
|
|
Gel-One Hyaluronate J7326
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS J7326
|
| Hospital Charge Code |
3397518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,004.50 |
| Max. Negotiated Rate |
$1,886.00 |
| Rate for Payer: Aetna Commercial |
$1,845.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,763.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,086.50
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cigna Commercial |
$1,886.00
|
| Rate for Payer: Health EOS Commercial |
$1,824.50
|
| Rate for Payer: HFN Commercial |
$1,886.00
|
| Rate for Payer: Multiplan Commercial |
$1,640.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,230.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,886.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,004.50
|
| Rate for Payer: Quartz Commercial |
$1,230.00
|
| Rate for Payer: WEA Trust Commercial |
$1,127.50
|
| Rate for Payer: WPS Commercial |
$1,518.44
|
|
|
GEL PORT 120MM C8XX2
|
Facility
|
IP
|
$4,906.00
|
|
| Hospital Charge Code |
2964653
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,403.94 |
| Max. Negotiated Rate |
$4,513.52 |
| Rate for Payer: Aetna Commercial |
$4,415.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,219.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,600.18
|
| Rate for Payer: Cash Price |
$1,471.80
|
| Rate for Payer: Cigna Commercial |
$4,513.52
|
| Rate for Payer: Health EOS Commercial |
$4,366.34
|
| Rate for Payer: HFN Commercial |
$4,513.52
|
| Rate for Payer: Multiplan Commercial |
$3,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,943.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,513.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,403.94
|
| Rate for Payer: Quartz Commercial |
$2,943.60
|
| Rate for Payer: WEA Trust Commercial |
$2,698.30
|
| Rate for Payer: WPS Commercial |
$3,633.87
|
|
|
GEL PORT 120MM C8XX2
|
Facility
|
OP
|
$4,906.00
|
|
| Hospital Charge Code |
2964653
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,373.68 |
| Max. Negotiated Rate |
$19,624.00 |
| Rate for Payer: Aetna Commercial |
$4,415.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,219.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,373.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,188.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,453.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,354.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,600.18
|
| Rate for Payer: Cash Price |
$1,471.80
|
| Rate for Payer: Cigna Commercial |
$4,513.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,745.40
|
| Rate for Payer: Health EOS Commercial |
$4,366.34
|
| Rate for Payer: HFN Commercial |
$4,513.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,679.50
|
| Rate for Payer: Multiplan Commercial |
$3,924.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,943.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,513.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,403.94
|
| Rate for Payer: Quartz Commercial |
$3,188.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,943.60
|
| Rate for Payer: The Alliance Commercial |
$19,624.00
|
| Rate for Payer: WEA Trust Commercial |
$2,698.30
|
| Rate for Payer: WPS Commercial |
$3,633.87
|
|
|
Gemzar 200 mg Charge
|
Professional
|
Both
|
$678.00
|
|
|
Service Code
|
HCPCS J9201
|
| Hospital Charge Code |
2958963
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$644.10 |
| Rate for Payer: Aetna Commercial |
$644.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$583.08
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$644.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.65
|
| Rate for Payer: Health EOS Commercial |
$616.98
|
| Rate for Payer: HFN Commercial |
$644.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.04
|
| Rate for Payer: Multiplan Commercial |
$542.40
|
| Rate for Payer: Preferred Network Access Commercial |
$644.10
|
| Rate for Payer: Quartz Beloit One Network |
$298.32
|
| Rate for Payer: Quartz Commercial |
$386.46
|
| Rate for Payer: The Alliance Commercial |
$339.00
|
| Rate for Payer: United Healthcare Medicaid |
$3.65
|
| Rate for Payer: WEA Trust Commercial |
$372.90
|
| Rate for Payer: WPS Commercial |
$9.14
|
|
|
Gemzar 200 mg Charge
|
Facility
|
IP
|
$678.00
|
|
|
Service Code
|
HCPCS J9201
|
| Hospital Charge Code |
2958963
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$332.22 |
| Max. Negotiated Rate |
$623.76 |
| Rate for Payer: Aetna Commercial |
$610.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$583.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$359.34
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$623.76
|
| Rate for Payer: Health EOS Commercial |
$603.42
|
| Rate for Payer: HFN Commercial |
$623.76
|
| Rate for Payer: Multiplan Commercial |
$542.40
|
| Rate for Payer: NAPHCARE Commercial |
$406.80
|
| Rate for Payer: Preferred Network Access Commercial |
$623.76
|
| Rate for Payer: Quartz Beloit One Network |
$332.22
|
| Rate for Payer: Quartz Commercial |
$406.80
|
| Rate for Payer: WEA Trust Commercial |
$372.90
|
| Rate for Payer: WPS Commercial |
$502.19
|
|
|
Gemzar 200 mg Charge
|
Facility
|
OP
|
$678.00
|
|
|
Service Code
|
HCPCS J9201
|
| Hospital Charge Code |
2958963
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.83 |
| Max. Negotiated Rate |
$2,712.00 |
| Rate for Payer: Aetna Commercial |
$610.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$583.08
|
| Rate for Payer: Aetna Managed Medicare |
$189.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$440.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$339.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$325.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$359.34
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$623.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.83
|
| Rate for Payer: Health EOS Commercial |
$603.42
|
| Rate for Payer: HFN Commercial |
$623.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$508.50
|
| Rate for Payer: Multiplan Commercial |
$542.40
|
| Rate for Payer: NAPHCARE Commercial |
$406.80
|
| Rate for Payer: Preferred Network Access Commercial |
$623.76
|
| Rate for Payer: Quartz Beloit One Network |
$332.22
|
| Rate for Payer: Quartz Commercial |
$440.70
|
| Rate for Payer: Quartz Medicare Advantage |
$406.80
|
| Rate for Payer: The Alliance Commercial |
$2,712.00
|
| Rate for Payer: WEA Trust Commercial |
$372.90
|
| Rate for Payer: WPS Commercial |
$9.14
|
|
|
GENERAL ANES - SET-UP CHARGE
|
Facility
|
OP
|
$1,737.00
|
|
| Hospital Charge Code |
4519587
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$486.36 |
| Max. Negotiated Rate |
$6,948.00 |
| Rate for Payer: Aetna Commercial |
$1,563.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,493.82
|
| Rate for Payer: Aetna Managed Medicare |
$486.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,129.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$868.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$833.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$920.61
|
| Rate for Payer: Cash Price |
$521.10
|
| Rate for Payer: Cigna Commercial |
$1,598.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$972.03
|
| Rate for Payer: Health EOS Commercial |
$1,545.93
|
| Rate for Payer: HFN Commercial |
$1,598.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,302.75
|
| Rate for Payer: Multiplan Commercial |
$1,389.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.04
|
| Rate for Payer: Quartz Beloit One Network |
$851.13
|
| Rate for Payer: Quartz Commercial |
$1,129.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,042.20
|
| Rate for Payer: The Alliance Commercial |
$6,948.00
|
| Rate for Payer: WEA Trust Commercial |
$955.35
|
| Rate for Payer: WPS Commercial |
$1,286.60
|
|
|
GENERAL ANES - SET-UP CHARGE
|
Facility
|
IP
|
$1,737.00
|
|
| Hospital Charge Code |
4519587
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$851.13 |
| Max. Negotiated Rate |
$1,598.04 |
| Rate for Payer: Aetna Commercial |
$1,563.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,493.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$920.61
|
| Rate for Payer: Cash Price |
$521.10
|
| Rate for Payer: Cigna Commercial |
$1,598.04
|
| Rate for Payer: Health EOS Commercial |
$1,545.93
|
| Rate for Payer: HFN Commercial |
$1,598.04
|
| Rate for Payer: Multiplan Commercial |
$1,389.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.04
|
| Rate for Payer: Quartz Beloit One Network |
$851.13
|
| Rate for Payer: Quartz Commercial |
$1,042.20
|
| Rate for Payer: WEA Trust Commercial |
$955.35
|
| Rate for Payer: WPS Commercial |
$1,286.60
|
|
|
General Health Panel
|
Professional
|
Both
|
$558.00
|
|
|
Service Code
|
CPT 80050
|
| Hospital Charge Code |
3473518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$150.84 |
| Max. Negotiated Rate |
$530.10 |
| Rate for Payer: Aetna Commercial |
$530.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.88
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$530.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$279.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$334.80
|
| Rate for Payer: Health EOS Commercial |
$507.78
|
| Rate for Payer: HFN Commercial |
$530.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$150.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$150.84
|
| Rate for Payer: Multiplan Commercial |
$446.40
|
| Rate for Payer: Preferred Network Access Commercial |
$530.10
|
| Rate for Payer: Quartz Beloit One Network |
$245.52
|
| Rate for Payer: Quartz Commercial |
$318.06
|
| Rate for Payer: The Alliance Commercial |
$279.00
|
| Rate for Payer: WEA Trust Commercial |
$306.90
|
| Rate for Payer: WPS Commercial |
$413.31
|
|
|
General Health Panel
|
Facility
|
OP
|
$558.00
|
|
|
Service Code
|
CPT 80050
|
| Hospital Charge Code |
3473518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$156.24 |
| Max. Negotiated Rate |
$2,232.00 |
| Rate for Payer: Aetna Commercial |
$502.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.88
|
| Rate for Payer: Aetna Managed Medicare |
$156.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$279.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$267.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.74
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$513.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$312.26
|
| Rate for Payer: Health EOS Commercial |
$496.62
|
| Rate for Payer: HFN Commercial |
$513.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$418.50
|
| Rate for Payer: Multiplan Commercial |
$446.40
|
| Rate for Payer: NAPHCARE Commercial |
$334.80
|
| Rate for Payer: Preferred Network Access Commercial |
$513.36
|
| Rate for Payer: Quartz Beloit One Network |
$273.42
|
| Rate for Payer: Quartz Commercial |
$362.70
|
| Rate for Payer: Quartz Medicare Advantage |
$334.80
|
| Rate for Payer: The Alliance Commercial |
$2,232.00
|
| Rate for Payer: United Healthcare PPO |
$418.50
|
| Rate for Payer: WEA Trust Commercial |
$306.90
|
| Rate for Payer: WPS Commercial |
$413.31
|
|
|
General Health Panel
|
Facility
|
IP
|
$558.00
|
|
|
Service Code
|
CPT 80050
|
| Hospital Charge Code |
3473518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$273.42 |
| Max. Negotiated Rate |
$513.36 |
| Rate for Payer: Aetna Commercial |
$502.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.74
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$513.36
|
| Rate for Payer: Health EOS Commercial |
$496.62
|
| Rate for Payer: HFN Commercial |
$513.36
|
| Rate for Payer: Multiplan Commercial |
$446.40
|
| Rate for Payer: NAPHCARE Commercial |
$334.80
|
| Rate for Payer: Preferred Network Access Commercial |
$513.36
|
| Rate for Payer: Quartz Beloit One Network |
$273.42
|
| Rate for Payer: Quartz Commercial |
$334.80
|
| Rate for Payer: WEA Trust Commercial |
$306.90
|
| Rate for Payer: WPS Commercial |
$413.31
|
|
|
GENERATOR SINGLE PIN 8CC
|
Facility
|
IP
|
$113,821.00
|
|
| Hospital Charge Code |
2965001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$55,772.29 |
| Max. Negotiated Rate |
$104,715.32 |
| Rate for Payer: Aetna Commercial |
$102,438.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$97,886.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60,325.13
|
| Rate for Payer: Cash Price |
$34,146.30
|
| Rate for Payer: Cigna Commercial |
$104,715.32
|
| Rate for Payer: Health EOS Commercial |
$101,300.69
|
| Rate for Payer: HFN Commercial |
$104,715.32
|
| Rate for Payer: Multiplan Commercial |
$91,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$68,292.60
|
| Rate for Payer: Preferred Network Access Commercial |
$104,715.32
|
| Rate for Payer: Quartz Beloit One Network |
$55,772.29
|
| Rate for Payer: Quartz Commercial |
$68,292.60
|
| Rate for Payer: WEA Trust Commercial |
$62,601.55
|
| Rate for Payer: WPS Commercial |
$84,307.21
|
|
|
GENERATOR SINGLE PIN 8CC
|
Facility
|
OP
|
$113,821.00
|
|
| Hospital Charge Code |
2965001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$31,869.88 |
| Max. Negotiated Rate |
$455,284.00 |
| Rate for Payer: Aetna Commercial |
$102,438.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$97,886.06
|
| Rate for Payer: Aetna Managed Medicare |
$31,869.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$73,983.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$56,910.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$54,634.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60,325.13
|
| Rate for Payer: Cash Price |
$34,146.30
|
| Rate for Payer: Cigna Commercial |
$104,715.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63,694.23
|
| Rate for Payer: Health EOS Commercial |
$101,300.69
|
| Rate for Payer: HFN Commercial |
$104,715.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85,365.75
|
| Rate for Payer: Multiplan Commercial |
$91,056.80
|
| Rate for Payer: NAPHCARE Commercial |
$68,292.60
|
| Rate for Payer: Preferred Network Access Commercial |
$104,715.32
|
| Rate for Payer: Quartz Beloit One Network |
$55,772.29
|
| Rate for Payer: Quartz Commercial |
$73,983.65
|
| Rate for Payer: Quartz Medicare Advantage |
$68,292.60
|
| Rate for Payer: The Alliance Commercial |
$455,284.00
|
| Rate for Payer: WEA Trust Commercial |
$62,601.55
|
| Rate for Payer: WPS Commercial |
$84,307.21
|
|
|
Genesis 4mm x 15mm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1163008
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,840.71 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
Genesis 4mm x 15mm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1163008
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$39,516.00 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: The Alliance Commercial |
$39,516.00
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
Genesis 4mm x 15mm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1163008
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.76 |
| Max. Negotiated Rate |
$9,385.05 |
| Rate for Payer: Aetna Commercial |
$9,385.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,385.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,939.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.40
|
| Rate for Payer: Health EOS Commercial |
$8,989.89
|
| Rate for Payer: HFN Commercial |
$9,385.05
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,385.05
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.76
|
| Rate for Payer: Quartz Commercial |
$5,631.03
|
| Rate for Payer: The Alliance Commercial |
$4,939.50
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
Genesis 4mm x 18mm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1163010
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$39,516.00 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: The Alliance Commercial |
$39,516.00
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
