|
GLOVE FLEXION FINGER LRG/XLRG RT #5035-02-01
|
Facility
|
OP
|
$373.00
|
|
| Hospital Charge Code |
2969600
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$108.62 |
| Max. Negotiated Rate |
$356.89 |
| Rate for Payer: Aetna Commercial |
$349.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$333.61
|
| Rate for Payer: Aetna Managed Medicare |
$108.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$252.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$193.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$186.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$205.60
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cigna Commercial |
$356.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$217.09
|
| Rate for Payer: Health EOS Commercial |
$345.25
|
| Rate for Payer: HFN Commercial |
$356.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$290.94
|
| Rate for Payer: Multiplan Commercial |
$310.34
|
| Rate for Payer: NAPHCARE Commercial |
$232.75
|
| Rate for Payer: Preferred Network Access Commercial |
$356.89
|
| Rate for Payer: Quartz Beloit One Network |
$190.08
|
| Rate for Payer: Quartz Commercial |
$252.15
|
| Rate for Payer: Quartz Medicare Advantage |
$232.75
|
| Rate for Payer: The Alliance Commercial |
$193.96
|
| Rate for Payer: WEA Trust Commercial |
$213.36
|
| Rate for Payer: WPS Commercial |
$287.32
|
|
|
GLOVE FLEXION FINGER SM/MED RT #5035-01-01
|
Facility
|
IP
|
$373.00
|
|
| Hospital Charge Code |
2969599
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$190.08 |
| Max. Negotiated Rate |
$356.89 |
| Rate for Payer: Aetna Commercial |
$349.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$333.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$205.60
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cigna Commercial |
$356.89
|
| Rate for Payer: Health EOS Commercial |
$345.25
|
| Rate for Payer: HFN Commercial |
$356.89
|
| Rate for Payer: Multiplan Commercial |
$310.34
|
| Rate for Payer: Preferred Network Access Commercial |
$356.89
|
| Rate for Payer: Quartz Beloit One Network |
$190.08
|
| Rate for Payer: Quartz Commercial |
$232.75
|
| Rate for Payer: WEA Trust Commercial |
$213.36
|
| Rate for Payer: WPS Commercial |
$287.32
|
|
|
GLOVE FLEXION FINGER SM/MED RT #5035-01-01
|
Facility
|
OP
|
$373.00
|
|
| Hospital Charge Code |
2969599
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$108.62 |
| Max. Negotiated Rate |
$356.89 |
| Rate for Payer: Aetna Commercial |
$349.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$333.61
|
| Rate for Payer: Aetna Managed Medicare |
$108.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$252.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$193.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$186.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$205.60
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cigna Commercial |
$356.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$217.09
|
| Rate for Payer: Health EOS Commercial |
$345.25
|
| Rate for Payer: HFN Commercial |
$356.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$290.94
|
| Rate for Payer: Multiplan Commercial |
$310.34
|
| Rate for Payer: NAPHCARE Commercial |
$232.75
|
| Rate for Payer: Preferred Network Access Commercial |
$356.89
|
| Rate for Payer: Quartz Beloit One Network |
$190.08
|
| Rate for Payer: Quartz Commercial |
$252.15
|
| Rate for Payer: Quartz Medicare Advantage |
$232.75
|
| Rate for Payer: The Alliance Commercial |
$193.96
|
| Rate for Payer: WEA Trust Commercial |
$213.36
|
| Rate for Payer: WPS Commercial |
$287.32
|
|
|
GLOVE FLEXION LEFT LRG/XLRG #5035-02-02
|
Facility
|
IP
|
$373.00
|
|
| Hospital Charge Code |
2971032
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$190.08 |
| Max. Negotiated Rate |
$356.89 |
| Rate for Payer: Aetna Commercial |
$349.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$333.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$205.60
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cigna Commercial |
$356.89
|
| Rate for Payer: Health EOS Commercial |
$345.25
|
| Rate for Payer: HFN Commercial |
$356.89
|
| Rate for Payer: Multiplan Commercial |
$310.34
|
| Rate for Payer: Preferred Network Access Commercial |
$356.89
|
| Rate for Payer: Quartz Beloit One Network |
$190.08
|
| Rate for Payer: Quartz Commercial |
$232.75
|
| Rate for Payer: WEA Trust Commercial |
$213.36
|
| Rate for Payer: WPS Commercial |
$287.32
|
|
|
GLOVE FLEXION LEFT LRG/XLRG #5035-02-02
|
Facility
|
OP
|
$373.00
|
|
| Hospital Charge Code |
2971032
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$108.62 |
| Max. Negotiated Rate |
$356.89 |
| Rate for Payer: Aetna Commercial |
$349.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$333.61
|
| Rate for Payer: Aetna Managed Medicare |
$108.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$252.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$193.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$186.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$205.60
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cigna Commercial |
$356.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$217.09
|
| Rate for Payer: Health EOS Commercial |
$345.25
|
| Rate for Payer: HFN Commercial |
$356.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$290.94
|
| Rate for Payer: Multiplan Commercial |
$310.34
|
| Rate for Payer: NAPHCARE Commercial |
$232.75
|
| Rate for Payer: Preferred Network Access Commercial |
$356.89
|
| Rate for Payer: Quartz Beloit One Network |
$190.08
|
| Rate for Payer: Quartz Commercial |
$252.15
|
| Rate for Payer: Quartz Medicare Advantage |
$232.75
|
| Rate for Payer: The Alliance Commercial |
$193.96
|
| Rate for Payer: WEA Trust Commercial |
$213.36
|
| Rate for Payer: WPS Commercial |
$287.32
|
|
|
GLOVE GENTLE COMP.EDEMA LRG/LF #A571-227
|
Facility
|
IP
|
$154.00
|
|
| Hospital Charge Code |
2970569
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$78.48 |
| Max. Negotiated Rate |
$147.35 |
| Rate for Payer: Aetna Commercial |
$144.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.88
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$147.35
|
| Rate for Payer: Health EOS Commercial |
$142.54
|
| Rate for Payer: HFN Commercial |
$147.35
|
| Rate for Payer: Multiplan Commercial |
$128.13
|
| Rate for Payer: Preferred Network Access Commercial |
$147.35
|
| Rate for Payer: Quartz Beloit One Network |
$78.48
|
| Rate for Payer: Quartz Commercial |
$96.10
|
| Rate for Payer: WEA Trust Commercial |
$88.09
|
| Rate for Payer: WPS Commercial |
$118.63
|
|
|
GLOVE GENTLE COMP.EDEMA LRG/LF #A571-227
|
Facility
|
OP
|
$154.00
|
|
| Hospital Charge Code |
2970569
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.84 |
| Max. Negotiated Rate |
$147.35 |
| Rate for Payer: Aetna Commercial |
$144.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.74
|
| Rate for Payer: Aetna Managed Medicare |
$44.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$104.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$80.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.88
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$147.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.63
|
| Rate for Payer: Health EOS Commercial |
$142.54
|
| Rate for Payer: HFN Commercial |
$147.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.12
|
| Rate for Payer: Multiplan Commercial |
$128.13
|
| Rate for Payer: NAPHCARE Commercial |
$96.10
|
| Rate for Payer: Preferred Network Access Commercial |
$147.35
|
| Rate for Payer: Quartz Beloit One Network |
$78.48
|
| Rate for Payer: Quartz Commercial |
$104.10
|
| Rate for Payer: Quartz Medicare Advantage |
$96.10
|
| Rate for Payer: The Alliance Commercial |
$80.08
|
| Rate for Payer: WEA Trust Commercial |
$88.09
|
| Rate for Payer: WPS Commercial |
$118.63
|
|
|
GLOVE GENTLE COMP.EDEMA LRG/RT #A571-226
|
Facility
|
OP
|
$153.00
|
|
| Hospital Charge Code |
2970565
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.55 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Aetna Managed Medicare |
$44.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$103.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.05
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.34
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: NAPHCARE Commercial |
$95.47
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$103.43
|
| Rate for Payer: Quartz Medicare Advantage |
$95.47
|
| Rate for Payer: The Alliance Commercial |
$79.56
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
GLOVE GENTLE COMP.EDEMA LRG/RT #A571-226
|
Facility
|
IP
|
$153.00
|
|
| Hospital Charge Code |
2970565
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$77.97 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$95.47
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
GLOVE GENTLE COMP.EDEMA MED/LF #A571-225
|
Facility
|
IP
|
$153.00
|
|
| Hospital Charge Code |
2970564
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$77.97 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$95.47
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
GLOVE GENTLE COMP.EDEMA MED/LF #A571-225
|
Facility
|
OP
|
$153.00
|
|
| Hospital Charge Code |
2970564
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.55 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Aetna Managed Medicare |
$44.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$103.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.05
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.34
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: NAPHCARE Commercial |
$95.47
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$103.43
|
| Rate for Payer: Quartz Medicare Advantage |
$95.47
|
| Rate for Payer: The Alliance Commercial |
$79.56
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
GLOVE GENTLE COMP.EDEMA MED/RT #A571-224
|
Facility
|
OP
|
$153.00
|
|
| Hospital Charge Code |
2970563
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.55 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Aetna Managed Medicare |
$44.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$103.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.05
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.34
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: NAPHCARE Commercial |
$95.47
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$103.43
|
| Rate for Payer: Quartz Medicare Advantage |
$95.47
|
| Rate for Payer: The Alliance Commercial |
$79.56
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
GLOVE GENTLE COMP.EDEMA MED/RT #A571-224
|
Facility
|
IP
|
$153.00
|
|
| Hospital Charge Code |
2970563
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$77.97 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$95.47
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
GLOVE GENTLE COMP.EDEMA SM/LFT #A571-223
|
Facility
|
OP
|
$153.00
|
|
| Hospital Charge Code |
2970562
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.55 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Aetna Managed Medicare |
$44.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$103.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.05
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.34
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: NAPHCARE Commercial |
$95.47
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$103.43
|
| Rate for Payer: Quartz Medicare Advantage |
$95.47
|
| Rate for Payer: The Alliance Commercial |
$79.56
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
GLOVE GENTLE COMP.EDEMA SM/LFT #A571-223
|
Facility
|
IP
|
$153.00
|
|
| Hospital Charge Code |
2970562
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$77.97 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$95.47
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
GLOVE GENTLE COMP.EDEMA SM/RT #A571-222
|
Facility
|
OP
|
$153.00
|
|
| Hospital Charge Code |
2970561
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.55 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Aetna Managed Medicare |
$44.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$103.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.05
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.34
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: NAPHCARE Commercial |
$95.47
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$103.43
|
| Rate for Payer: Quartz Medicare Advantage |
$95.47
|
| Rate for Payer: The Alliance Commercial |
$79.56
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
GLOVE GENTLE COMP.EDEMA SM/RT #A571-222
|
Facility
|
IP
|
$153.00
|
|
| Hospital Charge Code |
2970561
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$77.97 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$95.47
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
GLOVE GENTLE COMPRESSION RT/ME #A571-212
|
Facility
|
OP
|
$159.00
|
|
| Hospital Charge Code |
2969641
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$46.30 |
| Max. Negotiated Rate |
$152.13 |
| Rate for Payer: Aetna Commercial |
$148.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.21
|
| Rate for Payer: Aetna Managed Medicare |
$46.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$107.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$82.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$79.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.64
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$152.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.54
|
| Rate for Payer: Health EOS Commercial |
$147.17
|
| Rate for Payer: HFN Commercial |
$152.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$124.02
|
| Rate for Payer: Multiplan Commercial |
$132.29
|
| Rate for Payer: NAPHCARE Commercial |
$99.22
|
| Rate for Payer: Preferred Network Access Commercial |
$152.13
|
| Rate for Payer: Quartz Beloit One Network |
$81.03
|
| Rate for Payer: Quartz Commercial |
$107.48
|
| Rate for Payer: Quartz Medicare Advantage |
$99.22
|
| Rate for Payer: The Alliance Commercial |
$82.68
|
| Rate for Payer: WEA Trust Commercial |
$90.95
|
| Rate for Payer: WPS Commercial |
$122.48
|
|
|
GLOVE GENTLE COMPRESSION RT/ME #A571-212
|
Facility
|
IP
|
$159.00
|
|
| Hospital Charge Code |
2969641
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$81.03 |
| Max. Negotiated Rate |
$152.13 |
| Rate for Payer: Aetna Commercial |
$148.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$142.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.64
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$152.13
|
| Rate for Payer: Health EOS Commercial |
$147.17
|
| Rate for Payer: HFN Commercial |
$152.13
|
| Rate for Payer: Multiplan Commercial |
$132.29
|
| Rate for Payer: Preferred Network Access Commercial |
$152.13
|
| Rate for Payer: Quartz Beloit One Network |
$81.03
|
| Rate for Payer: Quartz Commercial |
$99.22
|
| Rate for Payer: WEA Trust Commercial |
$90.95
|
| Rate for Payer: WPS Commercial |
$122.48
|
|
|
GLOVES COMPRESSION W/O DARTS LG #55060703
|
Facility
|
OP
|
$780.00
|
|
| Hospital Charge Code |
2971628
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$227.14 |
| Max. Negotiated Rate |
$746.30 |
| Rate for Payer: Aetna Commercial |
$730.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$697.63
|
| Rate for Payer: Aetna Managed Medicare |
$227.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$527.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$405.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$389.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$429.94
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cigna Commercial |
$746.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$453.96
|
| Rate for Payer: Health EOS Commercial |
$721.97
|
| Rate for Payer: HFN Commercial |
$746.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$608.40
|
| Rate for Payer: Multiplan Commercial |
$648.96
|
| Rate for Payer: NAPHCARE Commercial |
$486.72
|
| Rate for Payer: Preferred Network Access Commercial |
$746.30
|
| Rate for Payer: Quartz Beloit One Network |
$397.49
|
| Rate for Payer: Quartz Commercial |
$527.28
|
| Rate for Payer: Quartz Medicare Advantage |
$486.72
|
| Rate for Payer: The Alliance Commercial |
$405.60
|
| Rate for Payer: WEA Trust Commercial |
$446.16
|
| Rate for Payer: WPS Commercial |
$600.83
|
|
|
GLOVES COMPRESSION W/O DARTS LG #55060703
|
Facility
|
IP
|
$780.00
|
|
| Hospital Charge Code |
2971628
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$397.49 |
| Max. Negotiated Rate |
$746.30 |
| Rate for Payer: Aetna Commercial |
$730.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$697.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$429.94
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cigna Commercial |
$746.30
|
| Rate for Payer: Health EOS Commercial |
$721.97
|
| Rate for Payer: HFN Commercial |
$746.30
|
| Rate for Payer: Multiplan Commercial |
$648.96
|
| Rate for Payer: Preferred Network Access Commercial |
$746.30
|
| Rate for Payer: Quartz Beloit One Network |
$397.49
|
| Rate for Payer: Quartz Commercial |
$486.72
|
| Rate for Payer: WEA Trust Commercial |
$446.16
|
| Rate for Payer: WPS Commercial |
$600.83
|
|
|
GLOVES COMPRESSION W/O DARTS XLG #55060704
|
Facility
|
IP
|
$769.00
|
|
| Hospital Charge Code |
2971620
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$391.88 |
| Max. Negotiated Rate |
$735.78 |
| Rate for Payer: Aetna Commercial |
$719.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$687.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$423.87
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cigna Commercial |
$735.78
|
| Rate for Payer: Health EOS Commercial |
$711.79
|
| Rate for Payer: HFN Commercial |
$735.78
|
| Rate for Payer: Multiplan Commercial |
$639.81
|
| Rate for Payer: Preferred Network Access Commercial |
$735.78
|
| Rate for Payer: Quartz Beloit One Network |
$391.88
|
| Rate for Payer: Quartz Commercial |
$479.86
|
| Rate for Payer: WEA Trust Commercial |
$439.87
|
| Rate for Payer: WPS Commercial |
$592.36
|
|
|
GLOVES COMPRESSION W/O DARTS XLG #55060704
|
Facility
|
OP
|
$769.00
|
|
| Hospital Charge Code |
2971620
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$223.93 |
| Max. Negotiated Rate |
$735.78 |
| Rate for Payer: Aetna Commercial |
$719.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$687.79
|
| Rate for Payer: Aetna Managed Medicare |
$223.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$519.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$399.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$383.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$423.87
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cigna Commercial |
$735.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$447.56
|
| Rate for Payer: Health EOS Commercial |
$711.79
|
| Rate for Payer: HFN Commercial |
$735.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$599.82
|
| Rate for Payer: Multiplan Commercial |
$639.81
|
| Rate for Payer: NAPHCARE Commercial |
$479.86
|
| Rate for Payer: Preferred Network Access Commercial |
$735.78
|
| Rate for Payer: Quartz Beloit One Network |
$391.88
|
| Rate for Payer: Quartz Commercial |
$519.84
|
| Rate for Payer: Quartz Medicare Advantage |
$479.86
|
| Rate for Payer: The Alliance Commercial |
$399.88
|
| Rate for Payer: WEA Trust Commercial |
$439.87
|
| Rate for Payer: WPS Commercial |
$592.36
|
|
|
glucagon 1 mg Charge
|
Professional
|
Both
|
$1,535.00
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
2958930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$171.45 |
| Max. Negotiated Rate |
$1,516.58 |
| Rate for Payer: Aetna Commercial |
$1,516.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,372.90
|
| Rate for Payer: Aetna Managed Medicare |
$171.45
|
| Rate for Payer: Anthem Medicare Advantage |
$171.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$171.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$171.45
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cigna Commercial |
$1,516.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$171.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$199.18
|
| Rate for Payer: Health EOS Commercial |
$1,452.72
|
| Rate for Payer: HFN Commercial |
$1,516.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$309.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$309.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$171.45
|
| Rate for Payer: Multiplan Commercial |
$1,277.12
|
| Rate for Payer: NAPHCARE Commercial |
$257.18
|
| Rate for Payer: Preferred Network Access Commercial |
$1,516.58
|
| Rate for Payer: Quartz Beloit One Network |
$702.42
|
| Rate for Payer: Quartz Commercial |
$909.95
|
| Rate for Payer: Quartz Medicare Advantage |
$171.45
|
| Rate for Payer: The Alliance Commercial |
$471.50
|
| Rate for Payer: United Healthcare Medicaid |
$171.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$171.45
|
| Rate for Payer: WEA Trust Commercial |
$878.02
|
| Rate for Payer: WPS Commercial |
$497.95
|
|
|
glucagon 1 mg Charge
|
Facility
|
IP
|
$1,535.00
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
2958930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$782.24 |
| Max. Negotiated Rate |
$1,468.69 |
| Rate for Payer: Aetna Commercial |
$1,436.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,372.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$846.09
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cigna Commercial |
$1,468.69
|
| Rate for Payer: Health EOS Commercial |
$1,420.80
|
| Rate for Payer: HFN Commercial |
$1,468.69
|
| Rate for Payer: Multiplan Commercial |
$1,277.12
|
| Rate for Payer: Preferred Network Access Commercial |
$1,468.69
|
| Rate for Payer: Quartz Beloit One Network |
$782.24
|
| Rate for Payer: Quartz Commercial |
$957.84
|
| Rate for Payer: WEA Trust Commercial |
$878.02
|
| Rate for Payer: WPS Commercial |
$1,182.41
|
|
