|
Golimumab Level
|
Facility
|
IP
|
$556.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
5502668
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$283.34 |
| Max. Negotiated Rate |
$531.98 |
| Rate for Payer: Aetna Commercial |
$520.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$497.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$306.47
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$531.98
|
| Rate for Payer: Health EOS Commercial |
$514.63
|
| Rate for Payer: HFN Commercial |
$531.98
|
| Rate for Payer: Multiplan Commercial |
$462.59
|
| Rate for Payer: Preferred Network Access Commercial |
$531.98
|
| Rate for Payer: Quartz Beloit One Network |
$283.34
|
| Rate for Payer: Quartz Commercial |
$346.94
|
| Rate for Payer: WEA Trust Commercial |
$318.03
|
| Rate for Payer: WPS Commercial |
$428.29
|
|
|
Golimumab Level
|
Facility
|
OP
|
$556.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
5502668
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$531.98 |
| Rate for Payer: Aetna Commercial |
$520.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$497.29
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.18
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$306.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Cigna Commercial |
$531.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$323.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$514.63
|
| Rate for Payer: HFN Commercial |
$531.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$462.59
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$531.98
|
| Rate for Payer: Quartz Beloit One Network |
$283.34
|
| Rate for Payer: Quartz Commercial |
$375.86
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$77.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: United Healthcare PPO |
$433.68
|
| Rate for Payer: WEA Trust Commercial |
$318.03
|
| Rate for Payer: Wellcare Medicare |
$19.39
|
| Rate for Payer: WPS Commercial |
$428.29
|
|
|
GONIOTOMY
|
Facility
|
OP
|
$17,399.87
|
|
|
Service Code
|
CPT 65820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,349.97 |
| Max. Negotiated Rate |
$17,399.87 |
| Rate for Payer: Aetna Managed Medicare |
$4,349.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,727.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,350.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,781.68
|
| Rate for Payer: Anthem Medicare Advantage |
$4,349.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4,349.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4,349.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4,349.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,107.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4,349.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,181.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4,349.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4,349.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4,349.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4,349.97
|
| Rate for Payer: NAPHCARE Commercial |
$6,524.95
|
| Rate for Payer: Quartz Medicare Advantage |
$4,349.97
|
| Rate for Payer: The Alliance Commercial |
$17,399.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4,349.97
|
| Rate for Payer: United Healthcare PPO |
$4,409.60
|
| Rate for Payer: Wellcare Medicare |
$4,349.97
|
|
|
Goserelin Acetate Implant J9202
|
Facility
|
IP
|
$3,564.00
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
4163762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,816.21 |
| Max. Negotiated Rate |
$3,410.04 |
| Rate for Payer: Aetna Commercial |
$3,335.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,187.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,964.48
|
| Rate for Payer: Cash Price |
$1,069.20
|
| Rate for Payer: Cigna Commercial |
$3,410.04
|
| Rate for Payer: Health EOS Commercial |
$3,298.84
|
| Rate for Payer: HFN Commercial |
$3,410.04
|
| Rate for Payer: Multiplan Commercial |
$2,965.25
|
| Rate for Payer: Preferred Network Access Commercial |
$3,410.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,816.21
|
| Rate for Payer: Quartz Commercial |
$2,223.94
|
| Rate for Payer: WEA Trust Commercial |
$2,038.61
|
| Rate for Payer: WPS Commercial |
$2,745.35
|
|
|
Goserelin Acetate Implant J9202
|
Facility
|
OP
|
$3,564.00
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
4163762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$808.60 |
| Max. Negotiated Rate |
$3,410.04 |
| Rate for Payer: Aetna Commercial |
$3,335.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,187.64
|
| Rate for Payer: Aetna Managed Medicare |
$808.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,409.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,853.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,779.15
|
| Rate for Payer: Anthem Medicare Advantage |
$808.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,964.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$808.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$808.60
|
| Rate for Payer: Cash Price |
$1,069.20
|
| Rate for Payer: Cash Price |
$1,069.20
|
| Rate for Payer: Cigna Commercial |
$3,410.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$808.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$824.63
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$808.60
|
| Rate for Payer: Health EOS Commercial |
$3,298.84
|
| Rate for Payer: HFN Commercial |
$3,410.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,007.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$808.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$808.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$808.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$808.60
|
| Rate for Payer: Multiplan Commercial |
$2,965.25
|
| Rate for Payer: NAPHCARE Commercial |
$1,212.90
|
| Rate for Payer: Preferred Network Access Commercial |
$3,410.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,816.21
|
| Rate for Payer: Quartz Commercial |
$2,409.26
|
| Rate for Payer: Quartz Medicare Advantage |
$808.60
|
| Rate for Payer: The Alliance Commercial |
$3,234.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$808.60
|
| Rate for Payer: WEA Trust Commercial |
$2,038.61
|
| Rate for Payer: Wellcare Medicare |
$808.60
|
| Rate for Payer: WPS Commercial |
$1,558.28
|
|
|
Goserelin Acetate Implant J9202
|
Professional
|
Both
|
$3,564.00
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
4163762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$623.31 |
| Max. Negotiated Rate |
$3,521.23 |
| Rate for Payer: Aetna Commercial |
$3,521.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,187.64
|
| Rate for Payer: Aetna Managed Medicare |
$808.60
|
| Rate for Payer: Anthem Medicare Advantage |
$808.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$808.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$808.60
|
| Rate for Payer: Cash Price |
$1,069.20
|
| Rate for Payer: Cash Price |
$1,069.20
|
| Rate for Payer: Cigna Commercial |
$3,521.23
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,853.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$623.31
|
| Rate for Payer: Health EOS Commercial |
$3,372.97
|
| Rate for Payer: HFN Commercial |
$3,521.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$817.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$817.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$808.60
|
| Rate for Payer: Multiplan Commercial |
$2,965.25
|
| Rate for Payer: NAPHCARE Commercial |
$1,212.90
|
| Rate for Payer: Preferred Network Access Commercial |
$3,521.23
|
| Rate for Payer: Quartz Beloit One Network |
$1,630.89
|
| Rate for Payer: Quartz Commercial |
$2,112.74
|
| Rate for Payer: Quartz Medicare Advantage |
$808.60
|
| Rate for Payer: The Alliance Commercial |
$2,223.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$808.60
|
| Rate for Payer: WEA Trust Commercial |
$2,038.61
|
| Rate for Payer: WPS Commercial |
$1,558.28
|
|
|
GOWN AERO CHAMBER XXL XLONG 44679
|
Facility
|
OP
|
$180.00
|
|
| Hospital Charge Code |
2963125
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.42 |
| Max. Negotiated Rate |
$172.22 |
| Rate for Payer: Aetna Commercial |
$168.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$160.99
|
| Rate for Payer: Aetna Managed Medicare |
$52.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$121.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$93.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$89.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.22
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna Commercial |
$172.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104.76
|
| Rate for Payer: Health EOS Commercial |
$166.61
|
| Rate for Payer: HFN Commercial |
$172.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$140.40
|
| Rate for Payer: Multiplan Commercial |
$149.76
|
| Rate for Payer: NAPHCARE Commercial |
$112.32
|
| Rate for Payer: Preferred Network Access Commercial |
$172.22
|
| Rate for Payer: Quartz Beloit One Network |
$91.73
|
| Rate for Payer: Quartz Commercial |
$121.68
|
| Rate for Payer: Quartz Medicare Advantage |
$112.32
|
| Rate for Payer: The Alliance Commercial |
$93.60
|
| Rate for Payer: WEA Trust Commercial |
$102.96
|
| Rate for Payer: WPS Commercial |
$138.65
|
|
|
GOWN AERO CHAMBER XXL XLONG 44679
|
Facility
|
IP
|
$180.00
|
|
| Hospital Charge Code |
2963125
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$91.73 |
| Max. Negotiated Rate |
$172.22 |
| Rate for Payer: Aetna Commercial |
$168.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$160.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.22
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna Commercial |
$172.22
|
| Rate for Payer: Health EOS Commercial |
$166.61
|
| Rate for Payer: HFN Commercial |
$172.22
|
| Rate for Payer: Multiplan Commercial |
$149.76
|
| Rate for Payer: Preferred Network Access Commercial |
$172.22
|
| Rate for Payer: Quartz Beloit One Network |
$91.73
|
| Rate for Payer: Quartz Commercial |
$112.32
|
| Rate for Payer: WEA Trust Commercial |
$102.96
|
| Rate for Payer: WPS Commercial |
$138.65
|
|
|
GOWN ISOLATION UNIVERSAL SIZE GOWN K-C69979
|
Facility
|
OP
|
$57.00
|
|
| Hospital Charge Code |
2969239
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$16.60 |
| Max. Negotiated Rate |
$54.54 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.98
|
| Rate for Payer: Aetna Managed Medicare |
$16.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.42
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$54.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.17
|
| Rate for Payer: Health EOS Commercial |
$52.76
|
| Rate for Payer: HFN Commercial |
$54.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.46
|
| Rate for Payer: Multiplan Commercial |
$47.42
|
| Rate for Payer: NAPHCARE Commercial |
$35.57
|
| Rate for Payer: Preferred Network Access Commercial |
$54.54
|
| Rate for Payer: Quartz Beloit One Network |
$29.05
|
| Rate for Payer: Quartz Commercial |
$38.53
|
| Rate for Payer: Quartz Medicare Advantage |
$35.57
|
| Rate for Payer: The Alliance Commercial |
$29.64
|
| Rate for Payer: WEA Trust Commercial |
$32.60
|
| Rate for Payer: WPS Commercial |
$43.91
|
|
|
GOWN ISOLATION UNIVERSAL SIZE GOWN K-C69979
|
Facility
|
IP
|
$57.00
|
|
| Hospital Charge Code |
2969239
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$29.05 |
| Max. Negotiated Rate |
$54.54 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.42
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$54.54
|
| Rate for Payer: Health EOS Commercial |
$52.76
|
| Rate for Payer: HFN Commercial |
$54.54
|
| Rate for Payer: Multiplan Commercial |
$47.42
|
| Rate for Payer: Preferred Network Access Commercial |
$54.54
|
| Rate for Payer: Quartz Beloit One Network |
$29.05
|
| Rate for Payer: Quartz Commercial |
$35.57
|
| Rate for Payer: WEA Trust Commercial |
$32.60
|
| Rate for Payer: WPS Commercial |
$43.91
|
|
|
GOWN LARGE STERILE 95111
|
Facility
|
IP
|
$90.00
|
|
| Hospital Charge Code |
2962815
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.86 |
| Max. Negotiated Rate |
$86.11 |
| Rate for Payer: Aetna Commercial |
$84.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.61
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$86.11
|
| Rate for Payer: Health EOS Commercial |
$83.30
|
| Rate for Payer: HFN Commercial |
$86.11
|
| Rate for Payer: Multiplan Commercial |
$74.88
|
| Rate for Payer: Preferred Network Access Commercial |
$86.11
|
| Rate for Payer: Quartz Beloit One Network |
$45.86
|
| Rate for Payer: Quartz Commercial |
$56.16
|
| Rate for Payer: WEA Trust Commercial |
$51.48
|
| Rate for Payer: WPS Commercial |
$69.33
|
|
|
GOWN LARGE STERILE 95111
|
Facility
|
OP
|
$90.00
|
|
| Hospital Charge Code |
2962815
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.21 |
| Max. Negotiated Rate |
$86.11 |
| Rate for Payer: Aetna Commercial |
$84.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.50
|
| Rate for Payer: Aetna Managed Medicare |
$26.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.61
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$86.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.38
|
| Rate for Payer: Health EOS Commercial |
$83.30
|
| Rate for Payer: HFN Commercial |
$86.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.20
|
| Rate for Payer: Multiplan Commercial |
$74.88
|
| Rate for Payer: NAPHCARE Commercial |
$56.16
|
| Rate for Payer: Preferred Network Access Commercial |
$86.11
|
| Rate for Payer: Quartz Beloit One Network |
$45.86
|
| Rate for Payer: Quartz Commercial |
$60.84
|
| Rate for Payer: Quartz Medicare Advantage |
$56.16
|
| Rate for Payer: The Alliance Commercial |
$46.80
|
| Rate for Payer: WEA Trust Commercial |
$51.48
|
| Rate for Payer: WPS Commercial |
$69.33
|
|
|
GOWN MICROCOOL XL
|
Facility
|
OP
|
$156.00
|
|
| Hospital Charge Code |
2963185
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.43 |
| Max. Negotiated Rate |
$149.26 |
| Rate for Payer: Aetna Commercial |
$146.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.53
|
| Rate for Payer: Aetna Managed Medicare |
$45.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$105.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$81.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$77.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.99
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$149.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.79
|
| Rate for Payer: Health EOS Commercial |
$144.39
|
| Rate for Payer: HFN Commercial |
$149.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.68
|
| Rate for Payer: Multiplan Commercial |
$129.79
|
| Rate for Payer: NAPHCARE Commercial |
$97.34
|
| Rate for Payer: Preferred Network Access Commercial |
$149.26
|
| Rate for Payer: Quartz Beloit One Network |
$79.50
|
| Rate for Payer: Quartz Commercial |
$105.46
|
| Rate for Payer: Quartz Medicare Advantage |
$97.34
|
| Rate for Payer: The Alliance Commercial |
$81.12
|
| Rate for Payer: WEA Trust Commercial |
$89.23
|
| Rate for Payer: WPS Commercial |
$120.17
|
|
|
GOWN MICROCOOL XL
|
Facility
|
IP
|
$156.00
|
|
| Hospital Charge Code |
2963185
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$79.50 |
| Max. Negotiated Rate |
$149.26 |
| Rate for Payer: Aetna Commercial |
$146.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.99
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cigna Commercial |
$149.26
|
| Rate for Payer: Health EOS Commercial |
$144.39
|
| Rate for Payer: HFN Commercial |
$149.26
|
| Rate for Payer: Multiplan Commercial |
$129.79
|
| Rate for Payer: Preferred Network Access Commercial |
$149.26
|
| Rate for Payer: Quartz Beloit One Network |
$79.50
|
| Rate for Payer: Quartz Commercial |
$97.34
|
| Rate for Payer: WEA Trust Commercial |
$89.23
|
| Rate for Payer: WPS Commercial |
$120.17
|
|
|
GOWN POLY XLRG REINFORCED 95221
|
Facility
|
IP
|
$123.00
|
|
| Hospital Charge Code |
2963221
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$62.68 |
| Max. Negotiated Rate |
$117.69 |
| Rate for Payer: Aetna Commercial |
$115.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.80
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$117.69
|
| Rate for Payer: Health EOS Commercial |
$113.85
|
| Rate for Payer: HFN Commercial |
$117.69
|
| Rate for Payer: Multiplan Commercial |
$102.34
|
| Rate for Payer: Preferred Network Access Commercial |
$117.69
|
| Rate for Payer: Quartz Beloit One Network |
$62.68
|
| Rate for Payer: Quartz Commercial |
$76.75
|
| Rate for Payer: WEA Trust Commercial |
$70.36
|
| Rate for Payer: WPS Commercial |
$94.75
|
|
|
GOWN POLY XLRG REINFORCED 95221
|
Facility
|
OP
|
$123.00
|
|
| Hospital Charge Code |
2963221
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.82 |
| Max. Negotiated Rate |
$117.69 |
| Rate for Payer: Aetna Commercial |
$115.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.01
|
| Rate for Payer: Aetna Managed Medicare |
$35.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$63.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.80
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$117.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.59
|
| Rate for Payer: Health EOS Commercial |
$113.85
|
| Rate for Payer: HFN Commercial |
$117.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$95.94
|
| Rate for Payer: Multiplan Commercial |
$102.34
|
| Rate for Payer: NAPHCARE Commercial |
$76.75
|
| Rate for Payer: Preferred Network Access Commercial |
$117.69
|
| Rate for Payer: Quartz Beloit One Network |
$62.68
|
| Rate for Payer: Quartz Commercial |
$83.15
|
| Rate for Payer: Quartz Medicare Advantage |
$76.75
|
| Rate for Payer: The Alliance Commercial |
$63.96
|
| Rate for Payer: WEA Trust Commercial |
$70.36
|
| Rate for Payer: WPS Commercial |
$94.75
|
|
|
GOWN SURGICAL ULTRA XL 95121
|
Facility
|
IP
|
$98.00
|
|
| Hospital Charge Code |
2963301
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.94 |
| Max. Negotiated Rate |
$93.77 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$61.15
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
GOWN SURGICAL ULTRA XL 95121
|
Facility
|
OP
|
$98.00
|
|
| Hospital Charge Code |
2963301
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$28.54 |
| Max. Negotiated Rate |
$93.77 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Aetna Managed Medicare |
$28.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.04
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.44
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: NAPHCARE Commercial |
$61.15
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$66.25
|
| Rate for Payer: Quartz Medicare Advantage |
$61.15
|
| Rate for Payer: The Alliance Commercial |
$50.96
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
G PROBE 15980
|
Facility
|
OP
|
$2,286.00
|
|
| Hospital Charge Code |
6202984
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$665.68 |
| Max. Negotiated Rate |
$2,187.24 |
| Rate for Payer: Aetna Commercial |
$2,139.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,044.60
|
| Rate for Payer: Aetna Managed Medicare |
$665.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,545.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,188.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,141.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,260.04
|
| Rate for Payer: Cash Price |
$685.80
|
| Rate for Payer: Cigna Commercial |
$2,187.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,330.45
|
| Rate for Payer: Health EOS Commercial |
$2,115.92
|
| Rate for Payer: HFN Commercial |
$2,187.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,783.08
|
| Rate for Payer: Multiplan Commercial |
$1,901.95
|
| Rate for Payer: NAPHCARE Commercial |
$1,426.46
|
| Rate for Payer: Preferred Network Access Commercial |
$2,187.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,164.95
|
| Rate for Payer: Quartz Commercial |
$1,545.34
|
| Rate for Payer: Quartz Medicare Advantage |
$1,426.46
|
| Rate for Payer: The Alliance Commercial |
$1,188.72
|
| Rate for Payer: WEA Trust Commercial |
$1,307.59
|
| Rate for Payer: WPS Commercial |
$1,760.91
|
|
|
G PROBE 15980
|
Facility
|
IP
|
$2,286.00
|
|
| Hospital Charge Code |
6202984
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,164.95 |
| Max. Negotiated Rate |
$2,187.24 |
| Rate for Payer: Aetna Commercial |
$2,139.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,044.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,260.04
|
| Rate for Payer: Cash Price |
$685.80
|
| Rate for Payer: Cigna Commercial |
$2,187.24
|
| Rate for Payer: Health EOS Commercial |
$2,115.92
|
| Rate for Payer: HFN Commercial |
$2,187.24
|
| Rate for Payer: Multiplan Commercial |
$1,901.95
|
| Rate for Payer: Preferred Network Access Commercial |
$2,187.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,164.95
|
| Rate for Payer: Quartz Commercial |
$1,426.46
|
| Rate for Payer: WEA Trust Commercial |
$1,307.59
|
| Rate for Payer: WPS Commercial |
$1,760.91
|
|
|
GPS IMPLANT KIT V2 A10012
|
Facility
|
IP
|
$3,921.51
|
|
| Hospital Charge Code |
6240173
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,998.40 |
| Max. Negotiated Rate |
$3,752.10 |
| Rate for Payer: Aetna Commercial |
$3,670.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,507.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,161.54
|
| Rate for Payer: Cash Price |
$1,176.45
|
| Rate for Payer: Cigna Commercial |
$3,752.10
|
| Rate for Payer: Health EOS Commercial |
$3,629.75
|
| Rate for Payer: HFN Commercial |
$3,752.10
|
| Rate for Payer: Multiplan Commercial |
$3,262.70
|
| Rate for Payer: Preferred Network Access Commercial |
$3,752.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,998.40
|
| Rate for Payer: Quartz Commercial |
$2,447.02
|
| Rate for Payer: WEA Trust Commercial |
$2,243.10
|
| Rate for Payer: WPS Commercial |
$3,020.74
|
|
|
GPS IMPLANT KIT V2 A10012
|
Facility
|
OP
|
$3,921.51
|
|
| Hospital Charge Code |
6240173
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,141.94 |
| Max. Negotiated Rate |
$3,752.10 |
| Rate for Payer: Aetna Commercial |
$3,670.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,507.40
|
| Rate for Payer: Aetna Managed Medicare |
$1,141.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,650.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,039.19
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,957.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,161.54
|
| Rate for Payer: Cash Price |
$1,176.45
|
| Rate for Payer: Cigna Commercial |
$3,752.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,282.32
|
| Rate for Payer: Health EOS Commercial |
$3,629.75
|
| Rate for Payer: HFN Commercial |
$3,752.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,058.78
|
| Rate for Payer: Multiplan Commercial |
$3,262.70
|
| Rate for Payer: NAPHCARE Commercial |
$2,447.02
|
| Rate for Payer: Preferred Network Access Commercial |
$3,752.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,998.40
|
| Rate for Payer: Quartz Commercial |
$2,650.94
|
| Rate for Payer: Quartz Medicare Advantage |
$2,447.02
|
| Rate for Payer: The Alliance Commercial |
$2,039.19
|
| Rate for Payer: WEA Trust Commercial |
$2,243.10
|
| Rate for Payer: WPS Commercial |
$3,020.74
|
|
|
Grafix Core per sq cm Q4132
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
HCPCS Q4132
|
| Hospital Charge Code |
4506681
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.65 |
| Max. Negotiated Rate |
$164.57 |
| Rate for Payer: Aetna Commercial |
$160.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.81
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$164.57
|
| Rate for Payer: Health EOS Commercial |
$159.20
|
| Rate for Payer: HFN Commercial |
$164.57
|
| Rate for Payer: Multiplan Commercial |
$143.10
|
| Rate for Payer: Preferred Network Access Commercial |
$164.57
|
| Rate for Payer: Quartz Beloit One Network |
$87.65
|
| Rate for Payer: Quartz Commercial |
$107.33
|
| Rate for Payer: WEA Trust Commercial |
$98.38
|
| Rate for Payer: WPS Commercial |
$132.49
|
|
|
Grafix Core per sq cm Q4132
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
HCPCS Q4132
|
| Hospital Charge Code |
4506681
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.86 |
| Max. Negotiated Rate |
$523.87 |
| Rate for Payer: Aetna Commercial |
$160.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.84
|
| Rate for Payer: Aetna Managed Medicare |
$130.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$116.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$89.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$85.86
|
| Rate for Payer: Anthem Medicare Advantage |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.97
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$164.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.97
|
| Rate for Payer: Health EOS Commercial |
$159.20
|
| Rate for Payer: HFN Commercial |
$164.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.97
|
| Rate for Payer: Multiplan Commercial |
$143.10
|
| Rate for Payer: NAPHCARE Commercial |
$196.45
|
| Rate for Payer: Preferred Network Access Commercial |
$164.57
|
| Rate for Payer: Quartz Beloit One Network |
$87.65
|
| Rate for Payer: Quartz Commercial |
$116.27
|
| Rate for Payer: Quartz Medicare Advantage |
$130.97
|
| Rate for Payer: The Alliance Commercial |
$523.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.97
|
| Rate for Payer: WEA Trust Commercial |
$98.38
|
| Rate for Payer: Wellcare Medicare |
$130.97
|
| Rate for Payer: WPS Commercial |
$287.15
|
|
|
Grafix Core per sq cm Q4132
|
Professional
|
Both
|
$172.00
|
|
|
Service Code
|
HCPCS Q4132
|
| Hospital Charge Code |
4506681
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.71 |
| Max. Negotiated Rate |
$428.02 |
| Rate for Payer: Aetna Commercial |
$169.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.84
|
| Rate for Payer: Aetna Managed Medicare |
$126.79
|
| Rate for Payer: Anthem Medicare Advantage |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.79
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$169.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$177.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.86
|
| Rate for Payer: Health EOS Commercial |
$162.78
|
| Rate for Payer: HFN Commercial |
$169.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$428.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$428.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.79
|
| Rate for Payer: Multiplan Commercial |
$143.10
|
| Rate for Payer: NAPHCARE Commercial |
$190.18
|
| Rate for Payer: Preferred Network Access Commercial |
$169.94
|
| Rate for Payer: Quartz Beloit One Network |
$78.71
|
| Rate for Payer: Quartz Commercial |
$101.96
|
| Rate for Payer: Quartz Medicare Advantage |
$126.79
|
| Rate for Payer: The Alliance Commercial |
$348.66
|
| Rate for Payer: United Healthcare Medicaid |
$177.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.79
|
| Rate for Payer: WEA Trust Commercial |
$98.38
|
| Rate for Payer: WPS Commercial |
$287.15
|
|
