|
Gravity tubing changed - Peripheral IV Care:
|
Facility
|
IP
|
$76.00
|
|
| Hospital Charge Code |
3000018
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$37.24 |
| Max. Negotiated Rate |
$69.92 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.28
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$69.92
|
| Rate for Payer: Health EOS Commercial |
$67.64
|
| Rate for Payer: HFN Commercial |
$69.92
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: NAPHCARE Commercial |
$45.60
|
| Rate for Payer: Preferred Network Access Commercial |
$69.92
|
| Rate for Payer: Quartz Beloit One Network |
$37.24
|
| Rate for Payer: Quartz Commercial |
$45.60
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
|
Gravity tubing - Peripheral IV Equipment:
|
Facility
|
OP
|
$76.00
|
|
| Hospital Charge Code |
3003557
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.28 |
| Max. Negotiated Rate |
$304.00 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Aetna Managed Medicare |
$21.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$49.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$38.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.28
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$69.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.53
|
| Rate for Payer: Health EOS Commercial |
$67.64
|
| Rate for Payer: HFN Commercial |
$69.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.00
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: NAPHCARE Commercial |
$45.60
|
| Rate for Payer: Preferred Network Access Commercial |
$69.92
|
| Rate for Payer: Quartz Beloit One Network |
$37.24
|
| Rate for Payer: Quartz Commercial |
$49.40
|
| Rate for Payer: Quartz Medicare Advantage |
$45.60
|
| Rate for Payer: The Alliance Commercial |
$304.00
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
|
Gravity tubing - Peripheral IV Equipment:
|
Facility
|
IP
|
$76.00
|
|
| Hospital Charge Code |
3003557
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$37.24 |
| Max. Negotiated Rate |
$69.92 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.28
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$69.92
|
| Rate for Payer: Health EOS Commercial |
$67.64
|
| Rate for Payer: HFN Commercial |
$69.92
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: NAPHCARE Commercial |
$45.60
|
| Rate for Payer: Preferred Network Access Commercial |
$69.92
|
| Rate for Payer: Quartz Beloit One Network |
$37.24
|
| Rate for Payer: Quartz Commercial |
$45.60
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
|
GREAT VESSEL INJURY REPAIR, TRAUMA
|
Facility
|
OP
|
$15,548.00
|
|
| Hospital Charge Code |
2960503
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,353.44 |
| Max. Negotiated Rate |
$62,192.00 |
| Rate for Payer: Aetna Commercial |
$13,993.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,371.28
|
| Rate for Payer: Aetna Managed Medicare |
$4,353.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,106.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,774.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,463.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,240.44
|
| Rate for Payer: Cash Price |
$4,664.40
|
| Rate for Payer: Cigna Commercial |
$14,304.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,700.66
|
| Rate for Payer: Health EOS Commercial |
$13,837.72
|
| Rate for Payer: HFN Commercial |
$14,304.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,661.00
|
| Rate for Payer: Multiplan Commercial |
$12,438.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,328.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,304.16
|
| Rate for Payer: Quartz Beloit One Network |
$7,618.52
|
| Rate for Payer: Quartz Commercial |
$10,106.20
|
| Rate for Payer: Quartz Medicare Advantage |
$9,328.80
|
| Rate for Payer: The Alliance Commercial |
$62,192.00
|
| Rate for Payer: WEA Trust Commercial |
$8,551.40
|
| Rate for Payer: WPS Commercial |
$11,516.40
|
|
|
GREAT VESSEL INJURY REPAIR, TRAUMA
|
Facility
|
IP
|
$15,548.00
|
|
| Hospital Charge Code |
2960503
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,618.52 |
| Max. Negotiated Rate |
$14,304.16 |
| Rate for Payer: Aetna Commercial |
$13,993.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,371.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,240.44
|
| Rate for Payer: Cash Price |
$4,664.40
|
| Rate for Payer: Cigna Commercial |
$14,304.16
|
| Rate for Payer: Health EOS Commercial |
$13,837.72
|
| Rate for Payer: HFN Commercial |
$14,304.16
|
| Rate for Payer: Multiplan Commercial |
$12,438.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,328.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,304.16
|
| Rate for Payer: Quartz Beloit One Network |
$7,618.52
|
| Rate for Payer: Quartz Commercial |
$9,328.80
|
| Rate for Payer: WEA Trust Commercial |
$8,551.40
|
| Rate for Payer: WPS Commercial |
$11,516.40
|
|
|
Green (prong O.D.: 3.0mm) - RAM Cannula
|
Facility
|
IP
|
$223.00
|
|
| Hospital Charge Code |
5983677
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$109.27 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$133.80
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
Green (prong O.D.: 3.0mm) - RAM Cannula
|
Facility
|
OP
|
$223.00
|
|
| Hospital Charge Code |
5983677
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$62.44 |
| Max. Negotiated Rate |
$892.00 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Aetna Managed Medicare |
$62.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$144.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$111.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$107.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.79
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$167.25
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$144.95
|
| Rate for Payer: Quartz Medicare Advantage |
$133.80
|
| Rate for Payer: The Alliance Commercial |
$892.00
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
GRIP 1.6MM HOLE SM 6704-5-016
|
Facility
|
IP
|
$5,030.00
|
|
| Hospital Charge Code |
2966079
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,464.70 |
| Max. Negotiated Rate |
$4,627.60 |
| Rate for Payer: Aetna Commercial |
$4,527.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,325.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,665.90
|
| Rate for Payer: Cash Price |
$1,509.00
|
| Rate for Payer: Cigna Commercial |
$4,627.60
|
| Rate for Payer: Health EOS Commercial |
$4,476.70
|
| Rate for Payer: HFN Commercial |
$4,627.60
|
| Rate for Payer: Multiplan Commercial |
$4,024.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,018.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,627.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,464.70
|
| Rate for Payer: Quartz Commercial |
$3,018.00
|
| Rate for Payer: WEA Trust Commercial |
$2,766.50
|
| Rate for Payer: WPS Commercial |
$3,725.72
|
|
|
GRIP 1.6MM HOLE SM 6704-5-016
|
Facility
|
OP
|
$5,030.00
|
|
| Hospital Charge Code |
2966079
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,408.40 |
| Max. Negotiated Rate |
$20,120.00 |
| Rate for Payer: Aetna Commercial |
$4,527.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,325.80
|
| Rate for Payer: Aetna Managed Medicare |
$1,408.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,269.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,515.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,414.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,665.90
|
| Rate for Payer: Cash Price |
$1,509.00
|
| Rate for Payer: Cigna Commercial |
$4,627.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,814.79
|
| Rate for Payer: Health EOS Commercial |
$4,476.70
|
| Rate for Payer: HFN Commercial |
$4,627.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,772.50
|
| Rate for Payer: Multiplan Commercial |
$4,024.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,018.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,627.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,464.70
|
| Rate for Payer: Quartz Commercial |
$3,269.50
|
| Rate for Payer: Quartz Medicare Advantage |
$3,018.00
|
| Rate for Payer: The Alliance Commercial |
$20,120.00
|
| Rate for Payer: WEA Trust Commercial |
$2,766.50
|
| Rate for Payer: WPS Commercial |
$3,725.72
|
|
|
GRIP 2.0MM HOLE LG 6704-7-020
|
Facility
|
IP
|
$5,030.00
|
|
| Hospital Charge Code |
2966080
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,464.70 |
| Max. Negotiated Rate |
$4,627.60 |
| Rate for Payer: Aetna Commercial |
$4,527.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,325.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,665.90
|
| Rate for Payer: Cash Price |
$1,509.00
|
| Rate for Payer: Cigna Commercial |
$4,627.60
|
| Rate for Payer: Health EOS Commercial |
$4,476.70
|
| Rate for Payer: HFN Commercial |
$4,627.60
|
| Rate for Payer: Multiplan Commercial |
$4,024.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,018.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,627.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,464.70
|
| Rate for Payer: Quartz Commercial |
$3,018.00
|
| Rate for Payer: WEA Trust Commercial |
$2,766.50
|
| Rate for Payer: WPS Commercial |
$3,725.72
|
|
|
GRIP 2.0MM HOLE LG 6704-7-020
|
Facility
|
OP
|
$5,030.00
|
|
| Hospital Charge Code |
2966080
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,408.40 |
| Max. Negotiated Rate |
$20,120.00 |
| Rate for Payer: Aetna Commercial |
$4,527.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,325.80
|
| Rate for Payer: Aetna Managed Medicare |
$1,408.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,269.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,515.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,414.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,665.90
|
| Rate for Payer: Cash Price |
$1,509.00
|
| Rate for Payer: Cigna Commercial |
$4,627.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,814.79
|
| Rate for Payer: Health EOS Commercial |
$4,476.70
|
| Rate for Payer: HFN Commercial |
$4,627.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,772.50
|
| Rate for Payer: Multiplan Commercial |
$4,024.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,018.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,627.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,464.70
|
| Rate for Payer: Quartz Commercial |
$3,269.50
|
| Rate for Payer: Quartz Medicare Advantage |
$3,018.00
|
| Rate for Payer: The Alliance Commercial |
$20,120.00
|
| Rate for Payer: WEA Trust Commercial |
$2,766.50
|
| Rate for Payer: WPS Commercial |
$3,725.72
|
|
|
GRIP 2.0MM HOLE MED 6704-6-020
|
Facility
|
OP
|
$5,030.00
|
|
| Hospital Charge Code |
2966081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,408.40 |
| Max. Negotiated Rate |
$20,120.00 |
| Rate for Payer: Aetna Commercial |
$4,527.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,325.80
|
| Rate for Payer: Aetna Managed Medicare |
$1,408.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,269.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,515.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,414.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,665.90
|
| Rate for Payer: Cash Price |
$1,509.00
|
| Rate for Payer: Cigna Commercial |
$4,627.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,814.79
|
| Rate for Payer: Health EOS Commercial |
$4,476.70
|
| Rate for Payer: HFN Commercial |
$4,627.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,772.50
|
| Rate for Payer: Multiplan Commercial |
$4,024.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,018.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,627.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,464.70
|
| Rate for Payer: Quartz Commercial |
$3,269.50
|
| Rate for Payer: Quartz Medicare Advantage |
$3,018.00
|
| Rate for Payer: The Alliance Commercial |
$20,120.00
|
| Rate for Payer: WEA Trust Commercial |
$2,766.50
|
| Rate for Payer: WPS Commercial |
$3,725.72
|
|
|
GRIP 2.0MM HOLE MED 6704-6-020
|
Facility
|
IP
|
$5,030.00
|
|
| Hospital Charge Code |
2966081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,464.70 |
| Max. Negotiated Rate |
$4,627.60 |
| Rate for Payer: Aetna Commercial |
$4,527.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,325.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,665.90
|
| Rate for Payer: Cash Price |
$1,509.00
|
| Rate for Payer: Cigna Commercial |
$4,627.60
|
| Rate for Payer: Health EOS Commercial |
$4,476.70
|
| Rate for Payer: HFN Commercial |
$4,627.60
|
| Rate for Payer: Multiplan Commercial |
$4,024.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,018.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,627.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,464.70
|
| Rate for Payer: Quartz Commercial |
$3,018.00
|
| Rate for Payer: WEA Trust Commercial |
$2,766.50
|
| Rate for Payer: WPS Commercial |
$3,725.72
|
|
|
GROIN EXPLORATION
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960091
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
GROIN EXPLORATION
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960091
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
GROUNDING PAD ABC THERMOGUARD PLUS DUAL FOIL RED (ARGON BEAM COAGULATOR) B-6400
|
Facility
|
OP
|
$138.00
|
|
| Hospital Charge Code |
5415002
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.64 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Aetna Managed Medicare |
$38.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$89.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.22
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$103.50
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$82.80
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$89.70
|
| Rate for Payer: Quartz Medicare Advantage |
$82.80
|
| Rate for Payer: The Alliance Commercial |
$552.00
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
GROUNDING PAD ABC THERMOGUARD PLUS DUAL FOIL RED (ARGON BEAM COAGULATOR) B-6400
|
Facility
|
IP
|
$138.00
|
|
| Hospital Charge Code |
5415002
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$67.62 |
| Max. Negotiated Rate |
$126.96 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$82.80
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$82.80
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Group Mnt 2 or more 30 minutes
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
HCPCS G0271
|
| Hospital Charge Code |
5390655
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$35.77 |
| Max. Negotiated Rate |
$67.16 |
| Rate for Payer: Aetna Commercial |
$65.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.69
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$67.16
|
| Rate for Payer: Health EOS Commercial |
$64.97
|
| Rate for Payer: HFN Commercial |
$67.16
|
| Rate for Payer: Multiplan Commercial |
$58.40
|
| Rate for Payer: NAPHCARE Commercial |
$43.80
|
| Rate for Payer: Preferred Network Access Commercial |
$67.16
|
| Rate for Payer: Quartz Beloit One Network |
$35.77
|
| Rate for Payer: Quartz Commercial |
$43.80
|
| Rate for Payer: WEA Trust Commercial |
$40.15
|
| Rate for Payer: WPS Commercial |
$54.07
|
|
|
Group Mnt 2 or more 30 minutes
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS G0271
|
| Hospital Charge Code |
5390655
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$20.44 |
| Max. Negotiated Rate |
$292.00 |
| Rate for Payer: Aetna Commercial |
$65.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.78
|
| Rate for Payer: Aetna Managed Medicare |
$20.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$47.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.69
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$67.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.85
|
| Rate for Payer: Health EOS Commercial |
$64.97
|
| Rate for Payer: HFN Commercial |
$67.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.75
|
| Rate for Payer: Multiplan Commercial |
$58.40
|
| Rate for Payer: NAPHCARE Commercial |
$43.80
|
| Rate for Payer: Preferred Network Access Commercial |
$67.16
|
| Rate for Payer: Quartz Beloit One Network |
$35.77
|
| Rate for Payer: Quartz Commercial |
$47.45
|
| Rate for Payer: Quartz Medicare Advantage |
$43.80
|
| Rate for Payer: The Alliance Commercial |
$292.00
|
| Rate for Payer: United Healthcare PPO |
$54.75
|
| Rate for Payer: WEA Trust Commercial |
$40.15
|
| Rate for Payer: WPS Commercial |
$54.07
|
|
|
Growth Hormone
|
Professional
|
Both
|
$2,885.00
|
|
|
Service Code
|
CPT 83003
|
| Hospital Charge Code |
977959
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.85 |
| Max. Negotiated Rate |
$2,740.75 |
| Rate for Payer: Aetna Commercial |
$2,740.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,481.10
|
| Rate for Payer: Cash Price |
$865.50
|
| Rate for Payer: Cash Price |
$865.50
|
| Rate for Payer: Cigna Commercial |
$2,740.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,442.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,731.00
|
| Rate for Payer: Health EOS Commercial |
$2,625.35
|
| Rate for Payer: HFN Commercial |
$2,740.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$58.85
|
| Rate for Payer: Multiplan Commercial |
$2,308.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,740.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,269.40
|
| Rate for Payer: Quartz Commercial |
$1,644.45
|
| Rate for Payer: The Alliance Commercial |
$1,442.50
|
| Rate for Payer: WEA Trust Commercial |
$1,586.75
|
| Rate for Payer: WPS Commercial |
$2,136.92
|
|
|
Growth Hormone
|
Facility
|
OP
|
$2,885.00
|
|
|
Service Code
|
CPT 83003
|
| Hospital Charge Code |
977959
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.67 |
| Max. Negotiated Rate |
$2,654.20 |
| Rate for Payer: Aetna Commercial |
$2,596.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,481.10
|
| Rate for Payer: Aetna Managed Medicare |
$16.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.17
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.67
|
| Rate for Payer: Anthem Medicaid |
$17.23
|
| Rate for Payer: Anthem Medicare Advantage |
$16.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,529.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.67
|
| Rate for Payer: Cash Price |
$865.50
|
| Rate for Payer: Cash Price |
$865.50
|
| Rate for Payer: Cigna Commercial |
$2,654.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,614.45
|
| Rate for Payer: Dean Health Medicaid |
$17.23
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.67
|
| Rate for Payer: Health EOS Commercial |
$2,567.65
|
| Rate for Payer: HFN Commercial |
$2,654.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.67
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.23
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.67
|
| Rate for Payer: Managed Health Services Medicaid |
$17.92
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.67
|
| Rate for Payer: Multiplan Commercial |
$2,308.00
|
| Rate for Payer: NAPHCARE Commercial |
$25.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,654.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.23
|
| Rate for Payer: Quartz Beloit One Network |
$1,413.65
|
| Rate for Payer: Quartz Commercial |
$1,875.25
|
| Rate for Payer: Quartz Medicare Advantage |
$16.67
|
| Rate for Payer: The Alliance Commercial |
$66.68
|
| Rate for Payer: United Healthcare Medicaid |
$17.23
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.67
|
| Rate for Payer: United Healthcare PPO |
$2,163.75
|
| Rate for Payer: WEA Trust Commercial |
$1,586.75
|
| Rate for Payer: Wellcare Medicare |
$16.67
|
| Rate for Payer: WMAP Medicaid |
$17.23
|
| Rate for Payer: WPS Commercial |
$2,136.92
|
|
|
Growth Hormone
|
Facility
|
IP
|
$2,885.00
|
|
|
Service Code
|
CPT 83003
|
| Hospital Charge Code |
977959
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,413.65 |
| Max. Negotiated Rate |
$2,654.20 |
| Rate for Payer: Aetna Commercial |
$2,596.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,481.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,529.05
|
| Rate for Payer: Cash Price |
$865.50
|
| Rate for Payer: Cigna Commercial |
$2,654.20
|
| Rate for Payer: Health EOS Commercial |
$2,567.65
|
| Rate for Payer: HFN Commercial |
$2,654.20
|
| Rate for Payer: Multiplan Commercial |
$2,308.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,731.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,654.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,413.65
|
| Rate for Payer: Quartz Commercial |
$1,731.00
|
| Rate for Payer: WEA Trust Commercial |
$1,586.75
|
| Rate for Payer: WPS Commercial |
$2,136.92
|
|
|
GUARD FINGER 4 PRONG PLSTC LRG
|
Facility
|
IP
|
$18.00
|
|
| Hospital Charge Code |
2974244
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$8.82 |
| Max. Negotiated Rate |
$16.56 |
| Rate for Payer: Aetna Commercial |
$16.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.54
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$16.56
|
| Rate for Payer: Health EOS Commercial |
$16.02
|
| Rate for Payer: HFN Commercial |
$16.56
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: NAPHCARE Commercial |
$10.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16.56
|
| Rate for Payer: Quartz Beloit One Network |
$8.82
|
| Rate for Payer: Quartz Commercial |
$10.80
|
| Rate for Payer: WEA Trust Commercial |
$9.90
|
| Rate for Payer: WPS Commercial |
$13.33
|
|
|
GUARD FINGER 4 PRONG PLSTC LRG
|
Facility
|
OP
|
$18.00
|
|
| Hospital Charge Code |
2974244
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5.04 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$16.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.48
|
| Rate for Payer: Aetna Managed Medicare |
$5.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.54
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$16.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.07
|
| Rate for Payer: Health EOS Commercial |
$16.02
|
| Rate for Payer: HFN Commercial |
$16.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.50
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: NAPHCARE Commercial |
$10.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16.56
|
| Rate for Payer: Quartz Beloit One Network |
$8.82
|
| Rate for Payer: Quartz Commercial |
$11.70
|
| Rate for Payer: Quartz Medicare Advantage |
$10.80
|
| Rate for Payer: The Alliance Commercial |
$72.00
|
| Rate for Payer: WEA Trust Commercial |
$9.90
|
| Rate for Payer: WPS Commercial |
$13.33
|
|
|
GUARD FINGER SIZE 1 (PK/5) 79290105
|
Facility
|
IP
|
$92.00
|
|
| Hospital Charge Code |
2969572
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$45.08 |
| Max. Negotiated Rate |
$84.64 |
| Rate for Payer: Aetna Commercial |
$82.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.76
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$84.64
|
| Rate for Payer: Health EOS Commercial |
$81.88
|
| Rate for Payer: HFN Commercial |
$84.64
|
| Rate for Payer: Multiplan Commercial |
$73.60
|
| Rate for Payer: NAPHCARE Commercial |
$55.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.64
|
| Rate for Payer: Quartz Beloit One Network |
$45.08
|
| Rate for Payer: Quartz Commercial |
$55.20
|
| Rate for Payer: WEA Trust Commercial |
$50.60
|
| Rate for Payer: WPS Commercial |
$68.14
|
|
