|
HYDROCELECTOMY/SPERMATOCELE REPAIR
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960123
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
HYDROCELECTOMY/SPERMATOCELE REPAIR
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960123
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
Hydrocodone & Metabolites, Serum
|
Facility
|
OP
|
$148.20
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
6209767
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.16 |
| Max. Negotiated Rate |
$141.80 |
| Rate for Payer: Aetna Commercial |
$138.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.55
|
| Rate for Payer: Aetna Managed Medicare |
$43.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$100.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$77.06
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$73.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.69
|
| Rate for Payer: Cash Price |
$44.46
|
| Rate for Payer: Cigna Commercial |
$141.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$86.25
|
| Rate for Payer: Health EOS Commercial |
$137.17
|
| Rate for Payer: HFN Commercial |
$141.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.60
|
| Rate for Payer: Multiplan Commercial |
$123.30
|
| Rate for Payer: NAPHCARE Commercial |
$92.48
|
| Rate for Payer: Preferred Network Access Commercial |
$141.80
|
| Rate for Payer: Quartz Beloit One Network |
$75.52
|
| Rate for Payer: Quartz Commercial |
$100.18
|
| Rate for Payer: Quartz Medicare Advantage |
$92.48
|
| Rate for Payer: The Alliance Commercial |
$77.06
|
| Rate for Payer: United Healthcare PPO |
$115.60
|
| Rate for Payer: WEA Trust Commercial |
$84.77
|
| Rate for Payer: WPS Commercial |
$114.16
|
|
|
Hydrocodone & Metabolites, Serum
|
Professional
|
Both
|
$148.20
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
6209767
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$67.82 |
| Max. Negotiated Rate |
$146.42 |
| Rate for Payer: Aetna Commercial |
$146.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.55
|
| Rate for Payer: Cash Price |
$44.46
|
| Rate for Payer: Cash Price |
$44.46
|
| Rate for Payer: Cigna Commercial |
$146.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$77.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.48
|
| Rate for Payer: Health EOS Commercial |
$140.26
|
| Rate for Payer: HFN Commercial |
$146.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$123.30
|
| Rate for Payer: Preferred Network Access Commercial |
$146.42
|
| Rate for Payer: Quartz Beloit One Network |
$67.82
|
| Rate for Payer: Quartz Commercial |
$87.85
|
| Rate for Payer: The Alliance Commercial |
$77.06
|
| Rate for Payer: WEA Trust Commercial |
$84.77
|
| Rate for Payer: WPS Commercial |
$114.16
|
|
|
Hydrocodone & Metabolites, Serum
|
Facility
|
IP
|
$148.20
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
6209767
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$75.52 |
| Max. Negotiated Rate |
$141.80 |
| Rate for Payer: Aetna Commercial |
$138.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.69
|
| Rate for Payer: Cash Price |
$44.46
|
| Rate for Payer: Cigna Commercial |
$141.80
|
| Rate for Payer: Health EOS Commercial |
$137.17
|
| Rate for Payer: HFN Commercial |
$141.80
|
| Rate for Payer: Multiplan Commercial |
$123.30
|
| Rate for Payer: Preferred Network Access Commercial |
$141.80
|
| Rate for Payer: Quartz Beloit One Network |
$75.52
|
| Rate for Payer: Quartz Commercial |
$92.48
|
| Rate for Payer: WEA Trust Commercial |
$84.77
|
| Rate for Payer: WPS Commercial |
$114.16
|
|
|
HYDROCOLLOID 3.8x3.8 DUODERM
|
Facility
|
IP
|
$157.00
|
|
| Hospital Charge Code |
2963864
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$80.01 |
| Max. Negotiated Rate |
$150.22 |
| Rate for Payer: Aetna Commercial |
$146.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.54
|
| Rate for Payer: Cash Price |
$47.10
|
| Rate for Payer: Cigna Commercial |
$150.22
|
| Rate for Payer: Health EOS Commercial |
$145.32
|
| Rate for Payer: HFN Commercial |
$150.22
|
| Rate for Payer: Multiplan Commercial |
$130.62
|
| Rate for Payer: Preferred Network Access Commercial |
$150.22
|
| Rate for Payer: Quartz Beloit One Network |
$80.01
|
| Rate for Payer: Quartz Commercial |
$97.97
|
| Rate for Payer: WEA Trust Commercial |
$89.80
|
| Rate for Payer: WPS Commercial |
$120.94
|
|
|
HYDROCOLLOID 3.8x3.8 DUODERM
|
Facility
|
OP
|
$157.00
|
|
| Hospital Charge Code |
2963864
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.72 |
| Max. Negotiated Rate |
$150.22 |
| Rate for Payer: Aetna Commercial |
$146.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.42
|
| Rate for Payer: Aetna Managed Medicare |
$45.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$106.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$81.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$78.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.54
|
| Rate for Payer: Cash Price |
$47.10
|
| Rate for Payer: Cigna Commercial |
$150.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.37
|
| Rate for Payer: Health EOS Commercial |
$145.32
|
| Rate for Payer: HFN Commercial |
$150.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$122.46
|
| Rate for Payer: Multiplan Commercial |
$130.62
|
| Rate for Payer: NAPHCARE Commercial |
$97.97
|
| Rate for Payer: Preferred Network Access Commercial |
$150.22
|
| Rate for Payer: Quartz Beloit One Network |
$80.01
|
| Rate for Payer: Quartz Commercial |
$106.13
|
| Rate for Payer: Quartz Medicare Advantage |
$97.97
|
| Rate for Payer: The Alliance Commercial |
$81.64
|
| Rate for Payer: WEA Trust Commercial |
$89.80
|
| Rate for Payer: WPS Commercial |
$120.94
|
|
|
HYDROCOLLOID 5.5x5.5 DUODERM 403327
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
2963706
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Aetna Managed Medicare |
$37.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$87.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$67.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.08
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.62
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: NAPHCARE Commercial |
$80.50
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$87.20
|
| Rate for Payer: Quartz Medicare Advantage |
$80.50
|
| Rate for Payer: The Alliance Commercial |
$67.08
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
HYDROCOLLOID 5.5x5.5 DUODERM 403327
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
2963706
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$65.74 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$80.50
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
HYDROCOLLOID 8x8 DUODERM
|
Facility
|
IP
|
$494.00
|
|
| Hospital Charge Code |
2963466
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$251.74 |
| Max. Negotiated Rate |
$472.66 |
| Rate for Payer: Aetna Commercial |
$462.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$441.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.29
|
| Rate for Payer: Cash Price |
$148.20
|
| Rate for Payer: Cigna Commercial |
$472.66
|
| Rate for Payer: Health EOS Commercial |
$457.25
|
| Rate for Payer: HFN Commercial |
$472.66
|
| Rate for Payer: Multiplan Commercial |
$411.01
|
| Rate for Payer: Preferred Network Access Commercial |
$472.66
|
| Rate for Payer: Quartz Beloit One Network |
$251.74
|
| Rate for Payer: Quartz Commercial |
$308.26
|
| Rate for Payer: WEA Trust Commercial |
$282.57
|
| Rate for Payer: WPS Commercial |
$380.53
|
|
|
HYDROCOLLOID 8x8 DUODERM
|
Facility
|
OP
|
$494.00
|
|
| Hospital Charge Code |
2963466
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$143.85 |
| Max. Negotiated Rate |
$472.66 |
| Rate for Payer: Aetna Commercial |
$462.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$441.83
|
| Rate for Payer: Aetna Managed Medicare |
$143.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$333.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$256.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.29
|
| Rate for Payer: Cash Price |
$148.20
|
| Rate for Payer: Cigna Commercial |
$472.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$287.51
|
| Rate for Payer: Health EOS Commercial |
$457.25
|
| Rate for Payer: HFN Commercial |
$472.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$385.32
|
| Rate for Payer: Multiplan Commercial |
$411.01
|
| Rate for Payer: NAPHCARE Commercial |
$308.26
|
| Rate for Payer: Preferred Network Access Commercial |
$472.66
|
| Rate for Payer: Quartz Beloit One Network |
$251.74
|
| Rate for Payer: Quartz Commercial |
$333.94
|
| Rate for Payer: Quartz Medicare Advantage |
$308.26
|
| Rate for Payer: The Alliance Commercial |
$256.88
|
| Rate for Payer: WEA Trust Commercial |
$282.57
|
| Rate for Payer: WPS Commercial |
$380.53
|
|
|
Hydrocolloid charge
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
HCPCS A6235
|
| Hospital Charge Code |
2844912
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$70.83 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$86.74
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
Hydrocolloid charge
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
HCPCS A6235
|
| Hospital Charge Code |
2844912
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.48 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Aetna Managed Medicare |
$40.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$72.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$69.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.90
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.42
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: NAPHCARE Commercial |
$86.74
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$93.96
|
| Rate for Payer: Quartz Medicare Advantage |
$86.74
|
| Rate for Payer: The Alliance Commercial |
$99.72
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
Hydrofiber charge
|
Facility
|
IP
|
$30.00
|
|
| Hospital Charge Code |
2844924
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna Commercial |
$28.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.54
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$28.70
|
| Rate for Payer: Health EOS Commercial |
$27.77
|
| Rate for Payer: HFN Commercial |
$28.70
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: Preferred Network Access Commercial |
$28.70
|
| Rate for Payer: Quartz Beloit One Network |
$15.29
|
| Rate for Payer: Quartz Commercial |
$18.72
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: WPS Commercial |
$23.11
|
|
|
Hydrofiber charge
|
Facility
|
OP
|
$30.00
|
|
| Hospital Charge Code |
2844924
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna Commercial |
$28.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Aetna Managed Medicare |
$8.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.54
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$28.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.46
|
| Rate for Payer: Health EOS Commercial |
$27.77
|
| Rate for Payer: HFN Commercial |
$28.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.40
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$28.70
|
| Rate for Payer: Quartz Beloit One Network |
$15.29
|
| Rate for Payer: Quartz Commercial |
$20.28
|
| Rate for Payer: Quartz Medicare Advantage |
$18.72
|
| Rate for Payer: The Alliance Commercial |
$15.60
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: WPS Commercial |
$23.11
|
|
|
Hydrofiber silver charge
|
Facility
|
IP
|
$407.00
|
|
| Hospital Charge Code |
2983557
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$207.41 |
| Max. Negotiated Rate |
$389.42 |
| Rate for Payer: Aetna Commercial |
$380.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$364.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$224.34
|
| Rate for Payer: Cash Price |
$122.10
|
| Rate for Payer: Cigna Commercial |
$389.42
|
| Rate for Payer: Health EOS Commercial |
$376.72
|
| Rate for Payer: HFN Commercial |
$389.42
|
| Rate for Payer: Multiplan Commercial |
$338.62
|
| Rate for Payer: Preferred Network Access Commercial |
$389.42
|
| Rate for Payer: Quartz Beloit One Network |
$207.41
|
| Rate for Payer: Quartz Commercial |
$253.97
|
| Rate for Payer: WEA Trust Commercial |
$232.80
|
| Rate for Payer: WPS Commercial |
$313.51
|
|
|
Hydrofiber silver charge
|
Facility
|
OP
|
$407.00
|
|
| Hospital Charge Code |
2983557
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$118.52 |
| Max. Negotiated Rate |
$389.42 |
| Rate for Payer: Aetna Commercial |
$380.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$364.02
|
| Rate for Payer: Aetna Managed Medicare |
$118.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$275.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$211.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$203.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$224.34
|
| Rate for Payer: Cash Price |
$122.10
|
| Rate for Payer: Cigna Commercial |
$389.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$236.87
|
| Rate for Payer: Health EOS Commercial |
$376.72
|
| Rate for Payer: HFN Commercial |
$389.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$317.46
|
| Rate for Payer: Multiplan Commercial |
$338.62
|
| Rate for Payer: NAPHCARE Commercial |
$253.97
|
| Rate for Payer: Preferred Network Access Commercial |
$389.42
|
| Rate for Payer: Quartz Beloit One Network |
$207.41
|
| Rate for Payer: Quartz Commercial |
$275.13
|
| Rate for Payer: Quartz Medicare Advantage |
$253.97
|
| Rate for Payer: The Alliance Commercial |
$211.64
|
| Rate for Payer: WEA Trust Commercial |
$232.80
|
| Rate for Payer: WPS Commercial |
$313.51
|
|
|
Hydrogel charge
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
HCPCS A6248
|
| Hospital Charge Code |
2844923
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$97.84 |
| Max. Negotiated Rate |
$183.71 |
| Rate for Payer: Aetna Commercial |
$179.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.83
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$183.71
|
| Rate for Payer: Health EOS Commercial |
$177.72
|
| Rate for Payer: HFN Commercial |
$183.71
|
| Rate for Payer: Multiplan Commercial |
$159.74
|
| Rate for Payer: Preferred Network Access Commercial |
$183.71
|
| Rate for Payer: Quartz Beloit One Network |
$97.84
|
| Rate for Payer: Quartz Commercial |
$119.81
|
| Rate for Payer: WEA Trust Commercial |
$109.82
|
| Rate for Payer: WPS Commercial |
$147.90
|
|
|
Hydrogel charge
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
HCPCS A6248
|
| Hospital Charge Code |
2844923
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$55.91 |
| Max. Negotiated Rate |
$183.71 |
| Rate for Payer: Aetna Commercial |
$179.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.72
|
| Rate for Payer: Aetna Managed Medicare |
$55.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$129.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$95.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.83
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$183.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.74
|
| Rate for Payer: Health EOS Commercial |
$177.72
|
| Rate for Payer: HFN Commercial |
$183.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$149.76
|
| Rate for Payer: Multiplan Commercial |
$159.74
|
| Rate for Payer: NAPHCARE Commercial |
$119.81
|
| Rate for Payer: Preferred Network Access Commercial |
$183.71
|
| Rate for Payer: Quartz Beloit One Network |
$97.84
|
| Rate for Payer: Quartz Commercial |
$129.79
|
| Rate for Payer: Quartz Medicare Advantage |
$119.81
|
| Rate for Payer: The Alliance Commercial |
$96.30
|
| Rate for Payer: WEA Trust Commercial |
$109.82
|
| Rate for Payer: WPS Commercial |
$147.90
|
|
|
Hydrogel Plugs
|
Facility
|
IP
|
$1,404.00
|
|
|
Service Code
|
HCPCS C2613
|
| Hospital Charge Code |
5577489
|
|
Hospital Revenue Code
|
621
|
| Min. Negotiated Rate |
$715.48 |
| Max. Negotiated Rate |
$1,343.35 |
| Rate for Payer: Aetna Commercial |
$1,314.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,255.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$773.88
|
| Rate for Payer: Cash Price |
$421.20
|
| Rate for Payer: Cigna Commercial |
$1,343.35
|
| Rate for Payer: Health EOS Commercial |
$1,299.54
|
| Rate for Payer: HFN Commercial |
$1,343.35
|
| Rate for Payer: Multiplan Commercial |
$1,168.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,343.35
|
| Rate for Payer: Quartz Beloit One Network |
$715.48
|
| Rate for Payer: Quartz Commercial |
$876.10
|
| Rate for Payer: WEA Trust Commercial |
$803.09
|
| Rate for Payer: WPS Commercial |
$1,081.50
|
|
|
Hydrogel Plugs
|
Professional
|
Both
|
$1,404.00
|
|
|
Service Code
|
HCPCS C2613
|
| Hospital Charge Code |
5577489
|
|
Hospital Revenue Code
|
621
|
| Min. Negotiated Rate |
$642.47 |
| Max. Negotiated Rate |
$1,387.15 |
| Rate for Payer: Aetna Commercial |
$1,387.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,255.74
|
| Rate for Payer: Cash Price |
$421.20
|
| Rate for Payer: Cigna Commercial |
$1,387.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$730.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$876.10
|
| Rate for Payer: Health EOS Commercial |
$1,328.75
|
| Rate for Payer: HFN Commercial |
$1,387.15
|
| Rate for Payer: Multiplan Commercial |
$1,168.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,387.15
|
| Rate for Payer: Quartz Beloit One Network |
$642.47
|
| Rate for Payer: Quartz Commercial |
$832.29
|
| Rate for Payer: The Alliance Commercial |
$730.08
|
| Rate for Payer: WEA Trust Commercial |
$803.09
|
| Rate for Payer: WPS Commercial |
$1,081.50
|
|
|
Hydrogel Plugs
|
Facility
|
OP
|
$1,404.00
|
|
|
Service Code
|
HCPCS C2613
|
| Hospital Charge Code |
5577489
|
|
Hospital Revenue Code
|
621
|
| Min. Negotiated Rate |
$408.84 |
| Max. Negotiated Rate |
$1,343.35 |
| Rate for Payer: Aetna Commercial |
$1,314.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,255.74
|
| Rate for Payer: Aetna Managed Medicare |
$408.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$949.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$730.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$700.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$773.88
|
| Rate for Payer: Cash Price |
$421.20
|
| Rate for Payer: Cigna Commercial |
$1,343.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$817.13
|
| Rate for Payer: Health EOS Commercial |
$1,299.54
|
| Rate for Payer: HFN Commercial |
$1,343.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,095.12
|
| Rate for Payer: Multiplan Commercial |
$1,168.13
|
| Rate for Payer: NAPHCARE Commercial |
$876.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,343.35
|
| Rate for Payer: Quartz Beloit One Network |
$715.48
|
| Rate for Payer: Quartz Commercial |
$949.10
|
| Rate for Payer: Quartz Medicare Advantage |
$876.10
|
| Rate for Payer: The Alliance Commercial |
$730.08
|
| Rate for Payer: WEA Trust Commercial |
$803.09
|
| Rate for Payer: WPS Commercial |
$1,081.50
|
|
|
HYDROGEL SOLO SITE 3oz NON-STE
|
Facility
|
IP
|
$200.00
|
|
| Hospital Charge Code |
2963980
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$101.92 |
| Max. Negotiated Rate |
$191.36 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$124.80
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
HYDROGEL SOLO SITE 3oz NON-STE
|
Facility
|
OP
|
$200.00
|
|
| Hospital Charge Code |
2963980
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$58.24 |
| Max. Negotiated Rate |
$191.36 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Aetna Managed Medicare |
$58.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$135.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$104.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$99.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.40
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$156.00
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: NAPHCARE Commercial |
$124.80
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$135.20
|
| Rate for Payer: Quartz Medicare Advantage |
$124.80
|
| Rate for Payer: The Alliance Commercial |
$104.00
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
HYDROGEL STERILE 8gr INTRASITE
|
Facility
|
IP
|
$93.00
|
|
| Hospital Charge Code |
2963182
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.39 |
| Max. Negotiated Rate |
$88.98 |
| Rate for Payer: Aetna Commercial |
$87.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.26
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$88.98
|
| Rate for Payer: Health EOS Commercial |
$86.08
|
| Rate for Payer: HFN Commercial |
$88.98
|
| Rate for Payer: Multiplan Commercial |
$77.38
|
| Rate for Payer: Preferred Network Access Commercial |
$88.98
|
| Rate for Payer: Quartz Beloit One Network |
$47.39
|
| Rate for Payer: Quartz Commercial |
$58.03
|
| Rate for Payer: WEA Trust Commercial |
$53.20
|
| Rate for Payer: WPS Commercial |
$71.64
|
|
