|
HYDRATOME RX49 CANNULATING M00583000
|
Facility
|
IP
|
$4,991.00
|
|
| Hospital Charge Code |
2973557
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,445.59 |
| Max. Negotiated Rate |
$4,591.72 |
| Rate for Payer: Aetna Commercial |
$4,491.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,292.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,645.23
|
| Rate for Payer: Cash Price |
$1,497.30
|
| Rate for Payer: Cigna Commercial |
$4,591.72
|
| Rate for Payer: Health EOS Commercial |
$4,441.99
|
| Rate for Payer: HFN Commercial |
$4,591.72
|
| Rate for Payer: Multiplan Commercial |
$3,992.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,994.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,591.72
|
| Rate for Payer: Quartz Beloit One Network |
$2,445.59
|
| Rate for Payer: Quartz Commercial |
$2,994.60
|
| Rate for Payer: WEA Trust Commercial |
$2,745.05
|
| Rate for Payer: WPS Commercial |
$3,696.83
|
|
|
HYDROCELECTOMY, PEDIATRIC
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2950480
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
HYDROCELECTOMY, PEDIATRIC
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2950480
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
HYDROCELECTOMY/SPERMATOCELE REPAIR
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960123
|
|
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
|
|
|
HYDROCELECTOMY/SPERMATOCELE REPAIR
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960123
|
|
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
|
|
|
Hydrocodone & Metabolites, Serum
|
Facility
|
OP
|
$148.20
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
6209767
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$41.50 |
| Max. Negotiated Rate |
$592.80 |
| Rate for Payer: Aetna Commercial |
$133.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.45
|
| Rate for Payer: Aetna Managed Medicare |
$41.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$96.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$74.10
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$71.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$78.55
|
| Rate for Payer: Cash Price |
$44.46
|
| Rate for Payer: Cigna Commercial |
$136.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.93
|
| Rate for Payer: Health EOS Commercial |
$131.90
|
| Rate for Payer: HFN Commercial |
$136.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$111.15
|
| Rate for Payer: Multiplan Commercial |
$118.56
|
| Rate for Payer: NAPHCARE Commercial |
$88.92
|
| Rate for Payer: Preferred Network Access Commercial |
$136.34
|
| Rate for Payer: Quartz Beloit One Network |
$72.62
|
| Rate for Payer: Quartz Commercial |
$96.33
|
| Rate for Payer: Quartz Medicare Advantage |
$88.92
|
| Rate for Payer: The Alliance Commercial |
$592.80
|
| Rate for Payer: United Healthcare PPO |
$111.15
|
| Rate for Payer: WEA Trust Commercial |
$81.51
|
| Rate for Payer: WPS Commercial |
$109.77
|
|
|
Hydrocodone & Metabolites, Serum
|
Professional
|
Both
|
$148.20
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
6209767
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.21 |
| Max. Negotiated Rate |
$140.79 |
| Rate for Payer: Aetna Commercial |
$140.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.45
|
| Rate for Payer: Cash Price |
$44.46
|
| Rate for Payer: Cash Price |
$44.46
|
| Rate for Payer: Cigna Commercial |
$140.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$74.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.92
|
| Rate for Payer: Health EOS Commercial |
$134.86
|
| Rate for Payer: HFN Commercial |
$140.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$118.56
|
| Rate for Payer: Preferred Network Access Commercial |
$140.79
|
| Rate for Payer: Quartz Beloit One Network |
$65.21
|
| Rate for Payer: Quartz Commercial |
$84.47
|
| Rate for Payer: The Alliance Commercial |
$74.10
|
| Rate for Payer: WEA Trust Commercial |
$81.51
|
| Rate for Payer: WPS Commercial |
$109.77
|
|
|
Hydrocodone & Metabolites, Serum
|
Facility
|
IP
|
$148.20
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
6209767
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$72.62 |
| Max. Negotiated Rate |
$136.34 |
| Rate for Payer: Aetna Commercial |
$133.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$127.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$78.55
|
| Rate for Payer: Cash Price |
$44.46
|
| Rate for Payer: Cigna Commercial |
$136.34
|
| Rate for Payer: Health EOS Commercial |
$131.90
|
| Rate for Payer: HFN Commercial |
$136.34
|
| Rate for Payer: Multiplan Commercial |
$118.56
|
| Rate for Payer: NAPHCARE Commercial |
$88.92
|
| Rate for Payer: Preferred Network Access Commercial |
$136.34
|
| Rate for Payer: Quartz Beloit One Network |
$72.62
|
| Rate for Payer: Quartz Commercial |
$88.92
|
| Rate for Payer: WEA Trust Commercial |
$81.51
|
| Rate for Payer: WPS Commercial |
$109.77
|
|
|
HYDROCOLLOID 3.8x3.8 DUODERM
|
Facility
|
OP
|
$157.00
|
|
| Hospital Charge Code |
2963864
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.96 |
| Max. Negotiated Rate |
$628.00 |
| Rate for Payer: Aetna Commercial |
$141.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.02
|
| Rate for Payer: Aetna Managed Medicare |
$43.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.21
|
| Rate for Payer: Cash Price |
$47.10
|
| Rate for Payer: Cigna Commercial |
$144.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.86
|
| Rate for Payer: Health EOS Commercial |
$139.73
|
| Rate for Payer: HFN Commercial |
$144.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.75
|
| Rate for Payer: Multiplan Commercial |
$125.60
|
| Rate for Payer: NAPHCARE Commercial |
$94.20
|
| Rate for Payer: Preferred Network Access Commercial |
$144.44
|
| Rate for Payer: Quartz Beloit One Network |
$76.93
|
| Rate for Payer: Quartz Commercial |
$102.05
|
| Rate for Payer: Quartz Medicare Advantage |
$94.20
|
| Rate for Payer: The Alliance Commercial |
$628.00
|
| Rate for Payer: WEA Trust Commercial |
$86.35
|
| Rate for Payer: WPS Commercial |
$116.29
|
|
|
HYDROCOLLOID 3.8x3.8 DUODERM
|
Facility
|
IP
|
$157.00
|
|
| Hospital Charge Code |
2963864
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$76.93 |
| Max. Negotiated Rate |
$144.44 |
| Rate for Payer: Aetna Commercial |
$141.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.21
|
| Rate for Payer: Cash Price |
$47.10
|
| Rate for Payer: Cigna Commercial |
$144.44
|
| Rate for Payer: Health EOS Commercial |
$139.73
|
| Rate for Payer: HFN Commercial |
$144.44
|
| Rate for Payer: Multiplan Commercial |
$125.60
|
| Rate for Payer: NAPHCARE Commercial |
$94.20
|
| Rate for Payer: Preferred Network Access Commercial |
$144.44
|
| Rate for Payer: Quartz Beloit One Network |
$76.93
|
| Rate for Payer: Quartz Commercial |
$94.20
|
| Rate for Payer: WEA Trust Commercial |
$86.35
|
| Rate for Payer: WPS Commercial |
$116.29
|
|
|
HYDROCOLLOID 5.5x5.5 DUODERM 403327
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
2963706
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$63.21 |
| Max. Negotiated Rate |
$118.68 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$77.40
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
HYDROCOLLOID 5.5x5.5 DUODERM 403327
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
2963706
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$36.12 |
| Max. Negotiated Rate |
$516.00 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Aetna Managed Medicare |
$36.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.19
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.75
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$83.85
|
| Rate for Payer: Quartz Medicare Advantage |
$77.40
|
| Rate for Payer: The Alliance Commercial |
$516.00
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
HYDROCOLLOID 8x8 DUODERM
|
Facility
|
IP
|
$494.00
|
|
| Hospital Charge Code |
2963466
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$242.06 |
| Max. Negotiated Rate |
$454.48 |
| Rate for Payer: Aetna Commercial |
$444.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$424.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$261.82
|
| Rate for Payer: Cash Price |
$148.20
|
| Rate for Payer: Cigna Commercial |
$454.48
|
| Rate for Payer: Health EOS Commercial |
$439.66
|
| Rate for Payer: HFN Commercial |
$454.48
|
| Rate for Payer: Multiplan Commercial |
$395.20
|
| Rate for Payer: NAPHCARE Commercial |
$296.40
|
| Rate for Payer: Preferred Network Access Commercial |
$454.48
|
| Rate for Payer: Quartz Beloit One Network |
$242.06
|
| Rate for Payer: Quartz Commercial |
$296.40
|
| Rate for Payer: WEA Trust Commercial |
$271.70
|
| Rate for Payer: WPS Commercial |
$365.91
|
|
|
HYDROCOLLOID 8x8 DUODERM
|
Facility
|
OP
|
$494.00
|
|
| Hospital Charge Code |
2963466
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$138.32 |
| Max. Negotiated Rate |
$1,976.00 |
| Rate for Payer: Aetna Commercial |
$444.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$424.84
|
| Rate for Payer: Aetna Managed Medicare |
$138.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$321.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$247.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$237.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$261.82
|
| Rate for Payer: Cash Price |
$148.20
|
| Rate for Payer: Cigna Commercial |
$454.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$276.44
|
| Rate for Payer: Health EOS Commercial |
$439.66
|
| Rate for Payer: HFN Commercial |
$454.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$370.50
|
| Rate for Payer: Multiplan Commercial |
$395.20
|
| Rate for Payer: NAPHCARE Commercial |
$296.40
|
| Rate for Payer: Preferred Network Access Commercial |
$454.48
|
| Rate for Payer: Quartz Beloit One Network |
$242.06
|
| Rate for Payer: Quartz Commercial |
$321.10
|
| Rate for Payer: Quartz Medicare Advantage |
$296.40
|
| Rate for Payer: The Alliance Commercial |
$1,976.00
|
| Rate for Payer: WEA Trust Commercial |
$271.70
|
| Rate for Payer: WPS Commercial |
$365.91
|
|
|
Hydrocolloid charge
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
HCPCS A6235
|
| Hospital Charge Code |
2844912
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.11 |
| Max. Negotiated Rate |
$127.88 |
| Rate for Payer: Aetna Commercial |
$125.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.67
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$127.88
|
| Rate for Payer: Health EOS Commercial |
$123.71
|
| Rate for Payer: HFN Commercial |
$127.88
|
| Rate for Payer: Multiplan Commercial |
$111.20
|
| Rate for Payer: NAPHCARE Commercial |
$83.40
|
| Rate for Payer: Preferred Network Access Commercial |
$127.88
|
| Rate for Payer: Quartz Beloit One Network |
$68.11
|
| Rate for Payer: Quartz Commercial |
$83.40
|
| Rate for Payer: WEA Trust Commercial |
$76.45
|
| Rate for Payer: WPS Commercial |
$102.96
|
|
|
Hydrocolloid charge
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
HCPCS A6235
|
| Hospital Charge Code |
2844912
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.92 |
| Max. Negotiated Rate |
$556.00 |
| Rate for Payer: Aetna Commercial |
$125.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.54
|
| Rate for Payer: Aetna Managed Medicare |
$38.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$90.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.67
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$127.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.78
|
| Rate for Payer: Health EOS Commercial |
$123.71
|
| Rate for Payer: HFN Commercial |
$127.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$104.25
|
| Rate for Payer: Multiplan Commercial |
$111.20
|
| Rate for Payer: NAPHCARE Commercial |
$83.40
|
| Rate for Payer: Preferred Network Access Commercial |
$127.88
|
| Rate for Payer: Quartz Beloit One Network |
$68.11
|
| Rate for Payer: Quartz Commercial |
$90.35
|
| Rate for Payer: Quartz Medicare Advantage |
$83.40
|
| Rate for Payer: The Alliance Commercial |
$556.00
|
| Rate for Payer: WEA Trust Commercial |
$76.45
|
| Rate for Payer: WPS Commercial |
$102.96
|
|
|
Hydrofiber charge
|
Facility
|
OP
|
$30.00
|
|
| Hospital Charge Code |
2844924
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$27.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.80
|
| Rate for Payer: Aetna Managed Medicare |
$8.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.90
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$27.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.79
|
| Rate for Payer: Health EOS Commercial |
$26.70
|
| Rate for Payer: HFN Commercial |
$27.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.50
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$27.60
|
| Rate for Payer: Quartz Beloit One Network |
$14.70
|
| Rate for Payer: Quartz Commercial |
$19.50
|
| Rate for Payer: Quartz Medicare Advantage |
$18.00
|
| Rate for Payer: The Alliance Commercial |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$16.50
|
| Rate for Payer: WPS Commercial |
$22.22
|
|
|
Hydrofiber charge
|
Facility
|
IP
|
$30.00
|
|
| Hospital Charge Code |
2844924
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$27.60 |
| Rate for Payer: Aetna Commercial |
$27.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.90
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$27.60
|
| Rate for Payer: Health EOS Commercial |
$26.70
|
| Rate for Payer: HFN Commercial |
$27.60
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$27.60
|
| Rate for Payer: Quartz Beloit One Network |
$14.70
|
| Rate for Payer: Quartz Commercial |
$18.00
|
| Rate for Payer: WEA Trust Commercial |
$16.50
|
| Rate for Payer: WPS Commercial |
$22.22
|
|
|
Hydrofiber silver charge
|
Facility
|
OP
|
$407.00
|
|
| Hospital Charge Code |
2983557
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$113.96 |
| Max. Negotiated Rate |
$1,628.00 |
| Rate for Payer: Aetna Commercial |
$366.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$350.02
|
| Rate for Payer: Aetna Managed Medicare |
$113.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$264.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$203.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$195.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.71
|
| Rate for Payer: Cash Price |
$122.10
|
| Rate for Payer: Cigna Commercial |
$374.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$227.76
|
| Rate for Payer: Health EOS Commercial |
$362.23
|
| Rate for Payer: HFN Commercial |
$374.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$305.25
|
| Rate for Payer: Multiplan Commercial |
$325.60
|
| Rate for Payer: NAPHCARE Commercial |
$244.20
|
| Rate for Payer: Preferred Network Access Commercial |
$374.44
|
| Rate for Payer: Quartz Beloit One Network |
$199.43
|
| Rate for Payer: Quartz Commercial |
$264.55
|
| Rate for Payer: Quartz Medicare Advantage |
$244.20
|
| Rate for Payer: The Alliance Commercial |
$1,628.00
|
| Rate for Payer: WEA Trust Commercial |
$223.85
|
| Rate for Payer: WPS Commercial |
$301.46
|
|
|
Hydrofiber silver charge
|
Facility
|
IP
|
$407.00
|
|
| Hospital Charge Code |
2983557
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$199.43 |
| Max. Negotiated Rate |
$374.44 |
| Rate for Payer: Aetna Commercial |
$366.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$350.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.71
|
| Rate for Payer: Cash Price |
$122.10
|
| Rate for Payer: Cigna Commercial |
$374.44
|
| Rate for Payer: Health EOS Commercial |
$362.23
|
| Rate for Payer: HFN Commercial |
$374.44
|
| Rate for Payer: Multiplan Commercial |
$325.60
|
| Rate for Payer: NAPHCARE Commercial |
$244.20
|
| Rate for Payer: Preferred Network Access Commercial |
$374.44
|
| Rate for Payer: Quartz Beloit One Network |
$199.43
|
| Rate for Payer: Quartz Commercial |
$244.20
|
| Rate for Payer: WEA Trust Commercial |
$223.85
|
| Rate for Payer: WPS Commercial |
$301.46
|
|
|
Hydrogel charge
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
HCPCS A6248
|
| Hospital Charge Code |
2844923
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$94.08 |
| Max. Negotiated Rate |
$176.64 |
| Rate for Payer: Aetna Commercial |
$172.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.76
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$176.64
|
| Rate for Payer: Health EOS Commercial |
$170.88
|
| Rate for Payer: HFN Commercial |
$176.64
|
| Rate for Payer: Multiplan Commercial |
$153.60
|
| Rate for Payer: NAPHCARE Commercial |
$115.20
|
| Rate for Payer: Preferred Network Access Commercial |
$176.64
|
| Rate for Payer: Quartz Beloit One Network |
$94.08
|
| Rate for Payer: Quartz Commercial |
$115.20
|
| Rate for Payer: WEA Trust Commercial |
$105.60
|
| Rate for Payer: WPS Commercial |
$142.21
|
|
|
Hydrogel charge
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
HCPCS A6248
|
| Hospital Charge Code |
2844923
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.76 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$172.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.12
|
| Rate for Payer: Aetna Managed Medicare |
$53.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$124.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$96.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$92.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.76
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$176.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$107.44
|
| Rate for Payer: Health EOS Commercial |
$170.88
|
| Rate for Payer: HFN Commercial |
$176.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$144.00
|
| Rate for Payer: Multiplan Commercial |
$153.60
|
| Rate for Payer: NAPHCARE Commercial |
$115.20
|
| Rate for Payer: Preferred Network Access Commercial |
$176.64
|
| Rate for Payer: Quartz Beloit One Network |
$94.08
|
| Rate for Payer: Quartz Commercial |
$124.80
|
| Rate for Payer: Quartz Medicare Advantage |
$115.20
|
| Rate for Payer: The Alliance Commercial |
$768.00
|
| Rate for Payer: WEA Trust Commercial |
$105.60
|
| Rate for Payer: WPS Commercial |
$142.21
|
|
|
Hydrogel Plugs
|
Facility
|
IP
|
$1,404.00
|
|
|
Service Code
|
HCPCS C2613
|
| Hospital Charge Code |
5577489
|
|
Hospital Revenue Code
|
621
|
| Min. Negotiated Rate |
$687.96 |
| Max. Negotiated Rate |
$1,291.68 |
| Rate for Payer: Aetna Commercial |
$1,263.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,207.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$744.12
|
| Rate for Payer: Cash Price |
$421.20
|
| Rate for Payer: Cigna Commercial |
$1,291.68
|
| Rate for Payer: Health EOS Commercial |
$1,249.56
|
| Rate for Payer: HFN Commercial |
$1,291.68
|
| Rate for Payer: Multiplan Commercial |
$1,123.20
|
| Rate for Payer: NAPHCARE Commercial |
$842.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,291.68
|
| Rate for Payer: Quartz Beloit One Network |
$687.96
|
| Rate for Payer: Quartz Commercial |
$842.40
|
| Rate for Payer: WEA Trust Commercial |
$772.20
|
| Rate for Payer: WPS Commercial |
$1,039.94
|
|
|
Hydrogel Plugs
|
Professional
|
Both
|
$1,404.00
|
|
|
Service Code
|
HCPCS C2613
|
| Hospital Charge Code |
5577489
|
|
Hospital Revenue Code
|
621
|
| Min. Negotiated Rate |
$617.76 |
| Max. Negotiated Rate |
$1,333.80 |
| Rate for Payer: Aetna Commercial |
$1,333.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,207.44
|
| Rate for Payer: Cash Price |
$421.20
|
| Rate for Payer: Cigna Commercial |
$1,333.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$702.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$842.40
|
| Rate for Payer: Health EOS Commercial |
$1,277.64
|
| Rate for Payer: HFN Commercial |
$1,333.80
|
| Rate for Payer: Multiplan Commercial |
$1,123.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,333.80
|
| Rate for Payer: Quartz Beloit One Network |
$617.76
|
| Rate for Payer: Quartz Commercial |
$800.28
|
| Rate for Payer: The Alliance Commercial |
$702.00
|
| Rate for Payer: WEA Trust Commercial |
$772.20
|
| Rate for Payer: WPS Commercial |
$1,039.94
|
|
|
Hydrogel Plugs
|
Facility
|
OP
|
$1,404.00
|
|
|
Service Code
|
HCPCS C2613
|
| Hospital Charge Code |
5577489
|
|
Hospital Revenue Code
|
621
|
| Min. Negotiated Rate |
$393.12 |
| Max. Negotiated Rate |
$5,616.00 |
| Rate for Payer: Aetna Commercial |
$1,263.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,207.44
|
| Rate for Payer: Aetna Managed Medicare |
$393.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$912.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$702.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$673.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$744.12
|
| Rate for Payer: Cash Price |
$421.20
|
| Rate for Payer: Cigna Commercial |
$1,291.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$785.68
|
| Rate for Payer: Health EOS Commercial |
$1,249.56
|
| Rate for Payer: HFN Commercial |
$1,291.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,053.00
|
| Rate for Payer: Multiplan Commercial |
$1,123.20
|
| Rate for Payer: NAPHCARE Commercial |
$842.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,291.68
|
| Rate for Payer: Quartz Beloit One Network |
$687.96
|
| Rate for Payer: Quartz Commercial |
$912.60
|
| Rate for Payer: Quartz Medicare Advantage |
$842.40
|
| Rate for Payer: The Alliance Commercial |
$5,616.00
|
| Rate for Payer: WEA Trust Commercial |
$772.20
|
| Rate for Payer: WPS Commercial |
$1,039.94
|
|
