|
INSERT TRIDENT 0 DEG 40MM G 623-00-40G
|
Facility
|
OP
|
$6,096.00
|
|
| Hospital Charge Code |
4519928
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.16 |
| Max. Negotiated Rate |
$5,832.65 |
| Rate for Payer: Aetna Commercial |
$5,705.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,452.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,775.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,120.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,169.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,043.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,360.12
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,832.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,547.87
|
| Rate for Payer: Health EOS Commercial |
$5,642.46
|
| Rate for Payer: HFN Commercial |
$5,832.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,754.88
|
| Rate for Payer: Multiplan Commercial |
$5,071.87
|
| Rate for Payer: NAPHCARE Commercial |
$3,803.90
|
| Rate for Payer: Preferred Network Access Commercial |
$5,832.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,106.52
|
| Rate for Payer: Quartz Commercial |
$4,120.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,803.90
|
| Rate for Payer: The Alliance Commercial |
$3,169.92
|
| Rate for Payer: WEA Trust Commercial |
$3,486.91
|
| Rate for Payer: WPS Commercial |
$4,695.75
|
|
|
INSERT TRIDENT 0 DEG 44MM F 623-00-44F
|
Facility
|
OP
|
$6,096.00
|
|
| Hospital Charge Code |
4263459
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.16 |
| Max. Negotiated Rate |
$5,832.65 |
| Rate for Payer: Aetna Commercial |
$5,705.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,452.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,775.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,120.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,169.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,043.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,360.12
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,832.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,547.87
|
| Rate for Payer: Health EOS Commercial |
$5,642.46
|
| Rate for Payer: HFN Commercial |
$5,832.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,754.88
|
| Rate for Payer: Multiplan Commercial |
$5,071.87
|
| Rate for Payer: NAPHCARE Commercial |
$3,803.90
|
| Rate for Payer: Preferred Network Access Commercial |
$5,832.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,106.52
|
| Rate for Payer: Quartz Commercial |
$4,120.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,803.90
|
| Rate for Payer: The Alliance Commercial |
$3,169.92
|
| Rate for Payer: WEA Trust Commercial |
$3,486.91
|
| Rate for Payer: WPS Commercial |
$4,695.75
|
|
|
INSERT TRIDENT 0 DEG 44MM F 623-00-44F
|
Facility
|
IP
|
$6,096.00
|
|
| Hospital Charge Code |
4263459
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,106.52 |
| Max. Negotiated Rate |
$5,832.65 |
| Rate for Payer: Aetna Commercial |
$5,705.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,452.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,360.12
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,832.65
|
| Rate for Payer: Health EOS Commercial |
$5,642.46
|
| Rate for Payer: HFN Commercial |
$5,832.65
|
| Rate for Payer: Multiplan Commercial |
$5,071.87
|
| Rate for Payer: Preferred Network Access Commercial |
$5,832.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,106.52
|
| Rate for Payer: Quartz Commercial |
$3,803.90
|
| Rate for Payer: WEA Trust Commercial |
$3,486.91
|
| Rate for Payer: WPS Commercial |
$4,695.75
|
|
|
INSERT TRIDENT 0 DEG 44MM G 623-00-44G
|
Facility
|
OP
|
$6,096.00
|
|
| Hospital Charge Code |
4508738
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.16 |
| Max. Negotiated Rate |
$5,832.65 |
| Rate for Payer: Aetna Commercial |
$5,705.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,452.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,775.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,120.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,169.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,043.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,360.12
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,832.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,547.87
|
| Rate for Payer: Health EOS Commercial |
$5,642.46
|
| Rate for Payer: HFN Commercial |
$5,832.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,754.88
|
| Rate for Payer: Multiplan Commercial |
$5,071.87
|
| Rate for Payer: NAPHCARE Commercial |
$3,803.90
|
| Rate for Payer: Preferred Network Access Commercial |
$5,832.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,106.52
|
| Rate for Payer: Quartz Commercial |
$4,120.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,803.90
|
| Rate for Payer: The Alliance Commercial |
$3,169.92
|
| Rate for Payer: WEA Trust Commercial |
$3,486.91
|
| Rate for Payer: WPS Commercial |
$4,695.75
|
|
|
INSERT TRIDENT 0 DEG 44MM G 623-00-44G
|
Facility
|
IP
|
$6,096.00
|
|
| Hospital Charge Code |
4508738
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,106.52 |
| Max. Negotiated Rate |
$5,832.65 |
| Rate for Payer: Aetna Commercial |
$5,705.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,452.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,360.12
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,832.65
|
| Rate for Payer: Health EOS Commercial |
$5,642.46
|
| Rate for Payer: HFN Commercial |
$5,832.65
|
| Rate for Payer: Multiplan Commercial |
$5,071.87
|
| Rate for Payer: Preferred Network Access Commercial |
$5,832.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,106.52
|
| Rate for Payer: Quartz Commercial |
$3,803.90
|
| Rate for Payer: WEA Trust Commercial |
$3,486.91
|
| Rate for Payer: WPS Commercial |
$4,695.75
|
|
|
INSERT TRIDENT 10 DEG 32MM D 623-10-32D
|
Facility
|
OP
|
$6,096.00
|
|
| Hospital Charge Code |
3127481
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.16 |
| Max. Negotiated Rate |
$5,832.65 |
| Rate for Payer: Aetna Commercial |
$5,705.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,452.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,775.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,120.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,169.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,043.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,360.12
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,832.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,547.87
|
| Rate for Payer: Health EOS Commercial |
$5,642.46
|
| Rate for Payer: HFN Commercial |
$5,832.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,754.88
|
| Rate for Payer: Multiplan Commercial |
$5,071.87
|
| Rate for Payer: NAPHCARE Commercial |
$3,803.90
|
| Rate for Payer: Preferred Network Access Commercial |
$5,832.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,106.52
|
| Rate for Payer: Quartz Commercial |
$4,120.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3,803.90
|
| Rate for Payer: The Alliance Commercial |
$3,169.92
|
| Rate for Payer: WEA Trust Commercial |
$3,486.91
|
| Rate for Payer: WPS Commercial |
$4,695.75
|
|
|
INSERT TRIDENT 10 DEG 32MM D 623-10-32D
|
Facility
|
IP
|
$6,096.00
|
|
| Hospital Charge Code |
3127481
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,106.52 |
| Max. Negotiated Rate |
$5,832.65 |
| Rate for Payer: Aetna Commercial |
$5,705.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,452.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,360.12
|
| Rate for Payer: Cash Price |
$1,828.80
|
| Rate for Payer: Cigna Commercial |
$5,832.65
|
| Rate for Payer: Health EOS Commercial |
$5,642.46
|
| Rate for Payer: HFN Commercial |
$5,832.65
|
| Rate for Payer: Multiplan Commercial |
$5,071.87
|
| Rate for Payer: Preferred Network Access Commercial |
$5,832.65
|
| Rate for Payer: Quartz Beloit One Network |
$3,106.52
|
| Rate for Payer: Quartz Commercial |
$3,803.90
|
| Rate for Payer: WEA Trust Commercial |
$3,486.91
|
| Rate for Payer: WPS Commercial |
$4,695.75
|
|
|
INSERT TRIDENT 10 DEG 36MM E 623-10-36E
|
Facility
|
OP
|
$6,332.00
|
|
| Hospital Charge Code |
3365517
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,843.88 |
| Max. Negotiated Rate |
$6,058.46 |
| Rate for Payer: Aetna Commercial |
$5,926.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,663.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,843.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,280.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,292.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,160.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,490.20
|
| Rate for Payer: Cash Price |
$1,899.60
|
| Rate for Payer: Cigna Commercial |
$6,058.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,685.22
|
| Rate for Payer: Health EOS Commercial |
$5,860.90
|
| Rate for Payer: HFN Commercial |
$6,058.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,938.96
|
| Rate for Payer: Multiplan Commercial |
$5,268.22
|
| Rate for Payer: NAPHCARE Commercial |
$3,951.17
|
| Rate for Payer: Preferred Network Access Commercial |
$6,058.46
|
| Rate for Payer: Quartz Beloit One Network |
$3,226.79
|
| Rate for Payer: Quartz Commercial |
$4,280.43
|
| Rate for Payer: Quartz Medicare Advantage |
$3,951.17
|
| Rate for Payer: The Alliance Commercial |
$3,292.64
|
| Rate for Payer: WEA Trust Commercial |
$3,621.90
|
| Rate for Payer: WPS Commercial |
$4,877.54
|
|
|
INSERT TRIDENT 10 DEG 36MM E 623-10-36E
|
Facility
|
IP
|
$6,332.00
|
|
| Hospital Charge Code |
3365517
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,226.79 |
| Max. Negotiated Rate |
$6,058.46 |
| Rate for Payer: Aetna Commercial |
$5,926.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,663.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,490.20
|
| Rate for Payer: Cash Price |
$1,899.60
|
| Rate for Payer: Cigna Commercial |
$6,058.46
|
| Rate for Payer: Health EOS Commercial |
$5,860.90
|
| Rate for Payer: HFN Commercial |
$6,058.46
|
| Rate for Payer: Multiplan Commercial |
$5,268.22
|
| Rate for Payer: Preferred Network Access Commercial |
$6,058.46
|
| Rate for Payer: Quartz Beloit One Network |
$3,226.79
|
| Rate for Payer: Quartz Commercial |
$3,951.17
|
| Rate for Payer: WEA Trust Commercial |
$3,621.90
|
| Rate for Payer: WPS Commercial |
$4,877.54
|
|
|
INSERT TRIDENT 10 DEG 36MM F 623-10-36F
|
Facility
|
IP
|
$7,603.00
|
|
| Hospital Charge Code |
3072475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,874.49 |
| Max. Negotiated Rate |
$7,274.55 |
| Rate for Payer: Aetna Commercial |
$7,116.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,800.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,190.77
|
| Rate for Payer: Cash Price |
$2,280.90
|
| Rate for Payer: Cigna Commercial |
$7,274.55
|
| Rate for Payer: Health EOS Commercial |
$7,037.34
|
| Rate for Payer: HFN Commercial |
$7,274.55
|
| Rate for Payer: Multiplan Commercial |
$6,325.70
|
| Rate for Payer: Preferred Network Access Commercial |
$7,274.55
|
| Rate for Payer: Quartz Beloit One Network |
$3,874.49
|
| Rate for Payer: Quartz Commercial |
$4,744.27
|
| Rate for Payer: WEA Trust Commercial |
$4,348.92
|
| Rate for Payer: WPS Commercial |
$5,856.59
|
|
|
INSERT TRIDENT 10 DEG 36MM F 623-10-36F
|
Facility
|
OP
|
$7,603.00
|
|
| Hospital Charge Code |
3072475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,213.99 |
| Max. Negotiated Rate |
$7,274.55 |
| Rate for Payer: Aetna Commercial |
$7,116.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,800.12
|
| Rate for Payer: Aetna Managed Medicare |
$2,213.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,139.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,953.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,795.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,190.77
|
| Rate for Payer: Cash Price |
$2,280.90
|
| Rate for Payer: Cigna Commercial |
$7,274.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,424.95
|
| Rate for Payer: Health EOS Commercial |
$7,037.34
|
| Rate for Payer: HFN Commercial |
$7,274.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,930.34
|
| Rate for Payer: Multiplan Commercial |
$6,325.70
|
| Rate for Payer: NAPHCARE Commercial |
$4,744.27
|
| Rate for Payer: Preferred Network Access Commercial |
$7,274.55
|
| Rate for Payer: Quartz Beloit One Network |
$3,874.49
|
| Rate for Payer: Quartz Commercial |
$5,139.63
|
| Rate for Payer: Quartz Medicare Advantage |
$4,744.27
|
| Rate for Payer: The Alliance Commercial |
$3,953.56
|
| Rate for Payer: WEA Trust Commercial |
$4,348.92
|
| Rate for Payer: WPS Commercial |
$5,856.59
|
|
|
INSERT TRIDENT 10 DEG 36MM G 623-10-36G
|
Facility
|
IP
|
$6,450.00
|
|
| Hospital Charge Code |
5179170
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,286.92 |
| Max. Negotiated Rate |
$6,171.36 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$1,935.00
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,024.80
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.44
|
|
|
INSERT TRIDENT 10 DEG 36MM G 623-10-36G
|
Facility
|
OP
|
$6,450.00
|
|
| Hospital Charge Code |
5179170
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,878.24 |
| Max. Negotiated Rate |
$6,171.36 |
| Rate for Payer: Aetna Commercial |
$6,037.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,768.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,878.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,360.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,354.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,219.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,555.24
|
| Rate for Payer: Cash Price |
$1,935.00
|
| Rate for Payer: Cigna Commercial |
$6,171.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,753.90
|
| Rate for Payer: Health EOS Commercial |
$5,970.12
|
| Rate for Payer: HFN Commercial |
$6,171.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,031.00
|
| Rate for Payer: Multiplan Commercial |
$5,366.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,024.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,171.36
|
| Rate for Payer: Quartz Beloit One Network |
$3,286.92
|
| Rate for Payer: Quartz Commercial |
$4,360.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4,024.80
|
| Rate for Payer: The Alliance Commercial |
$3,354.00
|
| Rate for Payer: WEA Trust Commercial |
$3,689.40
|
| Rate for Payer: WPS Commercial |
$4,968.44
|
|
|
INSERT TRIDENT X3 POLYETHYLENE 0DEG 36MM 723-00-36D
|
Facility
|
IP
|
$6,384.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6212958
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,253.29 |
| Max. Negotiated Rate |
$6,108.21 |
| Rate for Payer: Aetna Commercial |
$5,975.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,709.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,518.86
|
| Rate for Payer: Cash Price |
$1,915.20
|
| Rate for Payer: Cigna Commercial |
$6,108.21
|
| Rate for Payer: Health EOS Commercial |
$5,909.03
|
| Rate for Payer: HFN Commercial |
$6,108.21
|
| Rate for Payer: Multiplan Commercial |
$5,311.49
|
| Rate for Payer: Preferred Network Access Commercial |
$6,108.21
|
| Rate for Payer: Quartz Beloit One Network |
$3,253.29
|
| Rate for Payer: Quartz Commercial |
$3,983.62
|
| Rate for Payer: WEA Trust Commercial |
$3,651.65
|
| Rate for Payer: WPS Commercial |
$4,917.60
|
|
|
INSERT TRIDENT X3 POLYETHYLENE 0DEG 36MM 723-00-36D
|
Facility
|
OP
|
$6,384.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6212958
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,859.02 |
| Max. Negotiated Rate |
$6,108.21 |
| Rate for Payer: Aetna Commercial |
$5,975.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,709.85
|
| Rate for Payer: Aetna Managed Medicare |
$1,859.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,315.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,319.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,186.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,518.86
|
| Rate for Payer: Cash Price |
$1,915.20
|
| Rate for Payer: Cigna Commercial |
$6,108.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,715.49
|
| Rate for Payer: Health EOS Commercial |
$5,909.03
|
| Rate for Payer: HFN Commercial |
$6,108.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,979.52
|
| Rate for Payer: Multiplan Commercial |
$5,311.49
|
| Rate for Payer: NAPHCARE Commercial |
$3,983.62
|
| Rate for Payer: Preferred Network Access Commercial |
$6,108.21
|
| Rate for Payer: Quartz Beloit One Network |
$3,253.29
|
| Rate for Payer: Quartz Commercial |
$4,315.58
|
| Rate for Payer: Quartz Medicare Advantage |
$3,983.62
|
| Rate for Payer: The Alliance Commercial |
$3,319.68
|
| Rate for Payer: WEA Trust Commercial |
$3,651.65
|
| Rate for Payer: WPS Commercial |
$4,917.60
|
|
|
INSERT TUNNELED CV CATH 36558
|
Professional
|
Both
|
$3,724.00
|
|
|
Service Code
|
CPT 36558
|
| Hospital Charge Code |
3014532
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$223.70 |
| Max. Negotiated Rate |
$3,679.31 |
| Rate for Payer: Aetna Commercial |
$3,679.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,330.75
|
| Rate for Payer: Aetna Managed Medicare |
$223.70
|
| Rate for Payer: Anthem Medicare Advantage |
$223.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$223.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$223.70
|
| Rate for Payer: Cash Price |
$1,117.20
|
| Rate for Payer: Cash Price |
$1,117.20
|
| Rate for Payer: Cash Price |
$1,117.20
|
| Rate for Payer: Cigna Commercial |
$3,679.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$697.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$223.70
|
| Rate for Payer: Health EOS Commercial |
$3,524.39
|
| Rate for Payer: HFN Commercial |
$3,679.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$897.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$897.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$223.70
|
| Rate for Payer: Multiplan Commercial |
$3,098.37
|
| Rate for Payer: NAPHCARE Commercial |
$335.56
|
| Rate for Payer: Preferred Network Access Commercial |
$3,679.31
|
| Rate for Payer: Quartz Beloit One Network |
$1,704.10
|
| Rate for Payer: Quartz Commercial |
$2,207.59
|
| Rate for Payer: Quartz Medicare Advantage |
$223.70
|
| Rate for Payer: The Alliance Commercial |
$950.74
|
| Rate for Payer: United Healthcare Medicaid |
$697.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$223.70
|
| Rate for Payer: WEA Trust Commercial |
$2,130.13
|
| Rate for Payer: WPS Commercial |
$1,006.67
|
|
|
INSERT TUNNELED CV CATH 3655822
|
Professional
|
Both
|
$4,471.00
|
|
|
Service Code
|
CPT 36558 22
|
| Hospital Charge Code |
5190612
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$697.91 |
| Max. Negotiated Rate |
$4,417.35 |
| Rate for Payer: Aetna Commercial |
$4,417.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,998.86
|
| Rate for Payer: Cash Price |
$1,341.30
|
| Rate for Payer: Cash Price |
$1,341.30
|
| Rate for Payer: Cash Price |
$1,341.30
|
| Rate for Payer: Cigna Commercial |
$4,417.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$697.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,789.90
|
| Rate for Payer: Health EOS Commercial |
$4,231.35
|
| Rate for Payer: HFN Commercial |
$4,417.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$897.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$897.09
|
| Rate for Payer: Multiplan Commercial |
$3,719.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,417.35
|
| Rate for Payer: Quartz Beloit One Network |
$2,045.93
|
| Rate for Payer: Quartz Commercial |
$2,650.41
|
| Rate for Payer: The Alliance Commercial |
$2,324.92
|
| Rate for Payer: United Healthcare Medicaid |
$697.91
|
| Rate for Payer: WEA Trust Commercial |
$2,557.41
|
| Rate for Payer: WPS Commercial |
$3,444.01
|
|
|
INSERT TUNNELED CV CATH 36561
|
Professional
|
Both
|
$4,450.00
|
|
|
Service Code
|
CPT 36561
|
| Hospital Charge Code |
3014533
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$285.63 |
| Max. Negotiated Rate |
$4,396.60 |
| Rate for Payer: Aetna Commercial |
$4,396.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,980.08
|
| Rate for Payer: Aetna Managed Medicare |
$285.63
|
| Rate for Payer: Anthem Medicare Advantage |
$285.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$285.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$285.63
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cigna Commercial |
$4,396.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,058.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$285.63
|
| Rate for Payer: Health EOS Commercial |
$4,211.48
|
| Rate for Payer: HFN Commercial |
$4,396.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,145.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,145.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$285.63
|
| Rate for Payer: Multiplan Commercial |
$3,702.40
|
| Rate for Payer: NAPHCARE Commercial |
$428.44
|
| Rate for Payer: Preferred Network Access Commercial |
$4,396.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,036.32
|
| Rate for Payer: Quartz Commercial |
$2,637.96
|
| Rate for Payer: Quartz Medicare Advantage |
$285.63
|
| Rate for Payer: The Alliance Commercial |
$1,213.91
|
| Rate for Payer: United Healthcare Medicaid |
$1,058.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$285.63
|
| Rate for Payer: WEA Trust Commercial |
$2,545.40
|
| Rate for Payer: WPS Commercial |
$1,285.32
|
|
|
INSOLE PEGASSIST MENS XLG PTQM4
|
Facility
|
OP
|
$229.00
|
|
| Hospital Charge Code |
2974301
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$66.68 |
| Max. Negotiated Rate |
$219.11 |
| Rate for Payer: Aetna Commercial |
$214.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.82
|
| Rate for Payer: Aetna Managed Medicare |
$66.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$154.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$119.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$114.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.22
|
| Rate for Payer: Cash Price |
$68.70
|
| Rate for Payer: Cigna Commercial |
$219.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$133.28
|
| Rate for Payer: Health EOS Commercial |
$211.96
|
| Rate for Payer: HFN Commercial |
$219.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$178.62
|
| Rate for Payer: Multiplan Commercial |
$190.53
|
| Rate for Payer: NAPHCARE Commercial |
$142.90
|
| Rate for Payer: Preferred Network Access Commercial |
$219.11
|
| Rate for Payer: Quartz Beloit One Network |
$116.70
|
| Rate for Payer: Quartz Commercial |
$154.80
|
| Rate for Payer: Quartz Medicare Advantage |
$142.90
|
| Rate for Payer: The Alliance Commercial |
$119.08
|
| Rate for Payer: WEA Trust Commercial |
$130.99
|
| Rate for Payer: WPS Commercial |
$176.40
|
|
|
INSOLE PEGASSIST MENS XLG PTQM4
|
Facility
|
IP
|
$229.00
|
|
| Hospital Charge Code |
2974301
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$116.70 |
| Max. Negotiated Rate |
$219.11 |
| Rate for Payer: Aetna Commercial |
$214.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.22
|
| Rate for Payer: Cash Price |
$68.70
|
| Rate for Payer: Cigna Commercial |
$219.11
|
| Rate for Payer: Health EOS Commercial |
$211.96
|
| Rate for Payer: HFN Commercial |
$219.11
|
| Rate for Payer: Multiplan Commercial |
$190.53
|
| Rate for Payer: Preferred Network Access Commercial |
$219.11
|
| Rate for Payer: Quartz Beloit One Network |
$116.70
|
| Rate for Payer: Quartz Commercial |
$142.90
|
| Rate for Payer: WEA Trust Commercial |
$130.99
|
| Rate for Payer: WPS Commercial |
$176.40
|
|
|
INSTILLATION(S) OF THERAPEUTIC AGENT INTO RENAL PELVIS AND/OR URETER THROUGH ESTABLISHED NEPHROSTOMY, PYELOSTOMY OR URETEROSTOMY TUBE (EG, ANTICARCINOGENIC OR ANTIFUNGAL AGENT)
|
Facility
|
OP
|
$4,386.95
|
|
|
Service Code
|
CPT 50391
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$262.93 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Managed Medicare |
$262.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,030.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,388.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,270.32
|
| Rate for Payer: Anthem Medicare Advantage |
$262.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$262.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$262.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$262.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$262.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$978.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$262.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$262.93
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$262.93
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$262.93
|
| Rate for Payer: NAPHCARE Commercial |
$394.40
|
| Rate for Payer: Quartz Medicare Advantage |
$262.93
|
| Rate for Payer: The Alliance Commercial |
$1,051.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$262.93
|
| Rate for Payer: United Healthcare PPO |
$2,347.28
|
| Rate for Payer: Wellcare Medicare |
$262.93
|
|
|
INSTL THER AGENT RENAL PELVIS&/URETER VIA TUBE 50391
|
Professional
|
Both
|
$849.00
|
|
|
Service Code
|
CPT 50391
|
| Hospital Charge Code |
6174993
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$81.89 |
| Max. Negotiated Rate |
$838.81 |
| Rate for Payer: Aetna Commercial |
$838.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$759.35
|
| Rate for Payer: Aetna Managed Medicare |
$81.89
|
| Rate for Payer: Anthem Medicare Advantage |
$81.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$81.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$81.89
|
| Rate for Payer: Cash Price |
$254.70
|
| Rate for Payer: Cash Price |
$254.70
|
| Rate for Payer: Cash Price |
$254.70
|
| Rate for Payer: Cigna Commercial |
$838.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$126.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.89
|
| Rate for Payer: Health EOS Commercial |
$803.49
|
| Rate for Payer: HFN Commercial |
$838.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$340.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$340.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$81.89
|
| Rate for Payer: Multiplan Commercial |
$706.37
|
| Rate for Payer: NAPHCARE Commercial |
$122.83
|
| Rate for Payer: Preferred Network Access Commercial |
$838.81
|
| Rate for Payer: Quartz Beloit One Network |
$388.50
|
| Rate for Payer: Quartz Commercial |
$503.29
|
| Rate for Payer: Quartz Medicare Advantage |
$81.89
|
| Rate for Payer: The Alliance Commercial |
$348.03
|
| Rate for Payer: United Healthcare Medicaid |
$126.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$81.89
|
| Rate for Payer: WEA Trust Commercial |
$485.63
|
| Rate for Payer: WPS Commercial |
$368.50
|
|
|
INSTRUMENT MAGNET LARGE 20 X 16 DYNJMDL1
|
Facility
|
OP
|
$209.00
|
|
| Hospital Charge Code |
2963086
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$60.86 |
| Max. Negotiated Rate |
$199.97 |
| Rate for Payer: Aetna Commercial |
$195.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.93
|
| Rate for Payer: Aetna Managed Medicare |
$60.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$141.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$108.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$104.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.20
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$199.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.64
|
| Rate for Payer: Health EOS Commercial |
$193.45
|
| Rate for Payer: HFN Commercial |
$199.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$163.02
|
| Rate for Payer: Multiplan Commercial |
$173.89
|
| Rate for Payer: NAPHCARE Commercial |
$130.42
|
| Rate for Payer: Preferred Network Access Commercial |
$199.97
|
| Rate for Payer: Quartz Beloit One Network |
$106.51
|
| Rate for Payer: Quartz Commercial |
$141.28
|
| Rate for Payer: Quartz Medicare Advantage |
$130.42
|
| Rate for Payer: The Alliance Commercial |
$108.68
|
| Rate for Payer: WEA Trust Commercial |
$119.55
|
| Rate for Payer: WPS Commercial |
$160.99
|
|
|
INSTRUMENT MAGNET LARGE 20 X 16 DYNJMDL1
|
Facility
|
IP
|
$209.00
|
|
| Hospital Charge Code |
2963086
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$106.51 |
| Max. Negotiated Rate |
$199.97 |
| Rate for Payer: Aetna Commercial |
$195.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$186.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.20
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$199.97
|
| Rate for Payer: Health EOS Commercial |
$193.45
|
| Rate for Payer: HFN Commercial |
$199.97
|
| Rate for Payer: Multiplan Commercial |
$173.89
|
| Rate for Payer: Preferred Network Access Commercial |
$199.97
|
| Rate for Payer: Quartz Beloit One Network |
$106.51
|
| Rate for Payer: Quartz Commercial |
$130.42
|
| Rate for Payer: WEA Trust Commercial |
$119.55
|
| Rate for Payer: WPS Commercial |
$160.99
|
|
|
INSTRUMENT PACK EASYFUSE MID/HIND FOOT FFSP1530
|
Facility
|
OP
|
$3,074.00
|
|
| Hospital Charge Code |
6200963
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$895.15 |
| Max. Negotiated Rate |
$2,941.20 |
| Rate for Payer: Aetna Commercial |
$2,877.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,749.39
|
| Rate for Payer: Aetna Managed Medicare |
$895.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,078.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,598.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,534.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,694.39
|
| Rate for Payer: Cash Price |
$922.20
|
| Rate for Payer: Cigna Commercial |
$2,941.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,789.07
|
| Rate for Payer: Health EOS Commercial |
$2,845.29
|
| Rate for Payer: HFN Commercial |
$2,941.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,397.72
|
| Rate for Payer: Multiplan Commercial |
$2,557.57
|
| Rate for Payer: NAPHCARE Commercial |
$1,918.18
|
| Rate for Payer: Preferred Network Access Commercial |
$2,941.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,566.51
|
| Rate for Payer: Quartz Commercial |
$2,078.02
|
| Rate for Payer: Quartz Medicare Advantage |
$1,918.18
|
| Rate for Payer: The Alliance Commercial |
$1,598.48
|
| Rate for Payer: WEA Trust Commercial |
$1,758.33
|
| Rate for Payer: WPS Commercial |
$2,367.90
|
|
