|
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
|
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 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 PACK EASYFUSE MID/HIND FOOT FFSP1530
|
Facility
|
IP
|
$3,074.00
|
|
| Hospital Charge Code |
6200963
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,566.51 |
| 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: 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: Health EOS Commercial |
$2,845.29
|
| Rate for Payer: HFN Commercial |
$2,941.20
|
| Rate for Payer: Multiplan Commercial |
$2,557.57
|
| 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 |
$1,918.18
|
| Rate for Payer: WEA Trust Commercial |
$1,758.33
|
| Rate for Payer: WPS Commercial |
$2,367.90
|
|
|
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
|
|
|
INSTRUMENT PACK WITH BLADE PROSTEP MIS STERILE 57S1MI07
|
Facility
|
OP
|
$3,171.00
|
|
| Hospital Charge Code |
6172006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$923.40 |
| Max. Negotiated Rate |
$3,034.01 |
| Rate for Payer: Aetna Commercial |
$2,968.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,836.14
|
| Rate for Payer: Aetna Managed Medicare |
$923.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,143.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,648.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,582.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,747.86
|
| Rate for Payer: Cash Price |
$951.30
|
| Rate for Payer: Cigna Commercial |
$3,034.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,845.52
|
| Rate for Payer: Health EOS Commercial |
$2,935.08
|
| Rate for Payer: HFN Commercial |
$3,034.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,473.38
|
| Rate for Payer: Multiplan Commercial |
$2,638.27
|
| Rate for Payer: NAPHCARE Commercial |
$1,978.70
|
| Rate for Payer: Preferred Network Access Commercial |
$3,034.01
|
| Rate for Payer: Quartz Beloit One Network |
$1,615.94
|
| Rate for Payer: Quartz Commercial |
$2,143.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,978.70
|
| Rate for Payer: The Alliance Commercial |
$1,648.92
|
| Rate for Payer: WEA Trust Commercial |
$1,813.81
|
| Rate for Payer: WPS Commercial |
$2,442.62
|
|
|
INSTRUMENT PACK WITH BLADE PROSTEP MIS STERILE 57S1MI07
|
Facility
|
IP
|
$3,171.00
|
|
| Hospital Charge Code |
6172006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,615.94 |
| Max. Negotiated Rate |
$3,034.01 |
| Rate for Payer: Aetna Commercial |
$2,968.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,836.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,747.86
|
| Rate for Payer: Cash Price |
$951.30
|
| Rate for Payer: Cigna Commercial |
$3,034.01
|
| Rate for Payer: Health EOS Commercial |
$2,935.08
|
| Rate for Payer: HFN Commercial |
$3,034.01
|
| Rate for Payer: Multiplan Commercial |
$2,638.27
|
| Rate for Payer: Preferred Network Access Commercial |
$3,034.01
|
| Rate for Payer: Quartz Beloit One Network |
$1,615.94
|
| Rate for Payer: Quartz Commercial |
$1,978.70
|
| Rate for Payer: WEA Trust Commercial |
$1,813.81
|
| Rate for Payer: WPS Commercial |
$2,442.62
|
|
|
INSTRUMENTS DUAFIT SET A06 10401
|
Facility
|
IP
|
$3,947.00
|
|
| Hospital Charge Code |
6021650
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,011.39 |
| Max. Negotiated Rate |
$3,776.49 |
| Rate for Payer: Aetna Commercial |
$3,694.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,530.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,175.59
|
| Rate for Payer: Cash Price |
$1,184.10
|
| Rate for Payer: Cigna Commercial |
$3,776.49
|
| Rate for Payer: Health EOS Commercial |
$3,653.34
|
| Rate for Payer: HFN Commercial |
$3,776.49
|
| Rate for Payer: Multiplan Commercial |
$3,283.90
|
| Rate for Payer: Preferred Network Access Commercial |
$3,776.49
|
| Rate for Payer: Quartz Beloit One Network |
$2,011.39
|
| Rate for Payer: Quartz Commercial |
$2,462.93
|
| Rate for Payer: WEA Trust Commercial |
$2,257.68
|
| Rate for Payer: WPS Commercial |
$3,040.37
|
|
|
INSTRUMENTS DUAFIT SET A06 10401
|
Facility
|
OP
|
$3,947.00
|
|
| Hospital Charge Code |
6021650
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,149.37 |
| Max. Negotiated Rate |
$3,776.49 |
| Rate for Payer: Aetna Commercial |
$3,694.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,530.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,149.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,668.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,052.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,970.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,175.59
|
| Rate for Payer: Cash Price |
$1,184.10
|
| Rate for Payer: Cigna Commercial |
$3,776.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,297.15
|
| Rate for Payer: Health EOS Commercial |
$3,653.34
|
| Rate for Payer: HFN Commercial |
$3,776.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,078.66
|
| Rate for Payer: Multiplan Commercial |
$3,283.90
|
| Rate for Payer: NAPHCARE Commercial |
$2,462.93
|
| Rate for Payer: Preferred Network Access Commercial |
$3,776.49
|
| Rate for Payer: Quartz Beloit One Network |
$2,011.39
|
| Rate for Payer: Quartz Commercial |
$2,668.17
|
| Rate for Payer: Quartz Medicare Advantage |
$2,462.93
|
| Rate for Payer: The Alliance Commercial |
$2,052.44
|
| Rate for Payer: WEA Trust Commercial |
$2,257.68
|
| Rate for Payer: WPS Commercial |
$3,040.37
|
|
|
INSTRUMENT SET CARTIVA 8MM DISPOSABLE MTK-08
|
Facility
|
IP
|
$3,903.00
|
|
| Hospital Charge Code |
5831679
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,988.97 |
| Max. Negotiated Rate |
$3,734.39 |
| Rate for Payer: Aetna Commercial |
$3,653.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,490.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,151.33
|
| Rate for Payer: Cash Price |
$1,170.90
|
| Rate for Payer: Cigna Commercial |
$3,734.39
|
| Rate for Payer: Health EOS Commercial |
$3,612.62
|
| Rate for Payer: HFN Commercial |
$3,734.39
|
| Rate for Payer: Multiplan Commercial |
$3,247.30
|
| Rate for Payer: Preferred Network Access Commercial |
$3,734.39
|
| Rate for Payer: Quartz Beloit One Network |
$1,988.97
|
| Rate for Payer: Quartz Commercial |
$2,435.47
|
| Rate for Payer: WEA Trust Commercial |
$2,232.52
|
| Rate for Payer: WPS Commercial |
$3,006.48
|
|
|
INSTRUMENT SET CARTIVA 8MM DISPOSABLE MTK-08
|
Facility
|
OP
|
$3,903.00
|
|
| Hospital Charge Code |
5831679
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,136.55 |
| Max. Negotiated Rate |
$3,734.39 |
| Rate for Payer: Aetna Commercial |
$3,653.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,490.84
|
| Rate for Payer: Aetna Managed Medicare |
$1,136.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,638.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,029.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,948.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,151.33
|
| Rate for Payer: Cash Price |
$1,170.90
|
| Rate for Payer: Cigna Commercial |
$3,734.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,271.55
|
| Rate for Payer: Health EOS Commercial |
$3,612.62
|
| Rate for Payer: HFN Commercial |
$3,734.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,044.34
|
| Rate for Payer: Multiplan Commercial |
$3,247.30
|
| Rate for Payer: NAPHCARE Commercial |
$2,435.47
|
| Rate for Payer: Preferred Network Access Commercial |
$3,734.39
|
| Rate for Payer: Quartz Beloit One Network |
$1,988.97
|
| Rate for Payer: Quartz Commercial |
$2,638.43
|
| Rate for Payer: Quartz Medicare Advantage |
$2,435.47
|
| Rate for Payer: The Alliance Commercial |
$2,029.56
|
| Rate for Payer: WEA Trust Commercial |
$2,232.52
|
| Rate for Payer: WPS Commercial |
$3,006.48
|
|
|
INSTRUMENTS OSTEOCHANDRAL FLAP REPAIR SINGLE SHOT (DISP) AR-4009S
|
Facility
|
OP
|
$2,997.00
|
|
| Hospital Charge Code |
5885644
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$872.73 |
| Max. Negotiated Rate |
$2,867.53 |
| Rate for Payer: Aetna Commercial |
$2,805.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,680.52
|
| Rate for Payer: Aetna Managed Medicare |
$872.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,025.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,558.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,496.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,651.95
|
| Rate for Payer: Cash Price |
$899.10
|
| Rate for Payer: Cigna Commercial |
$2,867.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,744.25
|
| Rate for Payer: Health EOS Commercial |
$2,774.02
|
| Rate for Payer: HFN Commercial |
$2,867.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,337.66
|
| Rate for Payer: Multiplan Commercial |
$2,493.50
|
| Rate for Payer: NAPHCARE Commercial |
$1,870.13
|
| Rate for Payer: Preferred Network Access Commercial |
$2,867.53
|
| Rate for Payer: Quartz Beloit One Network |
$1,527.27
|
| Rate for Payer: Quartz Commercial |
$2,025.97
|
| Rate for Payer: Quartz Medicare Advantage |
$1,870.13
|
| Rate for Payer: The Alliance Commercial |
$1,558.44
|
| Rate for Payer: WEA Trust Commercial |
$1,714.28
|
| Rate for Payer: WPS Commercial |
$2,308.59
|
|
|
INSTRUMENTS OSTEOCHANDRAL FLAP REPAIR SINGLE SHOT (DISP) AR-4009S
|
Facility
|
IP
|
$2,997.00
|
|
| Hospital Charge Code |
5885644
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,527.27 |
| Max. Negotiated Rate |
$2,867.53 |
| Rate for Payer: Aetna Commercial |
$2,805.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,680.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,651.95
|
| Rate for Payer: Cash Price |
$899.10
|
| Rate for Payer: Cigna Commercial |
$2,867.53
|
| Rate for Payer: Health EOS Commercial |
$2,774.02
|
| Rate for Payer: HFN Commercial |
$2,867.53
|
| Rate for Payer: Multiplan Commercial |
$2,493.50
|
| Rate for Payer: Preferred Network Access Commercial |
$2,867.53
|
| Rate for Payer: Quartz Beloit One Network |
$1,527.27
|
| Rate for Payer: Quartz Commercial |
$1,870.13
|
| Rate for Payer: WEA Trust Commercial |
$1,714.28
|
| Rate for Payer: WPS Commercial |
$2,308.59
|
|
|
INSTRUMENTS RTS LESSER MTP M04 S0001
|
Facility
|
OP
|
$3,197.00
|
|
| Hospital Charge Code |
6021651
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$930.97 |
| Max. Negotiated Rate |
$3,058.89 |
| Rate for Payer: Aetna Commercial |
$2,992.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,859.40
|
| Rate for Payer: Aetna Managed Medicare |
$930.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,161.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,662.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,595.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,762.19
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$3,058.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,860.65
|
| Rate for Payer: Health EOS Commercial |
$2,959.14
|
| Rate for Payer: HFN Commercial |
$3,058.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,493.66
|
| Rate for Payer: Multiplan Commercial |
$2,659.90
|
| Rate for Payer: NAPHCARE Commercial |
$1,994.93
|
| Rate for Payer: Preferred Network Access Commercial |
$3,058.89
|
| Rate for Payer: Quartz Beloit One Network |
$1,629.19
|
| Rate for Payer: Quartz Commercial |
$2,161.17
|
| Rate for Payer: Quartz Medicare Advantage |
$1,994.93
|
| Rate for Payer: The Alliance Commercial |
$1,662.44
|
| Rate for Payer: WEA Trust Commercial |
$1,828.68
|
| Rate for Payer: WPS Commercial |
$2,462.65
|
|
|
INSTRUMENTS RTS LESSER MTP M04 S0001
|
Facility
|
IP
|
$3,197.00
|
|
| Hospital Charge Code |
6021651
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,629.19 |
| Max. Negotiated Rate |
$3,058.89 |
| Rate for Payer: Aetna Commercial |
$2,992.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,859.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,762.19
|
| Rate for Payer: Cash Price |
$959.10
|
| Rate for Payer: Cigna Commercial |
$3,058.89
|
| Rate for Payer: Health EOS Commercial |
$2,959.14
|
| Rate for Payer: HFN Commercial |
$3,058.89
|
| Rate for Payer: Multiplan Commercial |
$2,659.90
|
| Rate for Payer: Preferred Network Access Commercial |
$3,058.89
|
| Rate for Payer: Quartz Beloit One Network |
$1,629.19
|
| Rate for Payer: Quartz Commercial |
$1,994.93
|
| Rate for Payer: WEA Trust Commercial |
$1,828.68
|
| Rate for Payer: WPS Commercial |
$2,462.65
|
|
|
INSTRUMENTS RTS SZ 1-2 M03 S0002
|
Facility
|
IP
|
$3,885.00
|
|
| Hospital Charge Code |
6131658
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,979.80 |
| Max. Negotiated Rate |
$3,717.17 |
| Rate for Payer: Aetna Commercial |
$3,636.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,474.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,141.41
|
| Rate for Payer: Cash Price |
$1,165.50
|
| Rate for Payer: Cigna Commercial |
$3,717.17
|
| Rate for Payer: Health EOS Commercial |
$3,595.96
|
| Rate for Payer: HFN Commercial |
$3,717.17
|
| Rate for Payer: Multiplan Commercial |
$3,232.32
|
| Rate for Payer: Preferred Network Access Commercial |
$3,717.17
|
| Rate for Payer: Quartz Beloit One Network |
$1,979.80
|
| Rate for Payer: Quartz Commercial |
$2,424.24
|
| Rate for Payer: WEA Trust Commercial |
$2,222.22
|
| Rate for Payer: WPS Commercial |
$2,992.62
|
|
|
INSTRUMENTS RTS SZ 1-2 M03 S0002
|
Facility
|
OP
|
$3,885.00
|
|
| Hospital Charge Code |
6131658
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,131.31 |
| Max. Negotiated Rate |
$3,717.17 |
| Rate for Payer: Aetna Commercial |
$3,636.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,474.74
|
| Rate for Payer: Aetna Managed Medicare |
$1,131.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,626.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,020.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,939.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,141.41
|
| Rate for Payer: Cash Price |
$1,165.50
|
| Rate for Payer: Cigna Commercial |
$3,717.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,261.07
|
| Rate for Payer: Health EOS Commercial |
$3,595.96
|
| Rate for Payer: HFN Commercial |
$3,717.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,030.30
|
| Rate for Payer: Multiplan Commercial |
$3,232.32
|
| Rate for Payer: NAPHCARE Commercial |
$2,424.24
|
| Rate for Payer: Preferred Network Access Commercial |
$3,717.17
|
| Rate for Payer: Quartz Beloit One Network |
$1,979.80
|
| Rate for Payer: Quartz Commercial |
$2,626.26
|
| Rate for Payer: Quartz Medicare Advantage |
$2,424.24
|
| Rate for Payer: The Alliance Commercial |
$2,020.20
|
| Rate for Payer: WEA Trust Commercial |
$2,222.22
|
| Rate for Payer: WPS Commercial |
$2,992.62
|
|
|
Insulin Antibody
|
Facility
|
IP
|
$418.00
|
|
|
Service Code
|
CPT 86337
|
| Hospital Charge Code |
977996
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$213.01 |
| Max. Negotiated Rate |
$399.94 |
| Rate for Payer: Aetna Commercial |
$391.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$373.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$230.40
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$399.94
|
| Rate for Payer: Health EOS Commercial |
$386.90
|
| Rate for Payer: HFN Commercial |
$399.94
|
| Rate for Payer: Multiplan Commercial |
$347.78
|
| Rate for Payer: Preferred Network Access Commercial |
$399.94
|
| Rate for Payer: Quartz Beloit One Network |
$213.01
|
| Rate for Payer: Quartz Commercial |
$260.83
|
| Rate for Payer: WEA Trust Commercial |
$239.10
|
| Rate for Payer: WPS Commercial |
$321.99
|
|
|
Insulin Antibody
|
Facility
|
OP
|
$418.00
|
|
|
Service Code
|
CPT 86337
|
| Hospital Charge Code |
977996
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.27 |
| Max. Negotiated Rate |
$399.94 |
| Rate for Payer: Aetna Commercial |
$391.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$373.86
|
| Rate for Payer: Aetna Managed Medicare |
$22.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$38.97
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.96
|
| Rate for Payer: Anthem Medicare Advantage |
$22.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$230.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$22.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$22.27
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$399.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$22.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$243.28
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$22.27
|
| Rate for Payer: Health EOS Commercial |
$386.90
|
| Rate for Payer: HFN Commercial |
$399.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$22.27
|
| Rate for Payer: Independent Care Health Plan Medicare |
$22.27
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$22.27
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$22.27
|
| Rate for Payer: Multiplan Commercial |
$347.78
|
| Rate for Payer: NAPHCARE Commercial |
$33.40
|
| Rate for Payer: Preferred Network Access Commercial |
$399.94
|
| Rate for Payer: Quartz Beloit One Network |
$213.01
|
| Rate for Payer: Quartz Commercial |
$282.57
|
| Rate for Payer: Quartz Medicare Advantage |
$22.27
|
| Rate for Payer: The Alliance Commercial |
$89.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.27
|
| Rate for Payer: United Healthcare PPO |
$326.04
|
| Rate for Payer: WEA Trust Commercial |
$239.10
|
| Rate for Payer: Wellcare Medicare |
$22.27
|
| Rate for Payer: WPS Commercial |
$321.99
|
|
|
Insulin Antibody
|
Professional
|
Both
|
$418.00
|
|
|
Service Code
|
CPT 86337
|
| Hospital Charge Code |
977996
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.27 |
| Max. Negotiated Rate |
$412.98 |
| Rate for Payer: Aetna Commercial |
$412.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$373.86
|
| Rate for Payer: Aetna Managed Medicare |
$22.27
|
| Rate for Payer: Anthem Medicare Advantage |
$22.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$22.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$22.27
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$412.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$217.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.27
|
| Rate for Payer: Health EOS Commercial |
$395.60
|
| Rate for Payer: HFN Commercial |
$412.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$78.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$22.27
|
| Rate for Payer: Multiplan Commercial |
$347.78
|
| Rate for Payer: NAPHCARE Commercial |
$33.40
|
| Rate for Payer: Preferred Network Access Commercial |
$412.98
|
| Rate for Payer: Quartz Beloit One Network |
$191.28
|
| Rate for Payer: Quartz Commercial |
$247.79
|
| Rate for Payer: Quartz Medicare Advantage |
$22.27
|
| Rate for Payer: The Alliance Commercial |
$87.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.27
|
| Rate for Payer: WEA Trust Commercial |
$239.10
|
| Rate for Payer: WPS Commercial |
$97.97
|
|
|
Insulin Injection J1815
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
4017969
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$3.74
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
Insulin Injection J1815
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
4017969
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Aetna Managed Medicare |
$1.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.49
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: NAPHCARE Commercial |
$3.74
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$4.06
|
| Rate for Payer: Quartz Medicare Advantage |
$3.74
|
| Rate for Payer: The Alliance Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
Insulin Injection J1815
|
Professional
|
Both
|
$6.00
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
4017969
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$5.93 |
| Rate for Payer: Aetna Commercial |
$5.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.74
|
| Rate for Payer: Health EOS Commercial |
$5.68
|
| Rate for Payer: HFN Commercial |
$5.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.36
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5.93
|
| Rate for Payer: Quartz Beloit One Network |
$2.75
|
| Rate for Payer: Quartz Commercial |
$3.56
|
| Rate for Payer: The Alliance Commercial |
$3.12
|
| Rate for Payer: United Healthcare Medicaid |
$0.94
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
