|
KIT CTS RELIEF 9971
|
Facility
|
IP
|
$1,912.00
|
|
| Hospital Charge Code |
2964882
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$974.36 |
| Max. Negotiated Rate |
$1,829.40 |
| Rate for Payer: Aetna Commercial |
$1,789.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,710.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,053.89
|
| Rate for Payer: Cash Price |
$573.60
|
| Rate for Payer: Cigna Commercial |
$1,829.40
|
| Rate for Payer: Health EOS Commercial |
$1,769.75
|
| Rate for Payer: HFN Commercial |
$1,829.40
|
| Rate for Payer: Multiplan Commercial |
$1,590.78
|
| Rate for Payer: Preferred Network Access Commercial |
$1,829.40
|
| Rate for Payer: Quartz Beloit One Network |
$974.36
|
| Rate for Payer: Quartz Commercial |
$1,193.09
|
| Rate for Payer: WEA Trust Commercial |
$1,093.66
|
| Rate for Payer: WPS Commercial |
$1,472.81
|
|
|
KIT CTS RELIEF 9971
|
Facility
|
OP
|
$1,912.00
|
|
| Hospital Charge Code |
2964882
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$556.77 |
| Max. Negotiated Rate |
$1,829.40 |
| Rate for Payer: Aetna Commercial |
$1,789.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,710.09
|
| Rate for Payer: Aetna Managed Medicare |
$556.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,292.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$994.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$954.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,053.89
|
| Rate for Payer: Cash Price |
$573.60
|
| Rate for Payer: Cigna Commercial |
$1,829.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,112.78
|
| Rate for Payer: Health EOS Commercial |
$1,769.75
|
| Rate for Payer: HFN Commercial |
$1,829.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,491.36
|
| Rate for Payer: Multiplan Commercial |
$1,590.78
|
| Rate for Payer: NAPHCARE Commercial |
$1,193.09
|
| Rate for Payer: Preferred Network Access Commercial |
$1,829.40
|
| Rate for Payer: Quartz Beloit One Network |
$974.36
|
| Rate for Payer: Quartz Commercial |
$1,292.51
|
| Rate for Payer: Quartz Medicare Advantage |
$1,193.09
|
| Rate for Payer: The Alliance Commercial |
$994.24
|
| Rate for Payer: WEA Trust Commercial |
$1,093.66
|
| Rate for Payer: WPS Commercial |
$1,472.81
|
|
|
KIT CUSTOM MANIFOLD (QTY OF 10) K09-10187
|
Facility
|
IP
|
$370.00
|
|
| Hospital Charge Code |
2972968
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$188.55 |
| Max. Negotiated Rate |
$354.02 |
| Rate for Payer: Aetna Commercial |
$346.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.94
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$354.02
|
| Rate for Payer: Health EOS Commercial |
$342.47
|
| Rate for Payer: HFN Commercial |
$354.02
|
| Rate for Payer: Multiplan Commercial |
$307.84
|
| Rate for Payer: Preferred Network Access Commercial |
$354.02
|
| Rate for Payer: Quartz Beloit One Network |
$188.55
|
| Rate for Payer: Quartz Commercial |
$230.88
|
| Rate for Payer: WEA Trust Commercial |
$211.64
|
| Rate for Payer: WPS Commercial |
$285.01
|
|
|
KIT CUSTOM MANIFOLD (QTY OF 10) K09-10187
|
Facility
|
OP
|
$370.00
|
|
| Hospital Charge Code |
2972968
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$107.74 |
| Max. Negotiated Rate |
$354.02 |
| Rate for Payer: Aetna Commercial |
$346.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.93
|
| Rate for Payer: Aetna Managed Medicare |
$107.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$250.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$192.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$184.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.94
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$354.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$215.34
|
| Rate for Payer: Health EOS Commercial |
$342.47
|
| Rate for Payer: HFN Commercial |
$354.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$288.60
|
| Rate for Payer: Multiplan Commercial |
$307.84
|
| Rate for Payer: NAPHCARE Commercial |
$230.88
|
| Rate for Payer: Preferred Network Access Commercial |
$354.02
|
| Rate for Payer: Quartz Beloit One Network |
$188.55
|
| Rate for Payer: Quartz Commercial |
$250.12
|
| Rate for Payer: Quartz Medicare Advantage |
$230.88
|
| Rate for Payer: The Alliance Commercial |
$192.40
|
| Rate for Payer: WEA Trust Commercial |
$211.64
|
| Rate for Payer: WPS Commercial |
$285.01
|
|
|
KIT CV MULTI LUMEN 7-8F SHEATH ARWAK21142SK
|
Facility
|
OP
|
$1,564.00
|
|
| Hospital Charge Code |
3065500
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$455.44 |
| Max. Negotiated Rate |
$1,496.44 |
| Rate for Payer: Aetna Commercial |
$1,463.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,398.84
|
| Rate for Payer: Aetna Managed Medicare |
$455.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,057.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$813.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$780.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$862.08
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$1,496.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$910.25
|
| Rate for Payer: Health EOS Commercial |
$1,447.64
|
| Rate for Payer: HFN Commercial |
$1,496.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,219.92
|
| Rate for Payer: Multiplan Commercial |
$1,301.25
|
| Rate for Payer: NAPHCARE Commercial |
$975.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,496.44
|
| Rate for Payer: Quartz Beloit One Network |
$797.01
|
| Rate for Payer: Quartz Commercial |
$1,057.26
|
| Rate for Payer: Quartz Medicare Advantage |
$975.94
|
| Rate for Payer: The Alliance Commercial |
$813.28
|
| Rate for Payer: WEA Trust Commercial |
$894.61
|
| Rate for Payer: WPS Commercial |
$1,204.75
|
|
|
KIT CV MULTI LUMEN 7-8F SHEATH ARWAK21142SK
|
Facility
|
IP
|
$1,564.00
|
|
| Hospital Charge Code |
3065500
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$797.01 |
| Max. Negotiated Rate |
$1,496.44 |
| Rate for Payer: Aetna Commercial |
$1,463.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,398.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$862.08
|
| Rate for Payer: Cash Price |
$469.20
|
| Rate for Payer: Cigna Commercial |
$1,496.44
|
| Rate for Payer: Health EOS Commercial |
$1,447.64
|
| Rate for Payer: HFN Commercial |
$1,496.44
|
| Rate for Payer: Multiplan Commercial |
$1,301.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1,496.44
|
| Rate for Payer: Quartz Beloit One Network |
$797.01
|
| Rate for Payer: Quartz Commercial |
$975.94
|
| Rate for Payer: WEA Trust Commercial |
$894.61
|
| Rate for Payer: WPS Commercial |
$1,204.75
|
|
|
KIT DEMAYO KNEE POSITIONER 803-GP-10
|
Facility
|
OP
|
$518.00
|
|
| Hospital Charge Code |
2965163
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$150.84 |
| Max. Negotiated Rate |
$495.62 |
| Rate for Payer: Aetna Commercial |
$484.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$463.30
|
| Rate for Payer: Aetna Managed Medicare |
$150.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$258.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$285.52
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$495.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$301.48
|
| Rate for Payer: Health EOS Commercial |
$479.46
|
| Rate for Payer: HFN Commercial |
$495.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.04
|
| Rate for Payer: Multiplan Commercial |
$430.98
|
| Rate for Payer: NAPHCARE Commercial |
$323.23
|
| Rate for Payer: Preferred Network Access Commercial |
$495.62
|
| Rate for Payer: Quartz Beloit One Network |
$263.97
|
| Rate for Payer: Quartz Commercial |
$350.17
|
| Rate for Payer: Quartz Medicare Advantage |
$323.23
|
| Rate for Payer: The Alliance Commercial |
$269.36
|
| Rate for Payer: WEA Trust Commercial |
$296.30
|
| Rate for Payer: WPS Commercial |
$399.02
|
|
|
KIT DEMAYO KNEE POSITIONER 803-GP-10
|
Facility
|
IP
|
$518.00
|
|
| Hospital Charge Code |
2965163
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$263.97 |
| Max. Negotiated Rate |
$495.62 |
| Rate for Payer: Aetna Commercial |
$484.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$463.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$285.52
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cigna Commercial |
$495.62
|
| Rate for Payer: Health EOS Commercial |
$479.46
|
| Rate for Payer: HFN Commercial |
$495.62
|
| Rate for Payer: Multiplan Commercial |
$430.98
|
| Rate for Payer: Preferred Network Access Commercial |
$495.62
|
| Rate for Payer: Quartz Beloit One Network |
$263.97
|
| Rate for Payer: Quartz Commercial |
$323.23
|
| Rate for Payer: WEA Trust Commercial |
$296.30
|
| Rate for Payer: WPS Commercial |
$399.02
|
|
|
KIT DISP DX KNOTLESS FIBERTAK AR-8991DS
|
Facility
|
OP
|
$2,601.00
|
|
| Hospital Charge Code |
6181680
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$757.41 |
| Max. Negotiated Rate |
$2,488.64 |
| Rate for Payer: Aetna Commercial |
$2,434.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,326.33
|
| Rate for Payer: Aetna Managed Medicare |
$757.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,758.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,352.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,298.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,433.67
|
| Rate for Payer: Cash Price |
$780.30
|
| Rate for Payer: Cigna Commercial |
$2,488.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,513.78
|
| Rate for Payer: Health EOS Commercial |
$2,407.49
|
| Rate for Payer: HFN Commercial |
$2,488.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,028.78
|
| Rate for Payer: Multiplan Commercial |
$2,164.03
|
| Rate for Payer: NAPHCARE Commercial |
$1,623.02
|
| Rate for Payer: Preferred Network Access Commercial |
$2,488.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,325.47
|
| Rate for Payer: Quartz Commercial |
$1,758.28
|
| Rate for Payer: Quartz Medicare Advantage |
$1,623.02
|
| Rate for Payer: The Alliance Commercial |
$1,352.52
|
| Rate for Payer: WEA Trust Commercial |
$1,487.77
|
| Rate for Payer: WPS Commercial |
$2,003.55
|
|
|
KIT DISP DX KNOTLESS FIBERTAK AR-8991DS
|
Facility
|
IP
|
$2,601.00
|
|
| Hospital Charge Code |
6181680
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.47 |
| Max. Negotiated Rate |
$2,488.64 |
| Rate for Payer: Aetna Commercial |
$2,434.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,326.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,433.67
|
| Rate for Payer: Cash Price |
$780.30
|
| Rate for Payer: Cigna Commercial |
$2,488.64
|
| Rate for Payer: Health EOS Commercial |
$2,407.49
|
| Rate for Payer: HFN Commercial |
$2,488.64
|
| Rate for Payer: Multiplan Commercial |
$2,164.03
|
| Rate for Payer: Preferred Network Access Commercial |
$2,488.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,325.47
|
| Rate for Payer: Quartz Commercial |
$1,623.02
|
| Rate for Payer: WEA Trust Commercial |
$1,487.77
|
| Rate for Payer: WPS Commercial |
$2,003.55
|
|
|
KIT DISP INSTR 3.9MM KNOTLESS CORKSCREW AR-1941DS
|
Facility
|
IP
|
$4,490.00
|
|
| Hospital Charge Code |
5547341
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,288.10 |
| Max. Negotiated Rate |
$4,296.03 |
| Rate for Payer: Aetna Commercial |
$4,202.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,015.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,474.89
|
| Rate for Payer: Cash Price |
$1,347.00
|
| Rate for Payer: Cigna Commercial |
$4,296.03
|
| Rate for Payer: Health EOS Commercial |
$4,155.94
|
| Rate for Payer: HFN Commercial |
$4,296.03
|
| Rate for Payer: Multiplan Commercial |
$3,735.68
|
| Rate for Payer: Preferred Network Access Commercial |
$4,296.03
|
| Rate for Payer: Quartz Beloit One Network |
$2,288.10
|
| Rate for Payer: Quartz Commercial |
$2,801.76
|
| Rate for Payer: WEA Trust Commercial |
$2,568.28
|
| Rate for Payer: WPS Commercial |
$3,458.65
|
|
|
KIT DISP INSTR 3.9MM KNOTLESS CORKSCREW AR-1941DS
|
Facility
|
OP
|
$4,490.00
|
|
| Hospital Charge Code |
5547341
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,307.49 |
| Max. Negotiated Rate |
$4,296.03 |
| Rate for Payer: Aetna Commercial |
$4,202.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,015.86
|
| Rate for Payer: Aetna Managed Medicare |
$1,307.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,035.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,334.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,241.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,474.89
|
| Rate for Payer: Cash Price |
$1,347.00
|
| Rate for Payer: Cigna Commercial |
$4,296.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,613.18
|
| Rate for Payer: Health EOS Commercial |
$4,155.94
|
| Rate for Payer: HFN Commercial |
$4,296.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,502.20
|
| Rate for Payer: Multiplan Commercial |
$3,735.68
|
| Rate for Payer: NAPHCARE Commercial |
$2,801.76
|
| Rate for Payer: Preferred Network Access Commercial |
$4,296.03
|
| Rate for Payer: Quartz Beloit One Network |
$2,288.10
|
| Rate for Payer: Quartz Commercial |
$3,035.24
|
| Rate for Payer: Quartz Medicare Advantage |
$2,801.76
|
| Rate for Payer: The Alliance Commercial |
$2,334.80
|
| Rate for Payer: WEA Trust Commercial |
$2,568.28
|
| Rate for Payer: WPS Commercial |
$3,458.65
|
|
|
KIT DISP SWIVELOCK 3.5 X 8.5MM AR-8978DS
|
Facility
|
OP
|
$4,182.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4632645
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,217.80 |
| Max. Negotiated Rate |
$4,001.34 |
| Rate for Payer: Aetna Commercial |
$3,914.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,740.38
|
| Rate for Payer: Aetna Managed Medicare |
$1,217.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,827.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,174.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,087.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,305.12
|
| Rate for Payer: Cash Price |
$1,254.60
|
| Rate for Payer: Cigna Commercial |
$4,001.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,433.92
|
| Rate for Payer: Health EOS Commercial |
$3,870.86
|
| Rate for Payer: HFN Commercial |
$4,001.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,261.96
|
| Rate for Payer: Multiplan Commercial |
$3,479.42
|
| Rate for Payer: NAPHCARE Commercial |
$2,609.57
|
| Rate for Payer: Preferred Network Access Commercial |
$4,001.34
|
| Rate for Payer: Quartz Beloit One Network |
$2,131.15
|
| Rate for Payer: Quartz Commercial |
$2,827.03
|
| Rate for Payer: Quartz Medicare Advantage |
$2,609.57
|
| Rate for Payer: The Alliance Commercial |
$2,174.64
|
| Rate for Payer: WEA Trust Commercial |
$2,392.10
|
| Rate for Payer: WPS Commercial |
$3,221.39
|
|
|
KIT DISP SWIVELOCK 3.5 X 8.5MM AR-8978DS
|
Facility
|
IP
|
$4,182.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4632645
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.15 |
| Max. Negotiated Rate |
$4,001.34 |
| Rate for Payer: Aetna Commercial |
$3,914.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,740.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,305.12
|
| Rate for Payer: Cash Price |
$1,254.60
|
| Rate for Payer: Cigna Commercial |
$4,001.34
|
| Rate for Payer: Health EOS Commercial |
$3,870.86
|
| Rate for Payer: HFN Commercial |
$4,001.34
|
| Rate for Payer: Multiplan Commercial |
$3,479.42
|
| Rate for Payer: Preferred Network Access Commercial |
$4,001.34
|
| Rate for Payer: Quartz Beloit One Network |
$2,131.15
|
| Rate for Payer: Quartz Commercial |
$2,609.57
|
| Rate for Payer: WEA Trust Commercial |
$2,392.10
|
| Rate for Payer: WPS Commercial |
$3,221.39
|
|
|
KIT DRAINAGE ESSENTIAL 4992508
|
Facility
|
OP
|
$5,624.00
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
6153670
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,637.71 |
| Max. Negotiated Rate |
$5,381.04 |
| Rate for Payer: Aetna Commercial |
$5,264.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,030.11
|
| Rate for Payer: Aetna Managed Medicare |
$1,637.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,801.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,924.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,807.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,099.95
|
| Rate for Payer: Cash Price |
$1,687.20
|
| Rate for Payer: Cigna Commercial |
$5,381.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,273.17
|
| Rate for Payer: Health EOS Commercial |
$5,205.57
|
| Rate for Payer: HFN Commercial |
$5,381.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,386.72
|
| Rate for Payer: Multiplan Commercial |
$4,679.17
|
| Rate for Payer: NAPHCARE Commercial |
$3,509.38
|
| Rate for Payer: Preferred Network Access Commercial |
$5,381.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,865.99
|
| Rate for Payer: Quartz Commercial |
$3,801.82
|
| Rate for Payer: Quartz Medicare Advantage |
$3,509.38
|
| Rate for Payer: The Alliance Commercial |
$2,924.48
|
| Rate for Payer: WEA Trust Commercial |
$3,216.93
|
| Rate for Payer: WPS Commercial |
$4,332.17
|
|
|
KIT DRAINAGE ESSENTIAL 4992508
|
Facility
|
IP
|
$5,624.00
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
6153670
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,865.99 |
| Max. Negotiated Rate |
$5,381.04 |
| Rate for Payer: Aetna Commercial |
$5,264.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,030.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,099.95
|
| Rate for Payer: Cash Price |
$1,687.20
|
| Rate for Payer: Cigna Commercial |
$5,381.04
|
| Rate for Payer: Health EOS Commercial |
$5,205.57
|
| Rate for Payer: HFN Commercial |
$5,381.04
|
| Rate for Payer: Multiplan Commercial |
$4,679.17
|
| Rate for Payer: Preferred Network Access Commercial |
$5,381.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,865.99
|
| Rate for Payer: Quartz Commercial |
$3,509.38
|
| Rate for Payer: WEA Trust Commercial |
$3,216.93
|
| Rate for Payer: WPS Commercial |
$4,332.17
|
|
|
KIT DRAINAGE STARTER KIT 4992509
|
Facility
|
OP
|
$3,028.00
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
6153679
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.75 |
| Max. Negotiated Rate |
$2,897.19 |
| Rate for Payer: Aetna Commercial |
$2,834.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,708.24
|
| Rate for Payer: Aetna Managed Medicare |
$881.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,046.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,574.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,511.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,669.03
|
| Rate for Payer: Cash Price |
$908.40
|
| Rate for Payer: Cigna Commercial |
$2,897.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,762.30
|
| Rate for Payer: Health EOS Commercial |
$2,802.72
|
| Rate for Payer: HFN Commercial |
$2,897.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,361.84
|
| Rate for Payer: Multiplan Commercial |
$2,519.30
|
| Rate for Payer: NAPHCARE Commercial |
$1,889.47
|
| Rate for Payer: Preferred Network Access Commercial |
$2,897.19
|
| Rate for Payer: Quartz Beloit One Network |
$1,543.07
|
| Rate for Payer: Quartz Commercial |
$2,046.93
|
| Rate for Payer: Quartz Medicare Advantage |
$1,889.47
|
| Rate for Payer: The Alliance Commercial |
$1,574.56
|
| Rate for Payer: WEA Trust Commercial |
$1,732.02
|
| Rate for Payer: WPS Commercial |
$2,332.47
|
|
|
KIT DRAINAGE STARTER KIT 4992509
|
Facility
|
IP
|
$3,028.00
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
6153679
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,543.07 |
| Max. Negotiated Rate |
$2,897.19 |
| Rate for Payer: Aetna Commercial |
$2,834.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,708.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,669.03
|
| Rate for Payer: Cash Price |
$908.40
|
| Rate for Payer: Cigna Commercial |
$2,897.19
|
| Rate for Payer: Health EOS Commercial |
$2,802.72
|
| Rate for Payer: HFN Commercial |
$2,897.19
|
| Rate for Payer: Multiplan Commercial |
$2,519.30
|
| Rate for Payer: Preferred Network Access Commercial |
$2,897.19
|
| Rate for Payer: Quartz Beloit One Network |
$1,543.07
|
| Rate for Payer: Quartz Commercial |
$1,889.47
|
| Rate for Payer: WEA Trust Commercial |
$1,732.02
|
| Rate for Payer: WPS Commercial |
$2,332.47
|
|
|
Kit Duo Trach
|
Facility
|
OP
|
$175.00
|
|
| Hospital Charge Code |
3101738
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$167.44 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Aetna Managed Medicare |
$50.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$118.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$91.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$87.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$96.46
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$101.85
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$167.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.50
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: NAPHCARE Commercial |
$109.20
|
| Rate for Payer: Preferred Network Access Commercial |
$167.44
|
| Rate for Payer: Quartz Beloit One Network |
$89.18
|
| Rate for Payer: Quartz Commercial |
$118.30
|
| Rate for Payer: Quartz Medicare Advantage |
$109.20
|
| Rate for Payer: The Alliance Commercial |
$91.00
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.80
|
|
|
Kit Duo Trach
|
Facility
|
IP
|
$175.00
|
|
| Hospital Charge Code |
3101738
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$89.18 |
| Max. Negotiated Rate |
$167.44 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$96.46
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$167.44
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: Preferred Network Access Commercial |
$167.44
|
| Rate for Payer: Quartz Beloit One Network |
$89.18
|
| Rate for Payer: Quartz Commercial |
$109.20
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.80
|
|
|
KIT ENDOSCOPIC FOG DEFOGGER 220-50
|
Facility
|
OP
|
$93.00
|
|
| Hospital Charge Code |
2963695
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.08 |
| Max. Negotiated Rate |
$88.98 |
| Rate for Payer: Aetna Commercial |
$87.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.18
|
| Rate for Payer: Aetna Managed Medicare |
$27.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.26
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$88.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.13
|
| Rate for Payer: Health EOS Commercial |
$86.08
|
| Rate for Payer: HFN Commercial |
$88.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.54
|
| Rate for Payer: Multiplan Commercial |
$77.38
|
| Rate for Payer: NAPHCARE Commercial |
$58.03
|
| Rate for Payer: Preferred Network Access Commercial |
$88.98
|
| Rate for Payer: Quartz Beloit One Network |
$47.39
|
| Rate for Payer: Quartz Commercial |
$62.87
|
| Rate for Payer: Quartz Medicare Advantage |
$58.03
|
| Rate for Payer: The Alliance Commercial |
$48.36
|
| Rate for Payer: WEA Trust Commercial |
$53.20
|
| Rate for Payer: WPS Commercial |
$71.64
|
|
|
KIT ENDOSCOPIC FOG DEFOGGER 220-50
|
Facility
|
IP
|
$93.00
|
|
| Hospital Charge Code |
2963695
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.39 |
| Max. Negotiated Rate |
$88.98 |
| Rate for Payer: Aetna Commercial |
$87.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.26
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$88.98
|
| Rate for Payer: Health EOS Commercial |
$86.08
|
| Rate for Payer: HFN Commercial |
$88.98
|
| Rate for Payer: Multiplan Commercial |
$77.38
|
| Rate for Payer: Preferred Network Access Commercial |
$88.98
|
| Rate for Payer: Quartz Beloit One Network |
$47.39
|
| Rate for Payer: Quartz Commercial |
$58.03
|
| Rate for Payer: WEA Trust Commercial |
$53.20
|
| Rate for Payer: WPS Commercial |
$71.64
|
|
|
KIT ESSENTIAL PG #04494-10
|
Facility
|
IP
|
$808.00
|
|
| Hospital Charge Code |
2973508
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$411.76 |
| Max. Negotiated Rate |
$773.09 |
| Rate for Payer: Aetna Commercial |
$756.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$722.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$445.37
|
| Rate for Payer: Cash Price |
$242.40
|
| Rate for Payer: Cigna Commercial |
$773.09
|
| Rate for Payer: Health EOS Commercial |
$747.88
|
| Rate for Payer: HFN Commercial |
$773.09
|
| Rate for Payer: Multiplan Commercial |
$672.26
|
| Rate for Payer: Preferred Network Access Commercial |
$773.09
|
| Rate for Payer: Quartz Beloit One Network |
$411.76
|
| Rate for Payer: Quartz Commercial |
$504.19
|
| Rate for Payer: WEA Trust Commercial |
$462.18
|
| Rate for Payer: WPS Commercial |
$622.40
|
|
|
KIT ESSENTIAL PG #04494-10
|
Facility
|
OP
|
$808.00
|
|
| Hospital Charge Code |
2973508
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$235.29 |
| Max. Negotiated Rate |
$773.09 |
| Rate for Payer: Aetna Commercial |
$756.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$722.68
|
| Rate for Payer: Aetna Managed Medicare |
$235.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$546.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$420.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$403.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$445.37
|
| Rate for Payer: Cash Price |
$242.40
|
| Rate for Payer: Cigna Commercial |
$773.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$470.26
|
| Rate for Payer: Health EOS Commercial |
$747.88
|
| Rate for Payer: HFN Commercial |
$773.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$630.24
|
| Rate for Payer: Multiplan Commercial |
$672.26
|
| Rate for Payer: NAPHCARE Commercial |
$504.19
|
| Rate for Payer: Preferred Network Access Commercial |
$773.09
|
| Rate for Payer: Quartz Beloit One Network |
$411.76
|
| Rate for Payer: Quartz Commercial |
$546.21
|
| Rate for Payer: Quartz Medicare Advantage |
$504.19
|
| Rate for Payer: The Alliance Commercial |
$420.16
|
| Rate for Payer: WEA Trust Commercial |
$462.18
|
| Rate for Payer: WPS Commercial |
$622.40
|
|
|
KIT EXPECTANT FATHERS X-LARGE SCRUB DISPOSABLE
|
Facility
|
OP
|
$157.00
|
|
| Hospital Charge Code |
2963271
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$45.72 |
| Max. Negotiated Rate |
$150.22 |
| Rate for Payer: Aetna Commercial |
$146.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.42
|
| Rate for Payer: Aetna Managed Medicare |
$45.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$106.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$81.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$78.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.54
|
| Rate for Payer: Cash Price |
$47.10
|
| Rate for Payer: Cigna Commercial |
$150.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.37
|
| Rate for Payer: Health EOS Commercial |
$145.32
|
| Rate for Payer: HFN Commercial |
$150.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$122.46
|
| Rate for Payer: Multiplan Commercial |
$130.62
|
| Rate for Payer: NAPHCARE Commercial |
$97.97
|
| Rate for Payer: Preferred Network Access Commercial |
$150.22
|
| Rate for Payer: Quartz Beloit One Network |
$80.01
|
| Rate for Payer: Quartz Commercial |
$106.13
|
| Rate for Payer: Quartz Medicare Advantage |
$97.97
|
| Rate for Payer: The Alliance Commercial |
$81.64
|
| Rate for Payer: WEA Trust Commercial |
$89.80
|
| Rate for Payer: WPS Commercial |
$120.94
|
|
