|
KIT PD CATHETER PRE-STERNAL 8888121132
|
Facility
|
IP
|
$4,750.00
|
|
| Hospital Charge Code |
4520281
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,420.60 |
| Max. Negotiated Rate |
$4,544.80 |
| Rate for Payer: Aetna Commercial |
$4,446.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,248.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,618.20
|
| Rate for Payer: Cash Price |
$1,425.00
|
| Rate for Payer: Cigna Commercial |
$4,544.80
|
| Rate for Payer: Health EOS Commercial |
$4,396.60
|
| Rate for Payer: HFN Commercial |
$4,544.80
|
| Rate for Payer: Multiplan Commercial |
$3,952.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,544.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,420.60
|
| Rate for Payer: Quartz Commercial |
$2,964.00
|
| Rate for Payer: WEA Trust Commercial |
$2,717.00
|
| Rate for Payer: WPS Commercial |
$3,658.93
|
|
|
KIT PD CATHETER PRE-STERNAL 8888121132
|
Facility
|
OP
|
$4,750.00
|
|
| Hospital Charge Code |
4520281
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,383.20 |
| Max. Negotiated Rate |
$4,544.80 |
| Rate for Payer: Aetna Commercial |
$4,446.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,248.40
|
| Rate for Payer: Aetna Managed Medicare |
$1,383.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,211.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,470.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,371.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,618.20
|
| Rate for Payer: Cash Price |
$1,425.00
|
| Rate for Payer: Cigna Commercial |
$4,544.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,764.50
|
| Rate for Payer: Health EOS Commercial |
$4,396.60
|
| Rate for Payer: HFN Commercial |
$4,544.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,705.00
|
| Rate for Payer: Multiplan Commercial |
$3,952.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,964.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,544.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,420.60
|
| Rate for Payer: Quartz Commercial |
$3,211.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,964.00
|
| Rate for Payer: The Alliance Commercial |
$2,470.00
|
| Rate for Payer: WEA Trust Commercial |
$2,717.00
|
| Rate for Payer: WPS Commercial |
$3,658.93
|
|
|
KIT PERC INSERT FOR 3.0 KNOTLESS ST AR-1938PK
|
Facility
|
OP
|
$3,897.00
|
|
| Hospital Charge Code |
5611599
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,134.81 |
| Max. Negotiated Rate |
$3,728.65 |
| Rate for Payer: Aetna Commercial |
$3,647.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,485.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,134.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,634.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,026.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,945.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,148.03
|
| Rate for Payer: Cash Price |
$1,169.10
|
| Rate for Payer: Cigna Commercial |
$3,728.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,268.05
|
| Rate for Payer: Health EOS Commercial |
$3,607.06
|
| Rate for Payer: HFN Commercial |
$3,728.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,039.66
|
| Rate for Payer: Multiplan Commercial |
$3,242.30
|
| Rate for Payer: NAPHCARE Commercial |
$2,431.73
|
| Rate for Payer: Preferred Network Access Commercial |
$3,728.65
|
| Rate for Payer: Quartz Beloit One Network |
$1,985.91
|
| Rate for Payer: Quartz Commercial |
$2,634.37
|
| Rate for Payer: Quartz Medicare Advantage |
$2,431.73
|
| Rate for Payer: The Alliance Commercial |
$2,026.44
|
| Rate for Payer: WEA Trust Commercial |
$2,229.08
|
| Rate for Payer: WPS Commercial |
$3,001.86
|
|
|
KIT PERC INSERT FOR 3.0 KNOTLESS ST AR-1938PK
|
Facility
|
IP
|
$3,897.00
|
|
| Hospital Charge Code |
5611599
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,985.91 |
| Max. Negotiated Rate |
$3,728.65 |
| Rate for Payer: Aetna Commercial |
$3,647.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,485.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,148.03
|
| Rate for Payer: Cash Price |
$1,169.10
|
| Rate for Payer: Cigna Commercial |
$3,728.65
|
| Rate for Payer: Health EOS Commercial |
$3,607.06
|
| Rate for Payer: HFN Commercial |
$3,728.65
|
| Rate for Payer: Multiplan Commercial |
$3,242.30
|
| Rate for Payer: Preferred Network Access Commercial |
$3,728.65
|
| Rate for Payer: Quartz Beloit One Network |
$1,985.91
|
| Rate for Payer: Quartz Commercial |
$2,431.73
|
| Rate for Payer: WEA Trust Commercial |
$2,229.08
|
| Rate for Payer: WPS Commercial |
$3,001.86
|
|
|
KIT PERCUTANEOUS EXTENSION INTERSTIM SURESCAN MRI (RECHARGE FREE) 3560022
|
Facility
|
OP
|
$2,557.00
|
|
|
Service Code
|
HCPCS C1883
|
| Hospital Charge Code |
5603548
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$744.60 |
| Max. Negotiated Rate |
$2,446.54 |
| Rate for Payer: Aetna Commercial |
$2,393.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,286.98
|
| Rate for Payer: Aetna Managed Medicare |
$744.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,728.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,329.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,276.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,409.42
|
| Rate for Payer: Cash Price |
$767.10
|
| Rate for Payer: Cigna Commercial |
$2,446.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,488.17
|
| Rate for Payer: Health EOS Commercial |
$2,366.76
|
| Rate for Payer: HFN Commercial |
$2,446.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,994.46
|
| Rate for Payer: Multiplan Commercial |
$2,127.42
|
| Rate for Payer: NAPHCARE Commercial |
$1,595.57
|
| Rate for Payer: Preferred Network Access Commercial |
$2,446.54
|
| Rate for Payer: Quartz Beloit One Network |
$1,303.05
|
| Rate for Payer: Quartz Commercial |
$1,728.53
|
| Rate for Payer: Quartz Medicare Advantage |
$1,595.57
|
| Rate for Payer: The Alliance Commercial |
$1,329.64
|
| Rate for Payer: WEA Trust Commercial |
$1,462.60
|
| Rate for Payer: WPS Commercial |
$1,969.66
|
|
|
KIT PERCUTANEOUS EXTENSION INTERSTIM SURESCAN MRI (RECHARGE FREE) 3560022
|
Facility
|
IP
|
$2,557.00
|
|
|
Service Code
|
HCPCS C1883
|
| Hospital Charge Code |
5603548
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,303.05 |
| Max. Negotiated Rate |
$2,446.54 |
| Rate for Payer: Aetna Commercial |
$2,393.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,286.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,409.42
|
| Rate for Payer: Cash Price |
$767.10
|
| Rate for Payer: Cigna Commercial |
$2,446.54
|
| Rate for Payer: Health EOS Commercial |
$2,366.76
|
| Rate for Payer: HFN Commercial |
$2,446.54
|
| Rate for Payer: Multiplan Commercial |
$2,127.42
|
| Rate for Payer: Preferred Network Access Commercial |
$2,446.54
|
| Rate for Payer: Quartz Beloit One Network |
$1,303.05
|
| Rate for Payer: Quartz Commercial |
$1,595.57
|
| Rate for Payer: WEA Trust Commercial |
$1,462.60
|
| Rate for Payer: WPS Commercial |
$1,969.66
|
|
|
KIT PERCUTANEOUS SHEATH 8.5fr AK-09803
|
Facility
|
IP
|
$547.00
|
|
| Hospital Charge Code |
2962966
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$278.75 |
| Max. Negotiated Rate |
$523.37 |
| Rate for Payer: Aetna Commercial |
$511.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$489.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.51
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$523.37
|
| Rate for Payer: Health EOS Commercial |
$506.30
|
| Rate for Payer: HFN Commercial |
$523.37
|
| Rate for Payer: Multiplan Commercial |
$455.10
|
| Rate for Payer: Preferred Network Access Commercial |
$523.37
|
| Rate for Payer: Quartz Beloit One Network |
$278.75
|
| Rate for Payer: Quartz Commercial |
$341.33
|
| Rate for Payer: WEA Trust Commercial |
$312.88
|
| Rate for Payer: WPS Commercial |
$421.35
|
|
|
KIT PERCUTANEOUS SHEATH 8.5fr AK-09803
|
Facility
|
OP
|
$547.00
|
|
| Hospital Charge Code |
2962966
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$159.29 |
| Max. Negotiated Rate |
$523.37 |
| Rate for Payer: Aetna Commercial |
$511.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$489.24
|
| Rate for Payer: Aetna Managed Medicare |
$159.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$369.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$284.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$273.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$301.51
|
| Rate for Payer: Cash Price |
$164.10
|
| Rate for Payer: Cigna Commercial |
$523.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$318.35
|
| Rate for Payer: Health EOS Commercial |
$506.30
|
| Rate for Payer: HFN Commercial |
$523.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$426.66
|
| Rate for Payer: Multiplan Commercial |
$455.10
|
| Rate for Payer: NAPHCARE Commercial |
$341.33
|
| Rate for Payer: Preferred Network Access Commercial |
$523.37
|
| Rate for Payer: Quartz Beloit One Network |
$278.75
|
| Rate for Payer: Quartz Commercial |
$369.77
|
| Rate for Payer: Quartz Medicare Advantage |
$341.33
|
| Rate for Payer: The Alliance Commercial |
$284.44
|
| Rate for Payer: WEA Trust Commercial |
$312.88
|
| Rate for Payer: WPS Commercial |
$421.35
|
|
|
KIT PERICARDIAL CENTISIS 8.3FR #M00443051***DISC 3/23
|
Facility
|
OP
|
$2,338.00
|
|
| Hospital Charge Code |
2973600
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$680.83 |
| Max. Negotiated Rate |
$2,237.00 |
| Rate for Payer: Aetna Commercial |
$2,188.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,091.11
|
| Rate for Payer: Aetna Managed Medicare |
$680.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,580.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,215.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,167.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,288.71
|
| Rate for Payer: Cash Price |
$701.40
|
| Rate for Payer: Cigna Commercial |
$2,237.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,360.72
|
| Rate for Payer: Health EOS Commercial |
$2,164.05
|
| Rate for Payer: HFN Commercial |
$2,237.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,823.64
|
| Rate for Payer: Multiplan Commercial |
$1,945.22
|
| Rate for Payer: NAPHCARE Commercial |
$1,458.91
|
| Rate for Payer: Preferred Network Access Commercial |
$2,237.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,191.44
|
| Rate for Payer: Quartz Commercial |
$1,580.49
|
| Rate for Payer: Quartz Medicare Advantage |
$1,458.91
|
| Rate for Payer: The Alliance Commercial |
$1,215.76
|
| Rate for Payer: WEA Trust Commercial |
$1,337.34
|
| Rate for Payer: WPS Commercial |
$1,800.96
|
|
|
KIT PERICARDIAL CENTISIS 8.3FR #M00443051***DISC 3/23
|
Facility
|
IP
|
$2,338.00
|
|
| Hospital Charge Code |
2973600
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,191.44 |
| Max. Negotiated Rate |
$2,237.00 |
| Rate for Payer: Aetna Commercial |
$2,188.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,091.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,288.71
|
| Rate for Payer: Cash Price |
$701.40
|
| Rate for Payer: Cigna Commercial |
$2,237.00
|
| Rate for Payer: Health EOS Commercial |
$2,164.05
|
| Rate for Payer: HFN Commercial |
$2,237.00
|
| Rate for Payer: Multiplan Commercial |
$1,945.22
|
| Rate for Payer: Preferred Network Access Commercial |
$2,237.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,191.44
|
| Rate for Payer: Quartz Commercial |
$1,458.91
|
| Rate for Payer: WEA Trust Commercial |
$1,337.34
|
| Rate for Payer: WPS Commercial |
$1,800.96
|
|
|
KIT PERI PATCH REPAIR #8888285001
|
Facility
|
OP
|
$1,119.00
|
|
| Hospital Charge Code |
2974668
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$325.85 |
| Max. Negotiated Rate |
$1,070.66 |
| Rate for Payer: Aetna Commercial |
$1,047.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,000.83
|
| Rate for Payer: Aetna Managed Medicare |
$325.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$756.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$581.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$558.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$616.79
|
| Rate for Payer: Cash Price |
$335.70
|
| Rate for Payer: Cigna Commercial |
$1,070.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$651.26
|
| Rate for Payer: Health EOS Commercial |
$1,035.75
|
| Rate for Payer: HFN Commercial |
$1,070.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$872.82
|
| Rate for Payer: Multiplan Commercial |
$931.01
|
| Rate for Payer: NAPHCARE Commercial |
$698.26
|
| Rate for Payer: Preferred Network Access Commercial |
$1,070.66
|
| Rate for Payer: Quartz Beloit One Network |
$570.24
|
| Rate for Payer: Quartz Commercial |
$756.44
|
| Rate for Payer: Quartz Medicare Advantage |
$698.26
|
| Rate for Payer: The Alliance Commercial |
$581.88
|
| Rate for Payer: WEA Trust Commercial |
$640.07
|
| Rate for Payer: WPS Commercial |
$861.97
|
|
|
KIT PERI PATCH REPAIR #8888285001
|
Facility
|
IP
|
$1,119.00
|
|
| Hospital Charge Code |
2974668
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$570.24 |
| Max. Negotiated Rate |
$1,070.66 |
| Rate for Payer: Aetna Commercial |
$1,047.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,000.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$616.79
|
| Rate for Payer: Cash Price |
$335.70
|
| Rate for Payer: Cigna Commercial |
$1,070.66
|
| Rate for Payer: Health EOS Commercial |
$1,035.75
|
| Rate for Payer: HFN Commercial |
$1,070.66
|
| Rate for Payer: Multiplan Commercial |
$931.01
|
| Rate for Payer: Preferred Network Access Commercial |
$1,070.66
|
| Rate for Payer: Quartz Beloit One Network |
$570.24
|
| Rate for Payer: Quartz Commercial |
$698.26
|
| Rate for Payer: WEA Trust Commercial |
$640.07
|
| Rate for Payer: WPS Commercial |
$861.97
|
|
|
KIT PERITONEAL LAVAGE-ARROW
|
Facility
|
IP
|
$693.00
|
|
| Hospital Charge Code |
2962994
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$353.15 |
| Max. Negotiated Rate |
$663.06 |
| Rate for Payer: Aetna Commercial |
$648.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$619.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$381.98
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cigna Commercial |
$663.06
|
| Rate for Payer: Health EOS Commercial |
$641.44
|
| Rate for Payer: HFN Commercial |
$663.06
|
| Rate for Payer: Multiplan Commercial |
$576.58
|
| Rate for Payer: Preferred Network Access Commercial |
$663.06
|
| Rate for Payer: Quartz Beloit One Network |
$353.15
|
| Rate for Payer: Quartz Commercial |
$432.43
|
| Rate for Payer: WEA Trust Commercial |
$396.40
|
| Rate for Payer: WPS Commercial |
$533.82
|
|
|
KIT PERITONEAL LAVAGE-ARROW
|
Facility
|
OP
|
$693.00
|
|
| Hospital Charge Code |
2962994
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$201.80 |
| Max. Negotiated Rate |
$663.06 |
| Rate for Payer: Aetna Commercial |
$648.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$619.82
|
| Rate for Payer: Aetna Managed Medicare |
$201.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$468.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$360.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$345.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$381.98
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cigna Commercial |
$663.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$403.33
|
| Rate for Payer: Health EOS Commercial |
$641.44
|
| Rate for Payer: HFN Commercial |
$663.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$540.54
|
| Rate for Payer: Multiplan Commercial |
$576.58
|
| Rate for Payer: NAPHCARE Commercial |
$432.43
|
| Rate for Payer: Preferred Network Access Commercial |
$663.06
|
| Rate for Payer: Quartz Beloit One Network |
$353.15
|
| Rate for Payer: Quartz Commercial |
$468.47
|
| Rate for Payer: Quartz Medicare Advantage |
$432.43
|
| Rate for Payer: The Alliance Commercial |
$360.36
|
| Rate for Payer: WEA Trust Commercial |
$396.40
|
| Rate for Payer: WPS Commercial |
$533.82
|
|
|
KIT PNEUMOTHORAX
|
Facility
|
IP
|
$1,415.00
|
|
| Hospital Charge Code |
2962928
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$721.08 |
| Max. Negotiated Rate |
$1,353.87 |
| Rate for Payer: Aetna Commercial |
$1,324.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,265.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$779.95
|
| Rate for Payer: Cash Price |
$424.50
|
| Rate for Payer: Cigna Commercial |
$1,353.87
|
| Rate for Payer: Health EOS Commercial |
$1,309.72
|
| Rate for Payer: HFN Commercial |
$1,353.87
|
| Rate for Payer: Multiplan Commercial |
$1,177.28
|
| Rate for Payer: Preferred Network Access Commercial |
$1,353.87
|
| Rate for Payer: Quartz Beloit One Network |
$721.08
|
| Rate for Payer: Quartz Commercial |
$882.96
|
| Rate for Payer: WEA Trust Commercial |
$809.38
|
| Rate for Payer: WPS Commercial |
$1,089.97
|
|
|
KIT PNEUMOTHORAX
|
Facility
|
OP
|
$1,415.00
|
|
| Hospital Charge Code |
2962928
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$412.05 |
| Max. Negotiated Rate |
$1,353.87 |
| Rate for Payer: Aetna Commercial |
$1,324.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,265.58
|
| Rate for Payer: Aetna Managed Medicare |
$412.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$956.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$735.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$706.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$779.95
|
| Rate for Payer: Cash Price |
$424.50
|
| Rate for Payer: Cigna Commercial |
$1,353.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$823.53
|
| Rate for Payer: Health EOS Commercial |
$1,309.72
|
| Rate for Payer: HFN Commercial |
$1,353.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,103.70
|
| Rate for Payer: Multiplan Commercial |
$1,177.28
|
| Rate for Payer: NAPHCARE Commercial |
$882.96
|
| Rate for Payer: Preferred Network Access Commercial |
$1,353.87
|
| Rate for Payer: Quartz Beloit One Network |
$721.08
|
| Rate for Payer: Quartz Commercial |
$956.54
|
| Rate for Payer: Quartz Medicare Advantage |
$882.96
|
| Rate for Payer: The Alliance Commercial |
$735.80
|
| Rate for Payer: WEA Trust Commercial |
$809.38
|
| Rate for Payer: WPS Commercial |
$1,089.97
|
|
|
KIT PORT ACCESS 20GX.1 2652010"
|
Facility
|
IP
|
$279.00
|
|
| Hospital Charge Code |
4508808
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$142.18 |
| Max. Negotiated Rate |
$266.95 |
| Rate for Payer: Aetna Commercial |
$261.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.78
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: Health EOS Commercial |
$258.24
|
| Rate for Payer: HFN Commercial |
$266.95
|
| Rate for Payer: Multiplan Commercial |
$232.13
|
| Rate for Payer: Preferred Network Access Commercial |
$266.95
|
| Rate for Payer: Quartz Beloit One Network |
$142.18
|
| Rate for Payer: Quartz Commercial |
$174.10
|
| Rate for Payer: WEA Trust Commercial |
$159.59
|
| Rate for Payer: WPS Commercial |
$214.91
|
|
|
KIT PORT ACCESS 20GX.1 2652010"
|
Facility
|
OP
|
$279.00
|
|
| Hospital Charge Code |
4508808
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$81.24 |
| Max. Negotiated Rate |
$266.95 |
| Rate for Payer: Aetna Commercial |
$261.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.54
|
| Rate for Payer: Aetna Managed Medicare |
$81.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$188.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.78
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.38
|
| Rate for Payer: Health EOS Commercial |
$258.24
|
| Rate for Payer: HFN Commercial |
$266.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.62
|
| Rate for Payer: Multiplan Commercial |
$232.13
|
| Rate for Payer: NAPHCARE Commercial |
$174.10
|
| Rate for Payer: Preferred Network Access Commercial |
$266.95
|
| Rate for Payer: Quartz Beloit One Network |
$142.18
|
| Rate for Payer: Quartz Commercial |
$188.60
|
| Rate for Payer: Quartz Medicare Advantage |
$174.10
|
| Rate for Payer: The Alliance Commercial |
$145.08
|
| Rate for Payer: WEA Trust Commercial |
$159.59
|
| Rate for Payer: WPS Commercial |
$214.91
|
|
|
KIT PORT ACCESS 20GX.1.5 2652015"
|
Facility
|
OP
|
$279.00
|
|
| Hospital Charge Code |
4508810
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$81.24 |
| Max. Negotiated Rate |
$266.95 |
| Rate for Payer: Aetna Commercial |
$261.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.54
|
| Rate for Payer: Aetna Managed Medicare |
$81.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$188.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.78
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.38
|
| Rate for Payer: Health EOS Commercial |
$258.24
|
| Rate for Payer: HFN Commercial |
$266.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.62
|
| Rate for Payer: Multiplan Commercial |
$232.13
|
| Rate for Payer: NAPHCARE Commercial |
$174.10
|
| Rate for Payer: Preferred Network Access Commercial |
$266.95
|
| Rate for Payer: Quartz Beloit One Network |
$142.18
|
| Rate for Payer: Quartz Commercial |
$188.60
|
| Rate for Payer: Quartz Medicare Advantage |
$174.10
|
| Rate for Payer: The Alliance Commercial |
$145.08
|
| Rate for Payer: WEA Trust Commercial |
$159.59
|
| Rate for Payer: WPS Commercial |
$214.91
|
|
|
KIT PORT ACCESS 20GX.1.5 2652015"
|
Facility
|
IP
|
$279.00
|
|
| Hospital Charge Code |
4508810
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$142.18 |
| Max. Negotiated Rate |
$266.95 |
| Rate for Payer: Aetna Commercial |
$261.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.78
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: Health EOS Commercial |
$258.24
|
| Rate for Payer: HFN Commercial |
$266.95
|
| Rate for Payer: Multiplan Commercial |
$232.13
|
| Rate for Payer: Preferred Network Access Commercial |
$266.95
|
| Rate for Payer: Quartz Beloit One Network |
$142.18
|
| Rate for Payer: Quartz Commercial |
$174.10
|
| Rate for Payer: WEA Trust Commercial |
$159.59
|
| Rate for Payer: WPS Commercial |
$214.91
|
|
|
KIT PORT ACCESS 20GX.75 2652034"
|
Facility
|
OP
|
$279.00
|
|
| Hospital Charge Code |
4508806
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$81.24 |
| Max. Negotiated Rate |
$266.95 |
| Rate for Payer: Aetna Commercial |
$261.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.54
|
| Rate for Payer: Aetna Managed Medicare |
$81.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$188.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.78
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.38
|
| Rate for Payer: Health EOS Commercial |
$258.24
|
| Rate for Payer: HFN Commercial |
$266.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.62
|
| Rate for Payer: Multiplan Commercial |
$232.13
|
| Rate for Payer: NAPHCARE Commercial |
$174.10
|
| Rate for Payer: Preferred Network Access Commercial |
$266.95
|
| Rate for Payer: Quartz Beloit One Network |
$142.18
|
| Rate for Payer: Quartz Commercial |
$188.60
|
| Rate for Payer: Quartz Medicare Advantage |
$174.10
|
| Rate for Payer: The Alliance Commercial |
$145.08
|
| Rate for Payer: WEA Trust Commercial |
$159.59
|
| Rate for Payer: WPS Commercial |
$214.91
|
|
|
KIT PORT ACCESS 20GX.75 2652034"
|
Facility
|
IP
|
$279.00
|
|
| Hospital Charge Code |
4508806
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$142.18 |
| Max. Negotiated Rate |
$266.95 |
| Rate for Payer: Aetna Commercial |
$261.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.78
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: Health EOS Commercial |
$258.24
|
| Rate for Payer: HFN Commercial |
$266.95
|
| Rate for Payer: Multiplan Commercial |
$232.13
|
| Rate for Payer: Preferred Network Access Commercial |
$266.95
|
| Rate for Payer: Quartz Beloit One Network |
$142.18
|
| Rate for Payer: Quartz Commercial |
$174.10
|
| Rate for Payer: WEA Trust Commercial |
$159.59
|
| Rate for Payer: WPS Commercial |
$214.91
|
|
|
KIT PORT ACCESS 22GX.1 2652210"
|
Facility
|
IP
|
$279.00
|
|
| Hospital Charge Code |
4508809
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$142.18 |
| Max. Negotiated Rate |
$266.95 |
| Rate for Payer: Aetna Commercial |
$261.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.78
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: Health EOS Commercial |
$258.24
|
| Rate for Payer: HFN Commercial |
$266.95
|
| Rate for Payer: Multiplan Commercial |
$232.13
|
| Rate for Payer: Preferred Network Access Commercial |
$266.95
|
| Rate for Payer: Quartz Beloit One Network |
$142.18
|
| Rate for Payer: Quartz Commercial |
$174.10
|
| Rate for Payer: WEA Trust Commercial |
$159.59
|
| Rate for Payer: WPS Commercial |
$214.91
|
|
|
KIT PORT ACCESS 22GX.1 2652210"
|
Facility
|
OP
|
$279.00
|
|
| Hospital Charge Code |
4508809
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$81.24 |
| Max. Negotiated Rate |
$266.95 |
| Rate for Payer: Aetna Commercial |
$261.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.54
|
| Rate for Payer: Aetna Managed Medicare |
$81.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$188.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.78
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.38
|
| Rate for Payer: Health EOS Commercial |
$258.24
|
| Rate for Payer: HFN Commercial |
$266.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.62
|
| Rate for Payer: Multiplan Commercial |
$232.13
|
| Rate for Payer: NAPHCARE Commercial |
$174.10
|
| Rate for Payer: Preferred Network Access Commercial |
$266.95
|
| Rate for Payer: Quartz Beloit One Network |
$142.18
|
| Rate for Payer: Quartz Commercial |
$188.60
|
| Rate for Payer: Quartz Medicare Advantage |
$174.10
|
| Rate for Payer: The Alliance Commercial |
$145.08
|
| Rate for Payer: WEA Trust Commercial |
$159.59
|
| Rate for Payer: WPS Commercial |
$214.91
|
|
|
KIT PORT ACCESS 22GX.75 2652234"
|
Facility
|
OP
|
$279.00
|
|
| Hospital Charge Code |
4508807
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$81.24 |
| Max. Negotiated Rate |
$266.95 |
| Rate for Payer: Aetna Commercial |
$261.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.54
|
| Rate for Payer: Aetna Managed Medicare |
$81.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$188.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.78
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.38
|
| Rate for Payer: Health EOS Commercial |
$258.24
|
| Rate for Payer: HFN Commercial |
$266.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.62
|
| Rate for Payer: Multiplan Commercial |
$232.13
|
| Rate for Payer: NAPHCARE Commercial |
$174.10
|
| Rate for Payer: Preferred Network Access Commercial |
$266.95
|
| Rate for Payer: Quartz Beloit One Network |
$142.18
|
| Rate for Payer: Quartz Commercial |
$188.60
|
| Rate for Payer: Quartz Medicare Advantage |
$174.10
|
| Rate for Payer: The Alliance Commercial |
$145.08
|
| Rate for Payer: WEA Trust Commercial |
$159.59
|
| Rate for Payer: WPS Commercial |
$214.91
|
|
