|
KNIFE MICROSURGICAL STRAIGHT
|
Facility
|
IP
|
$1,281.00
|
|
| Hospital Charge Code |
2965957
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$627.69 |
| Max. Negotiated Rate |
$1,178.52 |
| Rate for Payer: Aetna Commercial |
$1,152.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,101.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$678.93
|
| Rate for Payer: Cash Price |
$384.30
|
| Rate for Payer: Cigna Commercial |
$1,178.52
|
| Rate for Payer: Health EOS Commercial |
$1,140.09
|
| Rate for Payer: HFN Commercial |
$1,178.52
|
| Rate for Payer: Multiplan Commercial |
$1,024.80
|
| Rate for Payer: NAPHCARE Commercial |
$768.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,178.52
|
| Rate for Payer: Quartz Beloit One Network |
$627.69
|
| Rate for Payer: Quartz Commercial |
$768.60
|
| Rate for Payer: WEA Trust Commercial |
$704.55
|
| Rate for Payer: WPS Commercial |
$948.84
|
|
|
KNIFE RETRACTABLE CANNULATED STRAIGHT AR-6527-01
|
Facility
|
IP
|
$3,043.00
|
|
| Hospital Charge Code |
4509017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,491.07 |
| Max. Negotiated Rate |
$2,799.56 |
| Rate for Payer: Aetna Commercial |
$2,738.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,616.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,612.79
|
| Rate for Payer: Cash Price |
$912.90
|
| Rate for Payer: Cigna Commercial |
$2,799.56
|
| Rate for Payer: Health EOS Commercial |
$2,708.27
|
| Rate for Payer: HFN Commercial |
$2,799.56
|
| Rate for Payer: Multiplan Commercial |
$2,434.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,825.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,799.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,491.07
|
| Rate for Payer: Quartz Commercial |
$1,825.80
|
| Rate for Payer: WEA Trust Commercial |
$1,673.65
|
| Rate for Payer: WPS Commercial |
$2,253.95
|
|
|
KNIFE RETRACTABLE CANNULATED STRAIGHT AR-6527-01
|
Facility
|
OP
|
$3,043.00
|
|
| Hospital Charge Code |
4509017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$852.04 |
| Max. Negotiated Rate |
$12,172.00 |
| Rate for Payer: Aetna Commercial |
$2,738.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,616.98
|
| Rate for Payer: Aetna Managed Medicare |
$852.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,977.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,521.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,460.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,612.79
|
| Rate for Payer: Cash Price |
$912.90
|
| Rate for Payer: Cigna Commercial |
$2,799.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,702.86
|
| Rate for Payer: Health EOS Commercial |
$2,708.27
|
| Rate for Payer: HFN Commercial |
$2,799.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,282.25
|
| Rate for Payer: Multiplan Commercial |
$2,434.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,825.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,799.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,491.07
|
| Rate for Payer: Quartz Commercial |
$1,977.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,825.80
|
| Rate for Payer: The Alliance Commercial |
$12,172.00
|
| Rate for Payer: WEA Trust Commercial |
$1,673.65
|
| Rate for Payer: WPS Commercial |
$2,253.95
|
|
|
KNIFE RX NEEDLE 4584
|
Facility
|
OP
|
$2,670.00
|
|
| Hospital Charge Code |
2973085
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$747.60 |
| Max. Negotiated Rate |
$10,680.00 |
| Rate for Payer: Aetna Commercial |
$2,403.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,296.20
|
| Rate for Payer: Aetna Managed Medicare |
$747.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,735.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,335.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,281.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,415.10
|
| Rate for Payer: Cash Price |
$801.00
|
| Rate for Payer: Cigna Commercial |
$2,456.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,494.13
|
| Rate for Payer: Health EOS Commercial |
$2,376.30
|
| Rate for Payer: HFN Commercial |
$2,456.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,002.50
|
| Rate for Payer: Multiplan Commercial |
$2,136.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,602.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,456.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,308.30
|
| Rate for Payer: Quartz Commercial |
$1,735.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,602.00
|
| Rate for Payer: The Alliance Commercial |
$10,680.00
|
| Rate for Payer: WEA Trust Commercial |
$1,468.50
|
| Rate for Payer: WPS Commercial |
$1,977.67
|
|
|
KNIFE RX NEEDLE 4584
|
Facility
|
IP
|
$2,670.00
|
|
| Hospital Charge Code |
2973085
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,308.30 |
| Max. Negotiated Rate |
$2,456.40 |
| Rate for Payer: Aetna Commercial |
$2,403.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,296.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,415.10
|
| Rate for Payer: Cash Price |
$801.00
|
| Rate for Payer: Cigna Commercial |
$2,456.40
|
| Rate for Payer: Health EOS Commercial |
$2,376.30
|
| Rate for Payer: HFN Commercial |
$2,456.40
|
| Rate for Payer: Multiplan Commercial |
$2,136.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,602.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,456.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,308.30
|
| Rate for Payer: Quartz Commercial |
$1,602.00
|
| Rate for Payer: WEA Trust Commercial |
$1,468.50
|
| Rate for Payer: WPS Commercial |
$1,977.67
|
|
|
KNIFE SIDEPORT CLEARCUT 1.0 8065921540
|
Facility
|
OP
|
$553.00
|
|
| Hospital Charge Code |
2964173
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$154.84 |
| Max. Negotiated Rate |
$2,212.00 |
| Rate for Payer: Aetna Commercial |
$497.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.58
|
| Rate for Payer: Aetna Managed Medicare |
$154.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$359.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$276.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$265.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.09
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$508.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$309.46
|
| Rate for Payer: Health EOS Commercial |
$492.17
|
| Rate for Payer: HFN Commercial |
$508.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$414.75
|
| Rate for Payer: Multiplan Commercial |
$442.40
|
| Rate for Payer: NAPHCARE Commercial |
$331.80
|
| Rate for Payer: Preferred Network Access Commercial |
$508.76
|
| Rate for Payer: Quartz Beloit One Network |
$270.97
|
| Rate for Payer: Quartz Commercial |
$359.45
|
| Rate for Payer: Quartz Medicare Advantage |
$331.80
|
| Rate for Payer: The Alliance Commercial |
$2,212.00
|
| Rate for Payer: WEA Trust Commercial |
$304.15
|
| Rate for Payer: WPS Commercial |
$409.61
|
|
|
KNIFE SIDEPORT CLEARCUT 1.0 8065921540
|
Facility
|
IP
|
$553.00
|
|
| Hospital Charge Code |
2964173
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$270.97 |
| Max. Negotiated Rate |
$508.76 |
| Rate for Payer: Aetna Commercial |
$497.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.09
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$508.76
|
| Rate for Payer: Health EOS Commercial |
$492.17
|
| Rate for Payer: HFN Commercial |
$508.76
|
| Rate for Payer: Multiplan Commercial |
$442.40
|
| Rate for Payer: NAPHCARE Commercial |
$331.80
|
| Rate for Payer: Preferred Network Access Commercial |
$508.76
|
| Rate for Payer: Quartz Beloit One Network |
$270.97
|
| Rate for Payer: Quartz Commercial |
$331.80
|
| Rate for Payer: WEA Trust Commercial |
$304.15
|
| Rate for Payer: WPS Commercial |
$409.61
|
|
|
KNIFE WITH HANDLE MYRINGOTOMY SPEAR DISP 7013-0791
|
Facility
|
IP
|
$261.00
|
|
| Hospital Charge Code |
2965125
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$127.89 |
| Max. Negotiated Rate |
$240.12 |
| Rate for Payer: Aetna Commercial |
$234.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.33
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$240.12
|
| Rate for Payer: Health EOS Commercial |
$232.29
|
| Rate for Payer: HFN Commercial |
$240.12
|
| Rate for Payer: Multiplan Commercial |
$208.80
|
| Rate for Payer: NAPHCARE Commercial |
$156.60
|
| Rate for Payer: Preferred Network Access Commercial |
$240.12
|
| Rate for Payer: Quartz Beloit One Network |
$127.89
|
| Rate for Payer: Quartz Commercial |
$156.60
|
| Rate for Payer: WEA Trust Commercial |
$143.55
|
| Rate for Payer: WPS Commercial |
$193.32
|
|
|
KNIFE WITH HANDLE MYRINGOTOMY SPEAR DISP 7013-0791
|
Facility
|
OP
|
$261.00
|
|
| Hospital Charge Code |
2965125
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.08 |
| Max. Negotiated Rate |
$1,044.00 |
| Rate for Payer: Aetna Commercial |
$234.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.46
|
| Rate for Payer: Aetna Managed Medicare |
$73.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$169.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$130.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$125.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.33
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$240.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.06
|
| Rate for Payer: Health EOS Commercial |
$232.29
|
| Rate for Payer: HFN Commercial |
$240.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$195.75
|
| Rate for Payer: Multiplan Commercial |
$208.80
|
| Rate for Payer: NAPHCARE Commercial |
$156.60
|
| Rate for Payer: Preferred Network Access Commercial |
$240.12
|
| Rate for Payer: Quartz Beloit One Network |
$127.89
|
| Rate for Payer: Quartz Commercial |
$169.65
|
| Rate for Payer: Quartz Medicare Advantage |
$156.60
|
| Rate for Payer: The Alliance Commercial |
$1,044.00
|
| Rate for Payer: WEA Trust Commercial |
$143.55
|
| Rate for Payer: WPS Commercial |
$193.32
|
|
|
KNOT PUSHER/SUTURE CUTTER WITH PORTAL SKID AR-5845
|
Facility
|
IP
|
$2,251.00
|
|
| Hospital Charge Code |
5611620
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,102.99 |
| Max. Negotiated Rate |
$2,070.92 |
| Rate for Payer: Aetna Commercial |
$2,025.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,935.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,193.03
|
| Rate for Payer: Cash Price |
$675.30
|
| Rate for Payer: Cigna Commercial |
$2,070.92
|
| Rate for Payer: Health EOS Commercial |
$2,003.39
|
| Rate for Payer: HFN Commercial |
$2,070.92
|
| Rate for Payer: Multiplan Commercial |
$1,800.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,350.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,070.92
|
| Rate for Payer: Quartz Beloit One Network |
$1,102.99
|
| Rate for Payer: Quartz Commercial |
$1,350.60
|
| Rate for Payer: WEA Trust Commercial |
$1,238.05
|
| Rate for Payer: WPS Commercial |
$1,667.32
|
|
|
KNOT PUSHER/SUTURE CUTTER WITH PORTAL SKID AR-5845
|
Facility
|
OP
|
$2,251.00
|
|
| Hospital Charge Code |
5611620
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$630.28 |
| Max. Negotiated Rate |
$9,004.00 |
| Rate for Payer: Aetna Commercial |
$2,025.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,935.86
|
| Rate for Payer: Aetna Managed Medicare |
$630.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,463.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,125.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,080.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,193.03
|
| Rate for Payer: Cash Price |
$675.30
|
| Rate for Payer: Cigna Commercial |
$2,070.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,259.66
|
| Rate for Payer: Health EOS Commercial |
$2,003.39
|
| Rate for Payer: HFN Commercial |
$2,070.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,688.25
|
| Rate for Payer: Multiplan Commercial |
$1,800.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,350.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,070.92
|
| Rate for Payer: Quartz Beloit One Network |
$1,102.99
|
| Rate for Payer: Quartz Commercial |
$1,463.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,350.60
|
| Rate for Payer: The Alliance Commercial |
$9,004.00
|
| Rate for Payer: WEA Trust Commercial |
$1,238.05
|
| Rate for Payer: WPS Commercial |
$1,667.32
|
|
|
Ko elastic with joints L1810
|
Professional
|
Both
|
$265.00
|
|
|
Service Code
|
HCPCS L1810
|
| Hospital Charge Code |
3133562
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$116.60 |
| Max. Negotiated Rate |
$364.79 |
| Rate for Payer: Aetna Commercial |
$251.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.90
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$251.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$132.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.00
|
| Rate for Payer: Health EOS Commercial |
$241.15
|
| Rate for Payer: HFN Commercial |
$251.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$364.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$364.79
|
| Rate for Payer: Multiplan Commercial |
$212.00
|
| Rate for Payer: Preferred Network Access Commercial |
$251.75
|
| Rate for Payer: Quartz Beloit One Network |
$116.60
|
| Rate for Payer: Quartz Commercial |
$151.05
|
| Rate for Payer: The Alliance Commercial |
$132.50
|
| Rate for Payer: WEA Trust Commercial |
$145.75
|
| Rate for Payer: WPS Commercial |
$196.29
|
|
|
Ko elastic with joints L1810
|
Facility
|
IP
|
$265.00
|
|
|
Service Code
|
HCPCS L1810
|
| Hospital Charge Code |
3133562
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$129.85 |
| Max. Negotiated Rate |
$243.80 |
| Rate for Payer: Aetna Commercial |
$238.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.45
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$243.80
|
| Rate for Payer: Health EOS Commercial |
$235.85
|
| Rate for Payer: HFN Commercial |
$243.80
|
| Rate for Payer: Multiplan Commercial |
$212.00
|
| Rate for Payer: NAPHCARE Commercial |
$159.00
|
| Rate for Payer: Preferred Network Access Commercial |
$243.80
|
| Rate for Payer: Quartz Beloit One Network |
$129.85
|
| Rate for Payer: Quartz Commercial |
$159.00
|
| Rate for Payer: WEA Trust Commercial |
$145.75
|
| Rate for Payer: WPS Commercial |
$196.29
|
|
|
Ko elastic with joints L1810
|
Facility
|
OP
|
$265.00
|
|
|
Service Code
|
HCPCS L1810
|
| Hospital Charge Code |
3133562
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$74.20 |
| Max. Negotiated Rate |
$1,060.00 |
| Rate for Payer: Aetna Commercial |
$238.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.90
|
| Rate for Payer: Aetna Managed Medicare |
$74.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.82
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$78.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.45
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$243.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$148.29
|
| Rate for Payer: Health EOS Commercial |
$235.85
|
| Rate for Payer: HFN Commercial |
$243.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$198.75
|
| Rate for Payer: Multiplan Commercial |
$212.00
|
| Rate for Payer: NAPHCARE Commercial |
$159.00
|
| Rate for Payer: Preferred Network Access Commercial |
$243.80
|
| Rate for Payer: Quartz Beloit One Network |
$129.85
|
| Rate for Payer: Quartz Commercial |
$172.25
|
| Rate for Payer: Quartz Medicare Advantage |
$159.00
|
| Rate for Payer: The Alliance Commercial |
$1,060.00
|
| Rate for Payer: WEA Trust Commercial |
$145.75
|
| Rate for Payer: WPS Commercial |
$196.29
|
|
|
Ko elastic w/joints pre ots L1812
|
Facility
|
IP
|
$313.00
|
|
|
Service Code
|
HCPCS L1812
|
| Hospital Charge Code |
4340587
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$153.37 |
| Max. Negotiated Rate |
$287.96 |
| Rate for Payer: Aetna Commercial |
$281.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$269.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$165.89
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$287.96
|
| Rate for Payer: Health EOS Commercial |
$278.57
|
| Rate for Payer: HFN Commercial |
$287.96
|
| Rate for Payer: Multiplan Commercial |
$250.40
|
| Rate for Payer: NAPHCARE Commercial |
$187.80
|
| Rate for Payer: Preferred Network Access Commercial |
$287.96
|
| Rate for Payer: Quartz Beloit One Network |
$153.37
|
| Rate for Payer: Quartz Commercial |
$187.80
|
| Rate for Payer: WEA Trust Commercial |
$172.15
|
| Rate for Payer: WPS Commercial |
$231.84
|
|
|
Ko elastic w/joints pre ots L1812
|
Professional
|
Both
|
$313.00
|
|
|
Service Code
|
HCPCS L1812
|
| Hospital Charge Code |
4340587
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$137.72 |
| Max. Negotiated Rate |
$297.35 |
| Rate for Payer: Aetna Commercial |
$297.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$269.18
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$297.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$156.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$187.80
|
| Rate for Payer: Health EOS Commercial |
$284.83
|
| Rate for Payer: HFN Commercial |
$297.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$287.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$287.70
|
| Rate for Payer: Multiplan Commercial |
$250.40
|
| Rate for Payer: Preferred Network Access Commercial |
$297.35
|
| Rate for Payer: Quartz Beloit One Network |
$137.72
|
| Rate for Payer: Quartz Commercial |
$178.41
|
| Rate for Payer: The Alliance Commercial |
$156.50
|
| Rate for Payer: WEA Trust Commercial |
$172.15
|
| Rate for Payer: WPS Commercial |
$231.84
|
|
|
Ko elastic w/joints pre ots L1812
|
Facility
|
OP
|
$313.00
|
|
|
Service Code
|
HCPCS L1812
|
| Hospital Charge Code |
4340587
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$63.59 |
| Max. Negotiated Rate |
$1,252.00 |
| Rate for Payer: Aetna Commercial |
$281.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$269.18
|
| Rate for Payer: Aetna Managed Medicare |
$87.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$63.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$63.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$165.89
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cash Price |
$93.90
|
| Rate for Payer: Cigna Commercial |
$287.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$175.15
|
| Rate for Payer: Health EOS Commercial |
$278.57
|
| Rate for Payer: HFN Commercial |
$287.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$234.75
|
| Rate for Payer: Multiplan Commercial |
$250.40
|
| Rate for Payer: NAPHCARE Commercial |
$187.80
|
| Rate for Payer: Preferred Network Access Commercial |
$287.96
|
| Rate for Payer: Quartz Beloit One Network |
$153.37
|
| Rate for Payer: Quartz Commercial |
$203.45
|
| Rate for Payer: Quartz Medicare Advantage |
$187.80
|
| Rate for Payer: The Alliance Commercial |
$1,252.00
|
| Rate for Payer: WEA Trust Commercial |
$172.15
|
| Rate for Payer: WPS Commercial |
$231.84
|
|
|
KOH Prep 87220PP
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
3128884
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.07 |
| Max. Negotiated Rate |
$99.75 |
| Rate for Payer: Aetna Commercial |
$99.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.30
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$99.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.00
|
| Rate for Payer: Health EOS Commercial |
$95.55
|
| Rate for Payer: HFN Commercial |
$99.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.07
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Preferred Network Access Commercial |
$99.75
|
| Rate for Payer: Quartz Beloit One Network |
$46.20
|
| Rate for Payer: Quartz Commercial |
$59.85
|
| Rate for Payer: The Alliance Commercial |
$52.50
|
| Rate for Payer: WEA Trust Commercial |
$57.75
|
| Rate for Payer: WPS Commercial |
$77.77
|
|
|
KOH Preparation
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
979914
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$36.80 |
| Rate for Payer: Aetna Commercial |
$36.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34.40
|
| Rate for Payer: Aetna Managed Medicare |
$4.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7.47
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7.09
|
| Rate for Payer: Anthem Medicaid |
$4.41
|
| Rate for Payer: Anthem Medicare Advantage |
$4.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.27
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$36.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.38
|
| Rate for Payer: Dean Health Medicaid |
$4.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.27
|
| Rate for Payer: Health EOS Commercial |
$35.60
|
| Rate for Payer: HFN Commercial |
$36.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.27
|
| Rate for Payer: Managed Health Services Medicaid |
$4.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.27
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.27
|
| Rate for Payer: Multiplan Commercial |
$32.00
|
| Rate for Payer: NAPHCARE Commercial |
$6.40
|
| Rate for Payer: Preferred Network Access Commercial |
$36.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4.41
|
| Rate for Payer: Quartz Beloit One Network |
$19.60
|
| Rate for Payer: Quartz Commercial |
$26.00
|
| Rate for Payer: Quartz Medicare Advantage |
$4.27
|
| Rate for Payer: The Alliance Commercial |
$17.08
|
| Rate for Payer: United Healthcare Medicaid |
$4.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.27
|
| Rate for Payer: United Healthcare PPO |
$30.00
|
| Rate for Payer: WEA Trust Commercial |
$22.00
|
| Rate for Payer: Wellcare Medicare |
$4.27
|
| Rate for Payer: WMAP Medicaid |
$4.41
|
| Rate for Payer: WPS Commercial |
$29.63
|
|
|
KOH Preparation
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
979914
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.07 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: HFN Commercial |
$38.00
|
| Rate for Payer: Health EOS Commercial |
$36.40
|
| Rate for Payer: Aetna Commercial |
$38.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34.40
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$38.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.07
|
| Rate for Payer: Multiplan Commercial |
$32.00
|
| Rate for Payer: Preferred Network Access Commercial |
$38.00
|
| Rate for Payer: Quartz Beloit One Network |
$17.60
|
| Rate for Payer: Quartz Commercial |
$22.80
|
| Rate for Payer: The Alliance Commercial |
$20.00
|
| Rate for Payer: WEA Trust Commercial |
$22.00
|
| Rate for Payer: WPS Commercial |
$29.63
|
|
|
KOH Preparation
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
979914
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$36.80 |
| Rate for Payer: Aetna Commercial |
$36.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$36.80
|
| Rate for Payer: Health EOS Commercial |
$35.60
|
| Rate for Payer: HFN Commercial |
$36.80
|
| Rate for Payer: Multiplan Commercial |
$32.00
|
| Rate for Payer: NAPHCARE Commercial |
$24.00
|
| Rate for Payer: Preferred Network Access Commercial |
$36.80
|
| Rate for Payer: Quartz Beloit One Network |
$19.60
|
| Rate for Payer: Quartz Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$22.00
|
| Rate for Payer: WPS Commercial |
$29.63
|
|
|
KO Rigid w/o joints pre ots L1836
|
Facility
|
OP
|
$335.00
|
|
|
Service Code
|
HCPCS L1836
|
| Hospital Charge Code |
4924610
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$87.70 |
| Max. Negotiated Rate |
$1,340.00 |
| Rate for Payer: Aetna Commercial |
$301.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$288.10
|
| Rate for Payer: Aetna Managed Medicare |
$93.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$87.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$87.70
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$87.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.55
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cigna Commercial |
$308.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$187.47
|
| Rate for Payer: Health EOS Commercial |
$298.15
|
| Rate for Payer: HFN Commercial |
$308.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$251.25
|
| Rate for Payer: Multiplan Commercial |
$268.00
|
| Rate for Payer: NAPHCARE Commercial |
$201.00
|
| Rate for Payer: Preferred Network Access Commercial |
$308.20
|
| Rate for Payer: Quartz Beloit One Network |
$164.15
|
| Rate for Payer: Quartz Commercial |
$217.75
|
| Rate for Payer: Quartz Medicare Advantage |
$201.00
|
| Rate for Payer: The Alliance Commercial |
$1,340.00
|
| Rate for Payer: WEA Trust Commercial |
$184.25
|
| Rate for Payer: WPS Commercial |
$248.13
|
|
|
KO Rigid w/o joints pre ots L1836
|
Professional
|
Both
|
$335.00
|
|
|
Service Code
|
HCPCS L1836
|
| Hospital Charge Code |
4924610
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$147.40 |
| Max. Negotiated Rate |
$368.57 |
| Rate for Payer: Aetna Commercial |
$318.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$288.10
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cigna Commercial |
$318.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$167.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$201.00
|
| Rate for Payer: Health EOS Commercial |
$304.85
|
| Rate for Payer: HFN Commercial |
$318.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$368.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$368.57
|
| Rate for Payer: Multiplan Commercial |
$268.00
|
| Rate for Payer: Preferred Network Access Commercial |
$318.25
|
| Rate for Payer: Quartz Beloit One Network |
$147.40
|
| Rate for Payer: Quartz Commercial |
$190.95
|
| Rate for Payer: The Alliance Commercial |
$167.50
|
| Rate for Payer: WEA Trust Commercial |
$184.25
|
| Rate for Payer: WPS Commercial |
$248.13
|
|
|
KO Rigid w/o joints pre ots L1836
|
Facility
|
IP
|
$335.00
|
|
|
Service Code
|
HCPCS L1836
|
| Hospital Charge Code |
4924610
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$164.15 |
| Max. Negotiated Rate |
$308.20 |
| Rate for Payer: Aetna Commercial |
$301.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$288.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.55
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cigna Commercial |
$308.20
|
| Rate for Payer: Health EOS Commercial |
$298.15
|
| Rate for Payer: HFN Commercial |
$308.20
|
| Rate for Payer: Multiplan Commercial |
$268.00
|
| Rate for Payer: NAPHCARE Commercial |
$201.00
|
| Rate for Payer: Preferred Network Access Commercial |
$308.20
|
| Rate for Payer: Quartz Beloit One Network |
$164.15
|
| Rate for Payer: Quartz Commercial |
$201.00
|
| Rate for Payer: WEA Trust Commercial |
$184.25
|
| Rate for Payer: WPS Commercial |
$248.13
|
|
|
K PAD
|
Facility
|
OP
|
$172.00
|
|
| Hospital Charge Code |
3075865
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$48.16 |
| Max. Negotiated Rate |
$688.00 |
| Rate for Payer: Aetna Commercial |
$154.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.92
|
| Rate for Payer: Aetna Managed Medicare |
$48.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$111.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$86.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$82.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.16
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$158.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.25
|
| Rate for Payer: Health EOS Commercial |
$153.08
|
| Rate for Payer: HFN Commercial |
$158.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$129.00
|
| Rate for Payer: Multiplan Commercial |
$137.60
|
| Rate for Payer: NAPHCARE Commercial |
$103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$158.24
|
| Rate for Payer: Quartz Beloit One Network |
$84.28
|
| Rate for Payer: Quartz Commercial |
$111.80
|
| Rate for Payer: Quartz Medicare Advantage |
$103.20
|
| Rate for Payer: The Alliance Commercial |
$688.00
|
| Rate for Payer: WEA Trust Commercial |
$94.60
|
| Rate for Payer: WPS Commercial |
$127.40
|
|
