|
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 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 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
|
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 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 EXPECTANT FATHERS X-LARGE SCRUB DISPOSABLE
|
Facility
|
IP
|
$157.00
|
|
| Hospital Charge Code |
2963271
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$80.01 |
| Max. Negotiated Rate |
$150.22 |
| Rate for Payer: Aetna Commercial |
$146.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.42
|
| 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: Health EOS Commercial |
$145.32
|
| Rate for Payer: HFN Commercial |
$150.22
|
| Rate for Payer: Multiplan Commercial |
$130.62
|
| Rate for Payer: Preferred Network Access Commercial |
$150.22
|
| Rate for Payer: Quartz Beloit One Network |
$80.01
|
| Rate for Payer: Quartz Commercial |
$97.97
|
| Rate for Payer: WEA Trust Commercial |
$89.80
|
| Rate for Payer: WPS Commercial |
$120.94
|
|
|
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
|
|
|
KIT FAST PACK CELL SAVER ELITE 125ML CSE-FP-125V
|
Facility
|
IP
|
$2,302.00
|
|
| Hospital Charge Code |
5804219
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,173.10 |
| Max. Negotiated Rate |
$2,202.55 |
| Rate for Payer: Aetna Commercial |
$2,154.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,058.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,268.86
|
| Rate for Payer: Cash Price |
$690.60
|
| Rate for Payer: Cigna Commercial |
$2,202.55
|
| Rate for Payer: Health EOS Commercial |
$2,130.73
|
| Rate for Payer: HFN Commercial |
$2,202.55
|
| Rate for Payer: Multiplan Commercial |
$1,915.26
|
| Rate for Payer: Preferred Network Access Commercial |
$2,202.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,173.10
|
| Rate for Payer: Quartz Commercial |
$1,436.45
|
| Rate for Payer: WEA Trust Commercial |
$1,316.74
|
| Rate for Payer: WPS Commercial |
$1,773.23
|
|
|
KIT FAST PACK CELL SAVER ELITE 125ML CSE-FP-125V
|
Facility
|
OP
|
$2,302.00
|
|
| Hospital Charge Code |
5804219
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$670.34 |
| Max. Negotiated Rate |
$2,202.55 |
| Rate for Payer: Aetna Commercial |
$2,154.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,058.91
|
| Rate for Payer: Aetna Managed Medicare |
$670.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,556.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,197.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,149.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,268.86
|
| Rate for Payer: Cash Price |
$690.60
|
| Rate for Payer: Cigna Commercial |
$2,202.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,339.76
|
| Rate for Payer: Health EOS Commercial |
$2,130.73
|
| Rate for Payer: HFN Commercial |
$2,202.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,795.56
|
| Rate for Payer: Multiplan Commercial |
$1,915.26
|
| Rate for Payer: NAPHCARE Commercial |
$1,436.45
|
| Rate for Payer: Preferred Network Access Commercial |
$2,202.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,173.10
|
| Rate for Payer: Quartz Commercial |
$1,556.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,436.45
|
| Rate for Payer: The Alliance Commercial |
$1,197.04
|
| Rate for Payer: WEA Trust Commercial |
$1,316.74
|
| Rate for Payer: WPS Commercial |
$1,773.23
|
|
|
KIT FAST PACK CELL SAVER ELITE 225ML CSE-FP-225V
|
Facility
|
IP
|
$2,302.00
|
|
| Hospital Charge Code |
5804218
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,173.10 |
| Max. Negotiated Rate |
$2,202.55 |
| Rate for Payer: Aetna Commercial |
$2,154.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,058.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,268.86
|
| Rate for Payer: Cash Price |
$690.60
|
| Rate for Payer: Cigna Commercial |
$2,202.55
|
| Rate for Payer: Health EOS Commercial |
$2,130.73
|
| Rate for Payer: HFN Commercial |
$2,202.55
|
| Rate for Payer: Multiplan Commercial |
$1,915.26
|
| Rate for Payer: Preferred Network Access Commercial |
$2,202.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,173.10
|
| Rate for Payer: Quartz Commercial |
$1,436.45
|
| Rate for Payer: WEA Trust Commercial |
$1,316.74
|
| Rate for Payer: WPS Commercial |
$1,773.23
|
|
|
KIT FAST PACK CELL SAVER ELITE 225ML CSE-FP-225V
|
Facility
|
OP
|
$2,302.00
|
|
| Hospital Charge Code |
5804218
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$670.34 |
| Max. Negotiated Rate |
$2,202.55 |
| Rate for Payer: Aetna Commercial |
$2,154.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,058.91
|
| Rate for Payer: Aetna Managed Medicare |
$670.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,556.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,197.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,149.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,268.86
|
| Rate for Payer: Cash Price |
$690.60
|
| Rate for Payer: Cigna Commercial |
$2,202.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,339.76
|
| Rate for Payer: Health EOS Commercial |
$2,130.73
|
| Rate for Payer: HFN Commercial |
$2,202.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,795.56
|
| Rate for Payer: Multiplan Commercial |
$1,915.26
|
| Rate for Payer: NAPHCARE Commercial |
$1,436.45
|
| Rate for Payer: Preferred Network Access Commercial |
$2,202.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,173.10
|
| Rate for Payer: Quartz Commercial |
$1,556.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,436.45
|
| Rate for Payer: The Alliance Commercial |
$1,197.04
|
| Rate for Payer: WEA Trust Commercial |
$1,316.74
|
| Rate for Payer: WPS Commercial |
$1,773.23
|
|
|
KIT FATHER LARGE
|
Facility
|
IP
|
$157.00
|
|
| Hospital Charge Code |
2963284
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$80.01 |
| Max. Negotiated Rate |
$150.22 |
| Rate for Payer: Aetna Commercial |
$146.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.42
|
| 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: Health EOS Commercial |
$145.32
|
| Rate for Payer: HFN Commercial |
$150.22
|
| Rate for Payer: Multiplan Commercial |
$130.62
|
| Rate for Payer: Preferred Network Access Commercial |
$150.22
|
| Rate for Payer: Quartz Beloit One Network |
$80.01
|
| Rate for Payer: Quartz Commercial |
$97.97
|
| Rate for Payer: WEA Trust Commercial |
$89.80
|
| Rate for Payer: WPS Commercial |
$120.94
|
|
|
KIT FATHER LARGE
|
Facility
|
OP
|
$157.00
|
|
| Hospital Charge Code |
2963284
|
|
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
|
|
|
KIT FEMORAL ARTERY 20G 8CM SAC-00820-1A
|
Facility
|
IP
|
$772.00
|
|
| Hospital Charge Code |
5641660
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$393.41 |
| Max. Negotiated Rate |
$738.65 |
| Rate for Payer: Aetna Commercial |
$722.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$690.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$425.53
|
| Rate for Payer: Cash Price |
$231.60
|
| Rate for Payer: Cigna Commercial |
$738.65
|
| Rate for Payer: Health EOS Commercial |
$714.56
|
| Rate for Payer: HFN Commercial |
$738.65
|
| Rate for Payer: Multiplan Commercial |
$642.30
|
| Rate for Payer: Preferred Network Access Commercial |
$738.65
|
| Rate for Payer: Quartz Beloit One Network |
$393.41
|
| Rate for Payer: Quartz Commercial |
$481.73
|
| Rate for Payer: WEA Trust Commercial |
$441.58
|
| Rate for Payer: WPS Commercial |
$594.67
|
|
|
KIT FEMORAL ARTERY 20G 8CM SAC-00820-1A
|
Facility
|
OP
|
$772.00
|
|
| Hospital Charge Code |
5641660
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$224.81 |
| Max. Negotiated Rate |
$738.65 |
| Rate for Payer: Aetna Commercial |
$722.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$690.48
|
| Rate for Payer: Aetna Managed Medicare |
$224.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$521.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$401.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$385.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$425.53
|
| Rate for Payer: Cash Price |
$231.60
|
| Rate for Payer: Cigna Commercial |
$738.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$449.30
|
| Rate for Payer: Health EOS Commercial |
$714.56
|
| Rate for Payer: HFN Commercial |
$738.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$602.16
|
| Rate for Payer: Multiplan Commercial |
$642.30
|
| Rate for Payer: NAPHCARE Commercial |
$481.73
|
| Rate for Payer: Preferred Network Access Commercial |
$738.65
|
| Rate for Payer: Quartz Beloit One Network |
$393.41
|
| Rate for Payer: Quartz Commercial |
$521.87
|
| Rate for Payer: Quartz Medicare Advantage |
$481.73
|
| Rate for Payer: The Alliance Commercial |
$401.44
|
| Rate for Payer: WEA Trust Commercial |
$441.58
|
| Rate for Payer: WPS Commercial |
$594.67
|
|
|
KIT FLEXIMA NEPHROSTOMY CATHETER SYSTEM VTC 8F X 25CM M001271860
|
Facility
|
OP
|
$3,710.00
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
2973046
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,080.35 |
| Max. Negotiated Rate |
$3,549.73 |
| Rate for Payer: Aetna Commercial |
$3,472.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,318.22
|
| Rate for Payer: Aetna Managed Medicare |
$1,080.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,507.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,929.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,852.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,044.95
|
| Rate for Payer: Cash Price |
$1,113.00
|
| Rate for Payer: Cigna Commercial |
$3,549.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,159.22
|
| Rate for Payer: Health EOS Commercial |
$3,433.98
|
| Rate for Payer: HFN Commercial |
$3,549.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,893.80
|
| Rate for Payer: Multiplan Commercial |
$3,086.72
|
| Rate for Payer: NAPHCARE Commercial |
$2,315.04
|
| Rate for Payer: Preferred Network Access Commercial |
$3,549.73
|
| Rate for Payer: Quartz Beloit One Network |
$1,890.62
|
| Rate for Payer: Quartz Commercial |
$2,507.96
|
| Rate for Payer: Quartz Medicare Advantage |
$2,315.04
|
| Rate for Payer: The Alliance Commercial |
$1,929.20
|
| Rate for Payer: WEA Trust Commercial |
$2,122.12
|
| Rate for Payer: WPS Commercial |
$2,857.81
|
|
|
KIT FLEXIMA NEPHROSTOMY CATHETER SYSTEM VTC 8F X 25CM M001271860
|
Facility
|
IP
|
$3,710.00
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
2973046
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,890.62 |
| Max. Negotiated Rate |
$3,549.73 |
| Rate for Payer: Aetna Commercial |
$3,472.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,318.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,044.95
|
| Rate for Payer: Cash Price |
$1,113.00
|
| Rate for Payer: Cigna Commercial |
$3,549.73
|
| Rate for Payer: Health EOS Commercial |
$3,433.98
|
| Rate for Payer: HFN Commercial |
$3,549.73
|
| Rate for Payer: Multiplan Commercial |
$3,086.72
|
| Rate for Payer: Preferred Network Access Commercial |
$3,549.73
|
| Rate for Payer: Quartz Beloit One Network |
$1,890.62
|
| Rate for Payer: Quartz Commercial |
$2,315.04
|
| Rate for Payer: WEA Trust Commercial |
$2,122.12
|
| Rate for Payer: WPS Commercial |
$2,857.81
|
|
|
KIT FLEXI-SEAL FECAL ODOR CONTROL 418000
|
Facility
|
OP
|
$3,701.00
|
|
| Hospital Charge Code |
2963010
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,077.73 |
| Max. Negotiated Rate |
$3,541.12 |
| Rate for Payer: Aetna Commercial |
$3,464.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,310.17
|
| Rate for Payer: Aetna Managed Medicare |
$1,077.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,501.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,924.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,847.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,039.99
|
| Rate for Payer: Cash Price |
$1,110.30
|
| Rate for Payer: Cigna Commercial |
$3,541.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,153.98
|
| Rate for Payer: Health EOS Commercial |
$3,425.65
|
| Rate for Payer: HFN Commercial |
$3,541.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,886.78
|
| Rate for Payer: Multiplan Commercial |
$3,079.23
|
| Rate for Payer: NAPHCARE Commercial |
$2,309.42
|
| Rate for Payer: Preferred Network Access Commercial |
$3,541.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,886.03
|
| Rate for Payer: Quartz Commercial |
$2,501.88
|
| Rate for Payer: Quartz Medicare Advantage |
$2,309.42
|
| Rate for Payer: The Alliance Commercial |
$1,924.52
|
| Rate for Payer: WEA Trust Commercial |
$2,116.97
|
| Rate for Payer: WPS Commercial |
$2,850.88
|
|
|
KIT FLEXI-SEAL FECAL ODOR CONTROL 418000
|
Facility
|
IP
|
$3,701.00
|
|
| Hospital Charge Code |
2963010
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,886.03 |
| Max. Negotiated Rate |
$3,541.12 |
| Rate for Payer: Aetna Commercial |
$3,464.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,310.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,039.99
|
| Rate for Payer: Cash Price |
$1,110.30
|
| Rate for Payer: Cigna Commercial |
$3,541.12
|
| Rate for Payer: Health EOS Commercial |
$3,425.65
|
| Rate for Payer: HFN Commercial |
$3,541.12
|
| Rate for Payer: Multiplan Commercial |
$3,079.23
|
| Rate for Payer: Preferred Network Access Commercial |
$3,541.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,886.03
|
| Rate for Payer: Quartz Commercial |
$2,309.42
|
| Rate for Payer: WEA Trust Commercial |
$2,116.97
|
| Rate for Payer: WPS Commercial |
$2,850.88
|
|
|
KIT GILL BIOPSY BRUSH G15045
|
Facility
|
IP
|
$1,269.00
|
|
| Hospital Charge Code |
2965865
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$646.68 |
| Max. Negotiated Rate |
$1,214.18 |
| Rate for Payer: Aetna Commercial |
$1,187.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,134.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$699.47
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cigna Commercial |
$1,214.18
|
| Rate for Payer: Health EOS Commercial |
$1,174.59
|
| Rate for Payer: HFN Commercial |
$1,214.18
|
| Rate for Payer: Multiplan Commercial |
$1,055.81
|
| Rate for Payer: Preferred Network Access Commercial |
$1,214.18
|
| Rate for Payer: Quartz Beloit One Network |
$646.68
|
| Rate for Payer: Quartz Commercial |
$791.86
|
| Rate for Payer: WEA Trust Commercial |
$725.87
|
| Rate for Payer: WPS Commercial |
$977.51
|
|
